In the UK, a patient with suspected infection has a modest NEWS2 score but is becoming mottled, clammy and confused. What should the nurse do?
Correct answer: B. Escalate the clinical concern immediately
- A. Wait until the NEWS2 score reaches five
- B. Escalate the clinical concern immediately
- C. Document the findings at the next observation round
- D. Use the score alone to decide whether help is needed
Explanation
NEWS2 is an aid to assessment and does not overrule serious clinical concern. Mottling, clamminess and new confusion can indicate poor perfusion or sepsis and require immediate escalation.
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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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