NEWS2 Score 1-4 – correct answer Low risk (monitored every 4-6hrs)
NEWS2 Score 3 in any single parameter – correct answer Low-medium risk
(monitored at least once per hour)
NEWS2 Score 5-6 – correct answer Medium risk (monitored once per hour)
NEWS2 Score >7 – correct answer High risk (continuous monitoring and emergency
response/possible transfer to ICU)
PEWS Score – correct answer High score is 9
Behavior/Neuro:
(0) Play & sleep appropriately, alert at baseline
(1) Somnolent when not disturbed, sleepy, irritable but consolable
(2) Reduced response to voice, difficult to arouse, anxious/ trouble and difficult to
console
(3) Reduced response to pain, lethargic/ confused, prolonged or frequent seizures
(require intervention); pupils asymmetric or sluggish
Cardiovascular:
(0) Pink, cap refill 1-2 sec
(1) Pale, cap refill 3 sec, intermittent ectopy
(2) Gray, cap refill 4 sec, tachycardia 20 above norm, bradycardia while asleep
(3) Gray or mottled, cap refill > 5 sec, tachycardia 30 above norm, bradycardia while
awake, new onset/ ↑ frequency of ectopy
Respiratory:
(0) WNL, no retractions, O2 per home regimen
(1) RR > 10 above norm, mild ↑ WOB (flare, retract, trach. tug), – Up to 1 LPM >
baseline or <4 LPM HNC or 1-2 LPM wall NC
- Desats with spont. recovery
(2) RR > 20 above norm, mod. ↑ WOB (flare, retract, grunt) - Up to 2 LPM > baseline or > 4-7 LPM O2 or 3-4 LPM wall NC
- Destas requiring reposition or ↑ O2 or Sxn > Q1H
- Resp tx Q2H
(3) RR > 25 above norm, severe ↑ WOB (head bob, paradoxical breathing) - > 2 LPM above baseline or >7 LPM O2
- Desats require positive pressure or suction > Q30 min
- Apnea requiring interventions other than repositioning
PEWS score 0-2 – correct answer monitoring Q4H
PEWS score 3-4 – correct answer repeat PEWS in 1 hour, vitals Q2H, Dr. response
within 60min
PEWS score 5 – correct answer repeat PEWS in 30min, vitals Q2H, Dr. response
within 10min
PEWS score 6+ – correct answer repeat PEWS in 20mins, vitals Q1H, immediate Dr.
reponse
SWOT analysis – correct answer strengths, weaknesses, opportunities, threats
Roger’s Theory of nursing core conditions for effective communication – correct answer
congruence, empathy, respect
NMC Code 4 Key areas – correct answer prioritise people, practise effectively,
preserve safety, promote professionalism and trust
6 Cs of NMC – correct answer care, compassion, courage, communication,
commitment, competence
color card scheme for adverse drug reactions – correct answer Yellow
friends and family test measures what – correct answer quality of care
ANTT – correct answer Aseptic non touch technique
You have observed an IV catheter insertion site W/erythema, swelling, pain and warm?
What VIP score would you document on his notes? – correct answer 3
Late finding of CF – correct answer Moist, productive cough
How to test placement of NG tube – correct answer Testing the acidity of aspirate
using
blue litmus paper
Who has the overall responsibility for the safe and appropriate management of
controlled drugs within the clinical area? – correct answer The nurse in charge
Except which procedure must all individuals providing nursing care must be competent
at?
A. Hand Hygiene
B. Use of protective equipment
C. Disposal of waste