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NCNZ IQN Theoretical Exam study materials
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NCNZ IQN Theoretical Exam practice questions

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Question 1Professional responsibility

A nurse pulls the curtain around a client's bed before assisting the client with a shower. Which right under the Code of Health and Disability Services Consumers' Rights is being upheld?

  1. Right 1, to be treated with respect Correct answer.
  2. Right 6, to be fully informed
  3. Right 9, to make a complaint
  4. Right 4, to services of an appropriate standard

Explanation

Right 1 gives every consumer the right to be treated with respect, and respect includes protecting the person's privacy and dignity during personal care. Screening the bed while washing upholds that right. The other rights address standards of service, information and complaint processes rather than privacy during care.

Question 2Professional responsibility

Cultural safety in New Zealand nursing practice is best described as:

  1. a nurse examining their own culture and its impact on the care given Correct answer.
  2. memorising the customs, values and rituals of each ethnic group in New Zealand
  3. treating every client in exactly the same way regardless of their background
  4. employing staff who reflect the ethnic mix of the local community

Explanation

Cultural safety requires the nurse to reflect on their own culture, beliefs and power to see how these affect the care a person receives. It is defined by the nurse's own analysis rather than by knowledge of particular groups. It is also a process, not a workforce target or a rule about treating everyone identically.

Question 3Professional responsibility

Which three principles are commonly used to apply the Treaty of Waitangi to New Zealand health services?

  1. Equity, access and efficiency
  2. Partnership, participation and protection Correct answer.
  3. Autonomy, beneficence and justice
  4. Consultation, collaboration and confidentiality

Explanation

New Zealand health policy commonly applies the Treaty through partnership, participation and protection, often called the three Ps. These guide how services are planned and delivered with Māori. The other sets are general health or ethics terms rather than the recognised Treaty framework.

Question 4Professional responsibility

Which organisation is the regulatory authority that registers nurses and sets standards of competence and conduct in New Zealand?

  1. The Ministry of Health
  2. The Health and Disability Commissioner
  3. The New Zealand Nurses Organisation
  4. The Nursing Council of New Zealand Correct answer.

Explanation

The Nursing Council of New Zealand is the responsible authority under the Health Practitioners Competence Assurance Act, registering nurses and setting scopes of practice, competencies and conduct standards. The other bodies fund, investigate or advocate rather than regulate the profession.

Question 5Professional responsibility

Which element is essential for a client to give valid informed consent to a procedure?

  1. The client has signed the consent form before any discussion.
  2. The client understands the information and chooses freely. Correct answer.
  3. The client's next of kin has been informed of the procedure.
  4. The nurse has documented the consent on the correct form.

Explanation

Informed consent requires effective communication of what is proposed, an understanding of that information, and a voluntary choice by a competent consumer. Signing a form is only evidence of the process and cannot replace it. Informing relatives or completing paperwork does not create valid consent.

Question 6Professional responsibility

A nurse may share a client's health information with someone outside the care team when:

  1. the client has given informed consent Correct answer.
  2. a colleague from another ward is curious about the admission
  3. a family member asks for an update on the test results
  4. the nurse thinks the details would be useful at handover

Explanation

Health information may be disclosed outside the treating team when the consumer consents, or when a specific legal exception applies. Curiosity, family relationship or general usefulness at handover do not authorise disclosure. Nurses should share only what is needed for the person's care.

Question 7Professional responsibility

A registered nurse has been visiting a client at home for six weeks. Which action breaches professional boundaries?

  1. Beginning a sexual relationship with the client Correct answer.
  2. Declining a friend request from the client on social media
  3. Referring the client to another service for specialist care
  4. Telling the client that personal gifts cannot be accepted

Explanation

A sexual or romantic relationship with a current client is always a boundary violation because of the power imbalance and the risk of harm. Declining social media contact, managing gifts and making appropriate referrals all protect the professional relationship.

Question 8Professional responsibility

Which ethical principle directs a nurse to act in ways that benefit the client?

  1. Justice
  2. Beneficence Correct answer.
  3. Veracity
  4. Autonomy

Explanation

Beneficence is the duty to promote good and act in the client's interests. Autonomy concerns self-determination, justice concerns fairness in the distribution of care, and veracity concerns truthfulness.

Question 9Professional responsibility

A competent adult with a chronic wound refuses the planned dressing change, saying 'not today'. What should the nurse do?

