In the UK, a patient's pulse feels irregular when the nurse begins the NEWS2 observations. Which action gives the most reliable pulse measurement?
Correct answer: C. Count the pulse for a complete 60 seconds
- A. Count for 15 seconds and multiply by four
- B. Count for 30 seconds and multiply by two
- C. Count the pulse for a complete 60 seconds
- D. Use the first automated reading only
Explanation
An irregular pulse should be counted for a full 60 seconds to avoid error from missed beats or an uneven rhythm. The nurse should also report any clinically concerning rhythm.
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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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