In the UK, a patient suddenly becomes breathless, cyanosed and unable to speak in full sentences. What should the nurse do first?
Correct answer: B. Assess airway and breathing while calling for urgent help
- A. Complete a full written SBAR before seeking help
- B. Assess airway and breathing while calling for urgent help
- C. Calculate the NEWS2 score before touching the patient
- D. Wait for the next scheduled set of observations
Explanation
Severe breathlessness and cyanosis indicate a possible life-threatening airway or breathing problem. The nurse should begin an immediate ABC assessment and summon urgent help; NEWS2 calculation and documentation follow initial stabilisation.
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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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