  1. Respect the refusal and document it Correct answer.
  2. Record the client as non-compliant with the care plan
  3. Ask the family to persuade the client to agree
  4. Proceed with the dressing because it is clinically indicated

Explanation

Every consumer has the right to refuse services and to withdraw consent, even where the refusal may lead to harm. The nurse accepts the decision, documents it and continues to offer care and reassess. Pressure from family or staff would override the client's lawful choice.

Question 10Professional responsibility

An unconscious client with no enduring power of attorney in place needs urgent treatment. Under the Code of Rights the nurse should ensure that:

  1. the client's next of kin gives written consent for the procedure
  2. the care is in the client's best interests Correct answer.
  3. a second doctor signs a form authorising treatment without consent
  4. the nurse waits until the client is able to consent to any treatment

Explanation

Where a consumer cannot consent and no one is entitled to consent for them, services may be provided if they are in the consumer's best interests, after reasonable steps to find out the consumer's views. A relative cannot give consent on the client's behalf unless legally entitled to do so. Delaying urgent care would itself cause harm.

Question 11Professional responsibility

A nurse notices bruising in an unusual pattern on a 4-year-old whose parents say the child fell. What is the most appropriate action?

  1. Ask the parents to explain the bruising again and document their answers
  2. Report the concern to Oranga Tamariki Correct answer.
  3. Wait until the next appointment to see whether more bruises appear
  4. Discuss the concern with other family members before acting

Explanation

Any person who believes a child has been, or is likely to be, harmed must report the concern to Oranga Tamariki or the Police. The nurse does not need proof and should not delay while investigating or consulting relatives. Documentation continues but does not replace reporting.

Question 12Professional responsibility

A nurse arriving for a night shift smells alcohol on a colleague's breath and notices the colleague is slurring words. What should the nurse do first?

  1. Raise the matter with other staff during handover
  2. Say nothing because the colleague is a senior staff member
  3. Send the colleague home in their own car
  4. Tell the shift coordinator immediately so clients are protected Correct answer.

Explanation

Client safety comes first, so the concern is escalated at once to someone who can remove the practitioner from clinical duties. Nurses have a professional duty to report a colleague whose practice may be impaired. The colleague is then supported through the proper process rather than being left to manage alone.

Question 13Professional responsibility

A nurse wants to post a photograph on social media of a thank-you card a client has given the ward. What is the professional response?

  1. Do not post it, as the client could be identified Correct answer.
  2. Post it because the card is the client's own words
  3. Post it if the client's name is covered with a sticker
  4. Post it only in a closed group for nurses

Explanation

Nurses must not post material that could identify a client without consent, and the card itself, handwriting or circumstances may identify the person. Covering a name does not remove that risk. A closed group or the card's authorship does not make the post acceptable.

Question 14Professional responsibility

A registered nurse delegates a blood pressure measurement to a health care assistant. Who is accountable for the decision to delegate that task?

  1. Whoever is named in the facility's delegation policy
  2. The registered nurse Correct answer.
  3. The clinical nurse manager on duty
  4. The health care assistant

Explanation

The registered nurse remains accountable for the decision to delegate and must be satisfied the task is within the assistant's role, competence and supervision arrangements. The assistant is accountable for performing the task correctly. Accountability for delegation cannot be transferred to a manager or a document.

Question 15Professional responsibility

A nurse believes a prescribed medication dose is dangerously high. The prescriber cannot be reached and the client is currently stable. What is the most appropriate action?

  1. Ask another client's doctor to rewrite the prescription
  2. Withhold the dose and escalate the concern Correct answer.
  3. Give the dose as prescribed because the prescriber is responsible
  4. Give half the dose and record the reason in the notes

Explanation

The nurse must act as the client's advocate, withholding a dose they reasonably believe is unsafe while escalating through the appropriate clinical chain. Unilaterally altering a dose creates a new error and is outside the nurse's authority. Responsibility for the prescription does not remove the nurse's own duty of care.

Question 16Professional responsibility

A client tells the nurse they want to complain about care received from another staff member. What should the nurse do?

  1. Explain that complaints must first go to the nurse manager
  2. Offer to raise the issue informally so no complaint is needed
  3. Suggest the client wait until discharge before deciding
  4. Give the client the information they need to complain Correct answer.

Explanation

Consumers have the right to complain to the provider or directly to the Health and Disability Commissioner and to have the complaint dealt with properly. The nurse supports that right and must not obstruct or redirect it. Helping the person access the complaints process is part of advocacy.

Question 17Professional responsibility

To maintain an annual practising certificate, a registered nurse in New Zealand must meet which requirement?

