In the UK, a nurse records a sudden fall in a patient's blood pressure and cannot obtain a reliable pulse oximeter reading. What should the nurse do first?
Correct answer: B. Assess the patient using an ABCDE approach
- A. Wait until the next scheduled observation round
- B. Assess the patient using an ABCDE approach
- C. Enter the previous oxygen saturation in the record
- D. Calculate NEWS2 using the available blood pressure
Explanation
An unreliable measurement and sudden deterioration require immediate clinical assessment using Airway, Breathing, Circulation, Disability and Exposure. The nurse should not wait, invent a value, or calculate a reassuring score from incomplete data.
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About Recognising Deterioration, NEWS2 and SBAR
Recognising deterioration involves trends in respiratory rate, oxygen saturation, blood pressure, pulse, temperature, consciousness and urine output, together with clinical concern. NEWS2 scoring, its oxygen scale and escalation thresholds support structured response, while SBAR communicates the situation, background, assessment and recommendation; NEWS2 supports judgement but does not replace bedside assessment or urgent action.
Practise Recognising Deterioration, NEWS2 and SBAR
50 free Recognising Deterioration, NEWS2 and SBAR MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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