NUR 245 acute nursing care
Exam Questions and Answers Graded A+
An introduction to recognising a deteriorating patient and the first steps to manage
an acutely unwell patient - Correct answer-Early warning signs - ADDS (adult
deterioration detection system), CEWT (children's early warning tool)
Manage patient systematically - A-E, head to toe, systems-based approach
Discuss the steps involved in the primary and secondary survey - Correct answer-
Primary survey (A-D):
- Airway:
o airway obstructions (blood, vomit, saliva, loose teeth, tongue)
o adventitious sounds - indicate airway obstruction
o secure C-spine if necessary
o if the airway is not maintained, breathing can't occur - hypoxia, then death
- Breathing:
o Rise/fall of the chest - minimum 2 breaths within 10 seconds
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,o Adventitious sounds
o Respiration rate, oxygen saturation
- Circulation:
o Manual pulse - radial, carotid, femoral, brachial
o Blood pressure
o No pulse - begin CPR, early defibrillation (shockable/ non-shockable rhythms)
- Disability:
o AVPU - alert to voice, pain or unresponsive
o GCS - Glasgow coma scale (out of 15)
o BGL - don't forget glucose
Secondary survey (E-I):
- Exposure: potential injuries/ illness
- Full set of vital, family presence, further investigation
- Give comfort measures: pain relief, warm blanket
- History, head to toe
- Inspect posterior surfaces
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,Link basic anatomy and physiology of the airway, lungs, circulation, and brain to
the primary and secondary survey - Correct answer-Airways: nasal cavity, pharynx,
larynx, trachea
- At risk of blocked airway: neurological conditions (CVA, seizures), anaphylaxis,
traumatic injury to face/ neck, submersion, foreign bodies
Breathing:
- Upper respiratory tract: nasal cavity, pharynx, larynx
- Lower respiratory tract: trachea, bronchus, primary bronchi, bronchioles, alveoli
- Conducting zone: nasal cavity to bronchioles
- Respiratory zone: alveoli - gas exchange
- At risk or breathing issues: asthma, COPD, CVA, trauma
Circulation:
- Cardiac cycle: atrial systole - isovolumetric ventricular contraction - ejection -
isovolumetric ventricular relaxation - passive ventricular filling
- At risk of compromised circulation: trauma (massive haemorrhage), CVA, septic,
cardiac arrest
Disability:
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, - Frontal lobe: memory, Broca's area - motor speech area
- Temporal lobe: auditory stimuli, Wernicke's area -understanding speech
- Parietal lobe: process spatial information, sensory cortex
- Occipital lobe: sight, interprets visual stimuli
- At risk of decreased consciousness: head injury, trauma, CVA, hypoxic patients
pros and cons of an ADDS chart, the difference between a MET call and a care call
- Correct answer-ADDS chart:
- Set out in order of deterioration, shows obvious MET criteria, provides guidance
of care
- Takes away some critical thinking
MET call: obs in purple area, sudden drop in SpO2 or fall in conscious level, nurse
instinct
Care call: family can call a review if they feel their loved one is deteriorating or
not getting the right help
Identify the signs and symptoms of an issue within A-D, discuss different
treatments for the deterioration in these - Correct answer-Airway obstruction:
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
Exam Questions and Answers Graded A+
An introduction to recognising a deteriorating patient and the first steps to manage
an acutely unwell patient - Correct answer-Early warning signs - ADDS (adult
deterioration detection system), CEWT (children's early warning tool)
Manage patient systematically - A-E, head to toe, systems-based approach
Discuss the steps involved in the primary and secondary survey - Correct answer-
Primary survey (A-D):
- Airway:
o airway obstructions (blood, vomit, saliva, loose teeth, tongue)
o adventitious sounds - indicate airway obstruction
o secure C-spine if necessary
o if the airway is not maintained, breathing can't occur - hypoxia, then death
- Breathing:
o Rise/fall of the chest - minimum 2 breaths within 10 seconds
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,o Adventitious sounds
o Respiration rate, oxygen saturation
- Circulation:
o Manual pulse - radial, carotid, femoral, brachial
o Blood pressure
o No pulse - begin CPR, early defibrillation (shockable/ non-shockable rhythms)
- Disability:
o AVPU - alert to voice, pain or unresponsive
o GCS - Glasgow coma scale (out of 15)
o BGL - don't forget glucose
Secondary survey (E-I):
- Exposure: potential injuries/ illness
- Full set of vital, family presence, further investigation
- Give comfort measures: pain relief, warm blanket
- History, head to toe
- Inspect posterior surfaces
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,Link basic anatomy and physiology of the airway, lungs, circulation, and brain to
the primary and secondary survey - Correct answer-Airways: nasal cavity, pharynx,
larynx, trachea
- At risk of blocked airway: neurological conditions (CVA, seizures), anaphylaxis,
traumatic injury to face/ neck, submersion, foreign bodies
Breathing:
- Upper respiratory tract: nasal cavity, pharynx, larynx
- Lower respiratory tract: trachea, bronchus, primary bronchi, bronchioles, alveoli
- Conducting zone: nasal cavity to bronchioles
- Respiratory zone: alveoli - gas exchange
- At risk or breathing issues: asthma, COPD, CVA, trauma
Circulation:
- Cardiac cycle: atrial systole - isovolumetric ventricular contraction - ejection -
isovolumetric ventricular relaxation - passive ventricular filling
- At risk of compromised circulation: trauma (massive haemorrhage), CVA, septic,
cardiac arrest
Disability:
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, - Frontal lobe: memory, Broca's area - motor speech area
- Temporal lobe: auditory stimuli, Wernicke's area -understanding speech
- Parietal lobe: process spatial information, sensory cortex
- Occipital lobe: sight, interprets visual stimuli
- At risk of decreased consciousness: head injury, trauma, CVA, hypoxic patients
pros and cons of an ADDS chart, the difference between a MET call and a care call
- Correct answer-ADDS chart:
- Set out in order of deterioration, shows obvious MET criteria, provides guidance
of care
- Takes away some critical thinking
MET call: obs in purple area, sudden drop in SpO2 or fall in conscious level, nurse
instinct
Care call: family can call a review if they feel their loved one is deteriorating or
not getting the right help
Identify the signs and symptoms of an issue within A-D, discuss different
treatments for the deterioration in these - Correct answer-Airway obstruction:
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
