In the UK, a patient has a documented treatment escalation plan stating that ward-based treatment is appropriate and transfer to intensive care is not. The NEWS2 score then rises to 7. What should the nurse do?

Correct answer: B. Follow the plan and urgently seek senior clinical review

  • A. Ignore the score because intensive care is excluded
  • B. Follow the plan and urgently seek senior clinical review
  • C. Transfer the patient to intensive care without discussion
  • D. Wait for the next routine observation round

Explanation

A high NEWS2 score requires urgent clinical review, but treatment must also follow the documented treatment escalation plan. The nurse should seek senior review for appropriate ward-based management rather than ignore the score or arrange an excluded transfer.

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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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