NSE 203
NSE 203 Final Review Study Questions
and Answers 2026
clinical deterioration not promptly recognized can
increase pt morbidity & mortality
barrier to recognizing & responding to clinical deterioration stems from ...
practice variations among HCP
consequences of not recognizing patient deterioration
increased mortality, resuscitation, implementation of higher lvl of care &
prolonged hospital admission
What is part of an ABCDE assessment?
1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
priority things to look for in pt airway?
- any blocked or threatened airways
- pt LOC
- abnormal respiratory assessment findings (ex; stridor)
if you suspect neurological trauma when assessing airway you ...
start w/ triple airway maneuver!!
Triple airway manoeuvre
chin lift, jaw thrust, patient oxygen
what does vital sign instability & visible patient deterioration tend to occur?
in most pts from 6-24 hrs before cardiac arrest
NSE 203
,NSE 203
clinical deterioration
patient compromising hemodynamic stability, marked by physiological
decompensation accompanied by subjective or objective findings.
dynamic state
variations in physiological parameters
decompensation
inability to maintain homeostatic fxn physiologically or psychologically
what are indicators of clinical deterioration
- 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
ABCDE
NEWS2
FAST
signs during primary survey that are significantly associated w/ death ...
- 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
national early warning score
purpose of NEWS2
NSE 203
, NSE 203
- 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?
a high NEWS2 score identifies a sick patient who is deteriorating &
requires urgent clinical review
what does NEWS2 score evaluate?
- RR
- O2 Sat
- systolic BP
- HR
- LOC or new confusion
- temp
what to do if NEWS score is greater or equal to 3
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
immediate discussion w/ ACT advanced practitioner or ACT dr
NEW score 0-4, clinical risk & response
low risk, ward-based response
NEW score of 3, clinical risk & response
low-medium, urgent ward-based response
NEW score of 5-6, clinical risk & response
medium, key threshold for urgent response
NEW score of 7+, clinical risk & response
high risk, urgent or emergency response
NSE 203
NSE 203 Final Review Study Questions
and Answers 2026
clinical deterioration not promptly recognized can
increase pt morbidity & mortality
barrier to recognizing & responding to clinical deterioration stems from ...
practice variations among HCP
consequences of not recognizing patient deterioration
increased mortality, resuscitation, implementation of higher lvl of care &
prolonged hospital admission
What is part of an ABCDE assessment?
1) airway
2) breathing
3) circulation
4) disability
5) environment & exposure
priority things to look for in pt airway?
- any blocked or threatened airways
- pt LOC
- abnormal respiratory assessment findings (ex; stridor)
if you suspect neurological trauma when assessing airway you ...
start w/ triple airway maneuver!!
Triple airway manoeuvre
chin lift, jaw thrust, patient oxygen
what does vital sign instability & visible patient deterioration tend to occur?
in most pts from 6-24 hrs before cardiac arrest
NSE 203
,NSE 203
clinical deterioration
patient compromising hemodynamic stability, marked by physiological
decompensation accompanied by subjective or objective findings.
dynamic state
variations in physiological parameters
decompensation
inability to maintain homeostatic fxn physiologically or psychologically
what are indicators of clinical deterioration
- 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
ABCDE
NEWS2
FAST
signs during primary survey that are significantly associated w/ death ...
- 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
national early warning score
purpose of NEWS2
NSE 203
, NSE 203
- 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?
a high NEWS2 score identifies a sick patient who is deteriorating &
requires urgent clinical review
what does NEWS2 score evaluate?
- RR
- O2 Sat
- systolic BP
- HR
- LOC or new confusion
- temp
what to do if NEWS score is greater or equal to 3
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
immediate discussion w/ ACT advanced practitioner or ACT dr
NEW score 0-4, clinical risk & response
low risk, ward-based response
NEW score of 3, clinical risk & response
low-medium, urgent ward-based response
NEW score of 5-6, clinical risk & response
medium, key threshold for urgent response
NEW score of 7+, clinical risk & response
high risk, urgent or emergency response
NSE 203
