Unit 3.2: Clinical Observations and Monitoring

• Topic 01

  Vital Signs

  45 questions
• Topic 02

  Pain Assessment Tools

  45 questions
• Topic 03

  Neurological Assessment

  46 questions
• Topic 04

  Fluid Balance Monitoring and Urine Output

  46 questions

A few questions from this unit, with the answer and a full explanation. The complete bank is available when you start practising.

1. A patient with a head injury has a GCS of 8 and is breathing spontaneously at a rate of 16 breaths per minute. What is the nurse's most important immediate airway consideration?

   • A
     At GCS ≤ 8 the patient cannot reliably protect their own airway; the nurse must position the patient safely (recovery position if not contraindicated), apply oxygen, call for senior medical help, and prepare for possible intubation
     Correct answer
   • B
     Oxygen should be withheld until the cause of the reduced GCS is determined to avoid masking a respiratory diagnosis
   • C
     The airway concern at GCS 8 only applies in unconscious patients; this patient is breathing so airway management is not yet needed
   • D
     Intubation should be performed immediately by the nurse without waiting for medical review
   Explanation

   At GCS ≤ 8, the ability to protect the airway — by maintaining muscle tone in the pharynx, coordinating swallowing, and generating an effective cough — is significantly compromised. A spontaneously breathing patient is not automatically airway-safe: aspiration, airway obstruction, and apnoea remain immediate risks.

   The nurse must:

   • Position the patient safely (lateral recovery position unless spinal injury is suspected)
   • Apply supplemental oxygen
   • Perform continuous monitoring
   • Call immediately for senior medical and anaesthetic review

   The decision to intubate rests with the medical team but must not be delayed. This is a core patient safety scenario in NICE NG51 and the Resuscitation Council ABCDE approach.

2. A nurse is applying 30 mL/hour as the oliguria threshold for all adults on a surgical ward. A 95 kg patient has a urine output of 42 mL/hour and is not escalated. Why is this decision incorrect?

   • A
     A urine output of 42 mL/hour only requires escalation if accompanied by hypotension
   • B
     30 mL/hour is the correct threshold for all adult patients; the nurse's decision is correct
   • C
     The weight-based threshold only applies to patients under 50 kg; 30 mL/hour is correct for heavier patients
   • D
     The weight-based threshold for a 95 kg patient is 47.5 mL/hour; a urine output of 42 mL/hour is below this threshold and meets the definition of oliguria
     Correct answer
   Explanation

   Minimum acceptable urine output = 0.5 mL/kg/hour. For 95 kg: 0.5 × 95 = 47.5 mL/hour. A urine output of 42 mL/hour is below this threshold. By using 30 mL/hour universally, the nurse has missed oliguria in a large patient. If this pattern persisted for 2 consecutive hours, the patient would formally meet the definition of oliguria. This is a known clinical safety issue and the weight-based formula is the correct standard, not the 30 mL/hour approximation designed for a 60 kg adult.

3. A patient has a single NEWS2 parameter score of 3 (systolic BP 88 mmHg) but all other parameters are normal, giving a total NEWS2 score of 3. Which clinical response is required, and why does a single parameter score of 3 have special significance?

   • A
     A total of 3 only requires monitoring every 4–6 hours; the single-parameter rule applies only when the total exceeds 5
   • B
     A systolic BP of 88 is concerning but does not change management until the total score exceeds 5
   • C
     A single parameter score of 3 triggers urgent review (the 5–6 response) but not emergency assessment
   • D
     A single parameter score of 3 triggers the same clinical response as a total score of 7 or above — emergency assessment by a critical care-competent team — regardless of the total score, because extreme deviation in any one parameter represents immediate clinical risk
     Correct answer
   Explanation

   NEWS2 has two separate triggers for the highest level of response: a total score of 7 or above, OR a single parameter scoring 3 (regardless of the total score). This dual trigger exists because extreme abnormality in a single parameter — such as a systolic BP of 88 mmHg — may represent an immediately life-threatening condition (e.g., septic shock, massive haemorrhage) even if all other parameters are currently normal. In this scenario, a systolic of 88 scores 3 for BP alone; the mandatory response is emergency assessment by a team with critical care competencies and continuous monitoring, identical to the response required for a total score of ≥ 7.