  1. Completion of a postgraduate certificate every three years
  2. 20 hours of professional development and 200 practice hours
  3. A competence assessment with the Council every year
  4. 60 hours of professional development each year Correct answer.

Explanation

The Nursing Council requires registered nurses to complete 60 hours of professional development and 450 hours of practice each year, recorded in a portfolio that may be audited. A postgraduate qualification is not a recertification requirement. Annual competence assessments are not required of every nurse.

Question 18Professional responsibility

A registered nurse is asked to perform a procedure they have been taught but have never performed without supervision. What is the appropriate action?

  1. Discuss it with the manager and arrange supervised practice Correct answer.
  2. Ask a student nurse to perform it under the nurse's observation
  3. Perform it and ask a colleague to check the result afterwards
  4. Refuse permanently because it is outside the nurse's scope

Explanation

A nurse must practise only within their competence and must maintain and extend competence through appropriate education and supervised practice. The scope of practice is broad enough to include the procedure if competence is achieved. Asking an unqualified student to perform it would place the client at risk.

Question 19Professional responsibility

Which documentation entry meets professional standards?

  1. '1400: pain 6/10, analgesia given as prescribed' Correct answer.
  2. 'Client was a nuisance all shift and kept buzzing'
  3. 'Seems to be in pain, probably needs more analgesia'
  4. 'Was fine today, nothing to report, will hand over'

Explanation

Clinical records must be factual, objective, timed and relevant, and should describe what was observed and done. Judgemental language, speculation and vague entries undermine care and are indefensible if the record is later examined. The objective entry also allows continuity for the next clinician.

Question 20Professional responsibility

A client is given the wrong medication. Under the Code of Rights the client has the right to:

  1. receive compensation from the district health board
  2. have the incident fully investigated before being told anything
  3. be told about the error and its likely consequences Correct answer.
  4. be transferred to another ward at no cost

Explanation

The Code requires providers to be open with consumers when an adverse event has harmed them, which sits within the right to services of an appropriate standard. The client is entitled to an honest explanation and an apology, not to have information withheld. Compensation and transfers are not rights created by the Code in this situation.

Question 21Professional responsibility

Under section 34 of the Health Practitioners Competence Assurance Act 2003, a health practitioner must notify the Registrar when they believe:

  1. a colleague poses a risk of harm to the public Correct answer.
  2. a colleague has not attended the employer's mandatory training
  3. a colleague has been rude to a client during a shift
  4. a colleague has been late for work more than once

Explanation

Section 34 imposes a duty on health practitioners to notify the Registrar as soon as practicable when they have reason to believe another practitioner poses a risk of harm to the public. The threshold is risk of harm, not general dissatisfaction with conduct. Employers manage routine employment matters such as lateness and training separately.

Question 22Professional responsibility

A facility has a blanket rule limiting drinks after 8pm for all residents to reduce night toileting. A resident with a urinary tract infection and thirst asks for water at 9pm. What is the most appropriate nursing response?

  1. Ask the resident's family to complain to the facility manager
  2. Give the drink and escalate the policy concern Correct answer.
  3. Give the drink but write up the resident as breaching the care plan
  4. Follow the rule because employers set the requirements for practice

Explanation

The nurse's first obligation is to the individual resident's health and wellbeing, so clinically needed fluid is provided, and the unsafe blanket rule is raised through the proper channels. Employer policy cannot override the duty to meet a person's needs. Documenting the resident as breaching the plan misplaces responsibility.

Question 23Professional responsibility

A nurse believes a rest home's staffing levels are unsafe but fears losing their job. Which statement is correct?

  1. Staffing levels are a matter for the employer alone to judge
  2. A protected disclosure can be made to an appropriate authority Correct answer.
  3. Reporting unsafe staffing is a breach of the employment agreement
  4. The nurse must complete every internal complaint step before any outside report

Explanation

The Protected Disclosures Act protects employees who report serious wrongdoing, including risks to public health and safety, to an appropriate authority. Confidentiality provisions in employment agreements do not override this protection. Nurses also have professional obligations to report risks to client safety.

Question 24Professional responsibility

Which situation is consistent with Right 8 of the Code of Rights, which covers teaching and research?

  1. A student observes a dressing change after the client agrees. Correct answer.
  2. A client is enrolled in a drug trial without being told.
  3. A student performs a procedure the client has already refused.
  4. A client's clinical notes are used in a case study without consent.

Explanation

Right 8 requires that consumers be informed of and consent to their participation in teaching or research, and they may decline without affecting their care. A student may be involved only with the client's knowledge and agreement. Using notes or enrolling people without consent breaches the right.

