NSE 203 FINAL EXAM REVIEW
COMPLETE 150 QUESTIONS AND 100%
VERIFIED ANSWERS
\.clinical deterioration not promptly recognized can - ANSWERS✔-increase pt
morbidity & mortality
\.barrier to recognizing & responding to clinical deterioration stems from ... -
ANSWERS✔-practice variations among HCP
\.consequences of not recognizing patient deterioration - ANSWERS✔-increased
mortality, resuscitation, implementation of higher lvl of care & prolonged hospital
admission
\.What is part of an ABCDE assessment? - ANSWERS✔-1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
\.priority things to look for in pt airway? - ANSWERS✔-- any blocked or threatened
airways
- pt LOC
,- abnormal respiratory assessment findings (ex; stridor)
\.if you suspect neurological trauma when assessing airway you ... - ANSWERS✔-
start w/ triple airway maneuver!!
\.Triple airway manoeuvre - ANSWERS✔-chin lift, jaw thrust, patient oxygen
\.what does vital sign instability & visible patient deterioration tend to occur? -
ANSWERS✔-in most pts from 6-24 hrs before cardiac arrest
\.clinical deterioration - ANSWERS✔-patient compromising *hemodynamic
stability, marked by physiological decompensation* accompanied by subjective or
objective findings.
\.dynamic state - ANSWERS✔-variations in physiological parameters
\.decompensation - ANSWERS✔-inability to maintain homeostatic fxn
physiologically or psychologically
\.what are indicators of clinical deterioration - ANSWERS✔-- sudden and/or
unstable changes in vital signs (RR, BP, HR, O2)
- for expert nurses, their intuition helps them determine if a patient looks right
- skin color changes
- decreased LOC
,\.assessments to recognize deterioration - ANSWERS✔-ABCDE
NEWS2
FAST
\.signs during primary survey that are *significantly associated w/ death* ... -
ANSWERS✔-- partial airway obstruction
- poor peripheral circulation
- greater than expected drain fluid loss
- decreased UO
- decreased GCS
- abnormal RR
- new pain
- low O2sat & low BP
- alteration in mentation
\.NEWS2 aka - ANSWERS✔-national early warning score
\.purpose of NEWS2 - ANSWERS✔-- improve detection of & response to clinical
deterioration in patients w/ acute illness
- provide *standardized approach* to care of deteriorating patient
- clear communication
- identify a *score* for urgent clinical response
, \.what does the NEWS2 score mean? - ANSWERS✔-*a high NEWS2 score*
identifies a sick patient who is deteriorating & requires *urgent clinical review*
\.what does NEWS2 score evaluate? - ANSWERS✔-- RR
- O2 Sat
- systolic BP
- HR
- LOC or new confusion
- temp
\.what to do if NEWS score is greater or equal to 3 - ANSWERS✔-discuss w/ duty
nurse/senior colleague, & complete a *sepsis screen for signs of infection*
\.what to do if NEWS score is greater or equal to 6 - ANSWERS✔-immediate
discussion w/ ACT advanced practitioner or ACT dr
\.NEW score 0-4, clinical risk & response - ANSWERS✔-low risk, ward-based
response
\.NEW score of 3, clinical risk & response - ANSWERS✔-low-medium, urgent ward-
based response
COMPLETE 150 QUESTIONS AND 100%
VERIFIED ANSWERS
\.clinical deterioration not promptly recognized can - ANSWERS✔-increase pt
morbidity & mortality
\.barrier to recognizing & responding to clinical deterioration stems from ... -
ANSWERS✔-practice variations among HCP
\.consequences of not recognizing patient deterioration - ANSWERS✔-increased
mortality, resuscitation, implementation of higher lvl of care & prolonged hospital
admission
\.What is part of an ABCDE assessment? - ANSWERS✔-1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
\.priority things to look for in pt airway? - ANSWERS✔-- any blocked or threatened
airways
- pt LOC
,- abnormal respiratory assessment findings (ex; stridor)
\.if you suspect neurological trauma when assessing airway you ... - ANSWERS✔-
start w/ triple airway maneuver!!
\.Triple airway manoeuvre - ANSWERS✔-chin lift, jaw thrust, patient oxygen
\.what does vital sign instability & visible patient deterioration tend to occur? -
ANSWERS✔-in most pts from 6-24 hrs before cardiac arrest
\.clinical deterioration - ANSWERS✔-patient compromising *hemodynamic
stability, marked by physiological decompensation* accompanied by subjective or
objective findings.
\.dynamic state - ANSWERS✔-variations in physiological parameters
\.decompensation - ANSWERS✔-inability to maintain homeostatic fxn
physiologically or psychologically
\.what are indicators of clinical deterioration - ANSWERS✔-- sudden and/or
unstable changes in vital signs (RR, BP, HR, O2)
- for expert nurses, their intuition helps them determine if a patient looks right
- skin color changes
- decreased LOC
,\.assessments to recognize deterioration - ANSWERS✔-ABCDE
NEWS2
FAST
\.signs during primary survey that are *significantly associated w/ death* ... -
ANSWERS✔-- partial airway obstruction
- poor peripheral circulation
- greater than expected drain fluid loss
- decreased UO
- decreased GCS
- abnormal RR
- new pain
- low O2sat & low BP
- alteration in mentation
\.NEWS2 aka - ANSWERS✔-national early warning score
\.purpose of NEWS2 - ANSWERS✔-- improve detection of & response to clinical
deterioration in patients w/ acute illness
- provide *standardized approach* to care of deteriorating patient
- clear communication
- identify a *score* for urgent clinical response
, \.what does the NEWS2 score mean? - ANSWERS✔-*a high NEWS2 score*
identifies a sick patient who is deteriorating & requires *urgent clinical review*
\.what does NEWS2 score evaluate? - ANSWERS✔-- RR
- O2 Sat
- systolic BP
- HR
- LOC or new confusion
- temp
\.what to do if NEWS score is greater or equal to 3 - ANSWERS✔-discuss w/ duty
nurse/senior colleague, & complete a *sepsis screen for signs of infection*
\.what to do if NEWS score is greater or equal to 6 - ANSWERS✔-immediate
discussion w/ ACT advanced practitioner or ACT dr
\.NEW score 0-4, clinical risk & response - ANSWERS✔-low risk, ward-based
response
\.NEW score of 3, clinical risk & response - ANSWERS✔-low-medium, urgent ward-
based response
