Clinical nursing: practice questions with explanations

1What clinical nursing asks of you

Clinical nursing applies the fundamentals to patients with real illnesses: after surgery, with heart failure, diabetes, sepsis or a stroke. The core skill is to recognise a problem early, respond safely and reassess.

Patients rarely become very ill without warning. Hours before a cardiac arrest there are often changes in breathing rate, pulse, blood pressure or alertness. Early warning scores such as NEWS2 exist to catch them.

Three tools from the fundamentals return in almost every case:

• The ABCDE approach: Airway, Breathing, Circulation, Disability, Exposure.
• The early warning score: 5–6 needs an urgent review, 7 or more an emergency response.
• SBAR for handover and escalation: Situation, Background, Assessment, Recommendation.

Most questions add one more layer: you need to recognise the pattern of a specific condition and know the first safe nursing action for it.

2Patterns of deterioration

Shock and bleeding. In early blood loss the heart rate rises first; blood pressure falls later. Fast pulse, cool pale skin, low urine output and a soaked dressing after surgery suggest haemorrhage.

Sepsis is a life-threatening response to infection: fever or low temperature, fast breathing, fast pulse, low blood pressure and new confusion. The Sepsis Six are given within an hour:

• Give oxygen to reach the target saturation.
• Take blood cultures, then give intravenous antibiotics.
• Give intravenous fluids.
• Measure lactate (a sign of poor tissue perfusion) and monitor urine output.

Oxygen targets. Most acutely ill adults: SpO₂ 94–98%. Patients at risk of CO₂ retention, such as some people with COPD: 88–92%.

Hypoglycaemia (blood glucose below 4 mmol/L) causes sweating, shaking, palpitations and confusion. If the patient is conscious and can swallow, give 15–20 g of fast-acting carbohydrate and recheck after 10–15 minutes. If not, glucagon or intravenous glucose is used.

Heart failure. A weight gain of about 2 kg in a few days means fluid retention. Pink, frothy sputum with crackles in both lungs means acute pulmonary oedema; sit the patient upright.

Stroke. Sudden facial drooping, arm weakness or speech problems (FAST) need emergency care. Nothing is given by mouth until a swallow screen is passed, because of the risk of aspiration.

3Fluids, electrolytes and medicines

Normal plasma potassium is about 3.5–5.0 mmol/L and sodium about 135–145 mmol/L.

• Vomiting, diarrhoea and loop diuretics such as furosemide cause low potassium, with weakness and arrhythmias.
• High potassium can stop the heart. A classic ECG sign is tall, peaked T waves. Intravenous calcium gluconate protects the heart within minutes; insulin with glucose shifts potassium into the cells.
• Low sodium causes confusion, headache and, when severe, seizures.

Many deteriorations come from medicines. Learn these patterns:

• Opioids: drowsiness, slow breathing and pinpoint pupils. Naloxone reverses them, but its effect may wear off before the opioid’s.
• Warfarin: bleeding with a high INR; vitamin K reverses it.
• Digoxin toxicity: nausea, a slow pulse and yellow-tinged vision.
• ACE inhibitors: a persistent dry cough.
• Heparin: a sudden fall in platelets after about 5–10 days suggests heparin-induced thrombocytopenia.

Blood transfusion. The most important check is the patient’s identity against the blood unit at the bedside. If a reaction starts (fever, rigors, breathlessness, low blood pressure), stop the transfusion, keep the line open with saline and call for help.

4From pattern to action

For every case question, use the same sequence:

1. Collect the clues: vital signs, symptoms, recent surgery, medicines and blood results.
2. Match them to a pattern, such as bleeding, sepsis, opioid toxicity or fluid overload.
3. Choose the first safe action within nursing practice: stop a harmful drug or transfusion, position the patient, give oxygen, check glucose.
4. Escalate with SBAR, and give prescribed or protocol treatment such as naloxone or antibiotics.
5. Monitor the response and record it. Ask what could happen next, and watch for it.

5A worked example

Follow the sequence. Try to say the next step before you open it.

6Common mistakes

• Waiting for the blood pressure to fall before acting in bleeding or sepsis. A rising heart rate and breathing rate come first.
• Slowing a transfusion when a reaction starts. The correct action is to stop it.
• Treating hypoglycaemia with chocolate. Its fat slows sugar absorption; use fast-acting glucose.
• Giving food or tablets by mouth to a stroke patient before a swallow screen.
• Stopping monitoring after naloxone. The opioid can outlast it.
• Aiming for 94–98% in every patient. Some people with COPD have a target of 88–92%.

7How exam questions look

• Easy (key terms and facts): signs, terms and targets. Typical symptoms of hypoglycaemia, what melaena means, the usual target saturation, what SBAR stands for.
• Medium (applying the concepts): linking signs to a cause and an action. A weight gain in heart failure, an ACE inhibitor cough, the Sepsis Six, care of a chest drain.
• Hard (cases and analysis): an acutely ill patient. You recognise patterns such as a falling GCS with a dilated pupil, a silent chest in asthma or anaphylaxis during a transfusion, and choose the priority.

For hard questions, decide what will harm the patient soonest. Remove the cause, support ABCDE, escalate and monitor.