Question 25Professional responsibility

A competent older resident keeps trying to leave the facility to walk to the local shops. Night staff ask the nurse to lock the resident's bedroom door. What is the most appropriate response?

  1. Ask the family to sign a consent form for a locked door
  2. Lock the door so the resident cannot walk towards traffic
  3. Explore less restrictive options and refuse to lock the door Correct answer.
  4. Give a sedative so the resident sleeps through the night

Explanation

A competent resident has the right to move freely, and locking them in is a form of restraint that cannot be justified by convenience or blanket safety fears. The nurse must look for the least restrictive way to manage risk, such as assessment, supervision and review of the care plan. Sedation used to manage behaviour is chemical restraint and requires proper authorisation and safeguards.

Question 26Professional responsibility

The Nursing Council Code of Conduct requires nurses to practise in a culturally safe way. This means the nurse should:

  1. Follow whatever the client's family asks for, to show respect
  2. Reflect on their own culture and beliefs and how these shape the care given Correct answer.
  3. Treat all clients in exactly the same way, whatever their background
  4. Learn the main customs of each client's ethnic group before giving care

Explanation

Cultural safety starts with the nurse examining their own attitudes, beliefs, biases and use of power, and recognising how these affect the care relationship. It is a process of self-reflection and partnership rather than a checklist of facts about other cultures.

Question 27Professional responsibility

A client is about to sign a consent form for an operation. What is the nurse's professional responsibility at this point?

  1. Explain the risks and benefits of the operation in detail to the client
  2. Confirm the client understands what they are consenting to Correct answer.
  3. Witness the signature and file the form without further discussion
  4. Obtain the signature before the surgeon speaks with the client

Explanation

Consent must be informed, and the practitioner carrying out the procedure is responsible for explaining its nature, risks and alternatives. The nurse supports the process by checking the client's understanding, answering questions within their scope and escalating any gaps before the form is signed.

Question 28Professional responsibility

After discharge, a client gives a nurse a gift voucher worth $300 as thanks. What is the most appropriate action?

  1. Accept the voucher, because refusing would damage the relationship
  2. Accept the voucher and share it among the ward staff
  3. Decline the voucher politely and explain the guidance on gifts Correct answer.
  4. Accept the voucher but not mention it to colleagues

Explanation

The Code of Conduct expects nurses to avoid gifts that could create obligation or be seen to influence care. Small tokens of thanks may be acceptable, but gifts of significant value are declined courteously and, where relevant, discussed with a manager.

Question 29Professional responsibility

A client asks to read their own clinical record. Under the Health Information Privacy Code, the nurse should:

  1. Ask the client to apply under the Official Information Act 1982
  2. Refuse, because clinical records belong to the service, not the client
  3. Explain the process and support the client's access to the record Correct answer.
  4. Release only the pages the doctor has approved for viewing

Explanation

Rule 6 of the Health Information Privacy Code gives people a right of access to their own health information. The service must respond within the required timeframe and may withhold information only in narrow circumstances, such as serious risk to someone, and must explain the reason.

Question 30Professional responsibility

A competent adult client's family asks the nurse not to tell the client that the diagnosis is terminal. The client then asks the nurse directly what is wrong. The nurse should:

  1. Redirect every question to the doctor without any discussion
  2. Say nothing until the family and the doctors agree what to disclose
  3. Say that the family has asked for the information to be withheld
  4. Check what the client wants to know, then answer honestly Correct answer.

Explanation

A competent adult is entitled to information about their own condition, and the nurse should not collude in deceiving them. The nurse explores what the client already knows and wants to know, responds honestly and sensitively within their role, and involves the medical team as needed.

Question 31Professional responsibility

A nurse who owns a small company selling wound-care products tells clients on the ward that these products work better than those the hospital supplies. What is the main professional concern?

  1. The nurse has breached the client's right to privacy
  2. The nurse has failed to offer the products free of charge
  3. The nurse has not recorded the conversation in the care plan
  4. The nurse's financial interest is in conflict with the client's interest Correct answer.

Explanation

Nurses must not use the professional relationship for personal gain and must declare and manage conflicts of interest. Advice given to clients must be based on their needs, not on the nurse's commercial benefit.

Question 32Professional responsibility

Two days after a client dies, a reporter from the local paper phones the ward asking the nurse to confirm details of the client's illness. What should the nurse do?

  1. Check with the family, then answer the reporter's questions
  2. Decline to confirm or discuss any details about the client Correct answer.
  3. Answer the questions, because the client is no longer alive
  4. Confirm only the details already published in the death notice

Explanation

The duty of confidentiality continues after death, and health information about a deceased person may be disclosed only in limited circumstances, such as to an executor or representative, or where the law requires it. The request should be declined and referred to the service's privacy officer.

Question 33Professional responsibility

At the start of a very busy shift with limited staff, a nurse must decide how to allocate time among clients. Which approach best reflects the principle of justice?

  1. Care for the clients whose family members are present
  2. Allocate care by clinical need using an agreed prioritisation tool Correct answer.
  3. Attend first to the clients who are most likely to complain
  4. Give the same amount of time to every client, whatever their need

Explanation

In resource-limited situations, justice requires fair and consistent decisions based on need, using transparent criteria that can be explained and reviewed. Decisions based on who is most vocal or most socially connected are not equitable.

Question 34Professional responsibility

A client who speaks little English is being asked to consent to a procedure, and the nurse notices the client nodding and smiling. What should the nurse arrange?

  1. The client's 12-year-old child to interpret
  2. A consent form in the client's language with no discussion
  3. Written information only, to read at home
  4. A trained interpreter for the consent discussion Correct answer.

Explanation

Right 5 of the Code of Rights gives the right to effective communication, and valid consent depends on genuine understanding. A trained interpreter should be used, and children or family members should not be asked to interpret clinical discussions.

Question 35Professional responsibility

A former client sends a nurse a friend request on a social media site. What is the most appropriate response?

  1. Accept and use the site to check on the client's recovery
  2. Accept, provided clinical matters are never discussed online
  3. Accept the request, because the client is no longer in care
  4. Decline the request and discuss the boundary in supervision Correct answer.

Explanation

The professional relationship and its power imbalance do not end at discharge, and personal social media contact blurs boundaries. The request is declined and any discomfort or concern is discussed with a manager or in clinical supervision.

Question 36Professional responsibility

A nurse wants to photograph a client's wound on a personal mobile phone to show a colleague for advice. What should the nurse do instead?

  1. Use an approved work device and store the image in the record Correct answer.
  2. Send it to the colleague's personal phone for a quick opinion
  3. Take the photo and delete it immediately after sending
  4. Take the photo only when the client's face is out of view

Explanation

Clinical images are health information and must be captured, stored and shared through approved secure systems that form part of the clinical record. Personal devices and messaging apps risk breaching the Health Information Privacy Code.

Question 37Professional responsibility

An older client with early dementia tells the nurse she wants to go home. What should the nurse do first?

  1. Ask her family to sign her out against medical advice
  2. Begin the process of appointing a welfare guardian
  3. Explore her reasons and support her to join the decision Correct answer.
  4. Explain that the doctor will decide when she can go home

Explanation

A diagnosis of dementia does not remove a person's right to make decisions; competence is presumed and decision-making should be supported. The nurse explores the person's reasons, provides information and involves them in planning, arranging a formal capacity assessment only if genuine doubt remains.

Question 38Professional responsibility

Police arrive on the ward and ask the nurse for a client's address and test results, saying they are investigating an assault. They have no warrant or court order. What is the correct professional response?

  1. Refuse to speak to the police and shut the unit doors
  2. Provide the test results but not the client's address
  3. Give the information, as police are entitled to it on request
  4. Refer the request to the privacy officer before releasing anything Correct answer.

Explanation

Health information should be released to police only where the law requires or permits it, and each request must be assessed on its legal basis. Directing the request to the privacy officer or following the facility's process allows that assessment to be made correctly and consistently.

Question 39Professional responsibility

A nurse has a conscientious objection to assisting with a procedure. The client is stable and the procedure is not urgent. What is professionally required of the nurse?

  1. Inform the client of the objection and arrange access elsewhere Correct answer.
  2. Persuade the client that the procedure is unnecessary
  3. Assist with the procedure anyway to avoid breaching the Code
  4. Refuse to discuss the matter and withdraw from the client's care

Explanation

New Zealand law recognises conscientious objection provided the practitioner tells the person about the objection and ensures they can obtain the service from another provider. The protection does not extend to emergency care needed to save a life, and the nurse must not obstruct, judge or pressure the client.

Question 40Professional responsibility

A manager tells staff not to tell a client about a serious medication error, 'to avoid a complaint'. What is the nurse's professional obligation?

  1. Follow the manager's instruction, because employers direct practice
  2. Report the error only if the client later asks about it
  3. Tell the client privately but leave no record of the conversation
  4. Advocate for open disclosure and escalate the instruction Correct answer.

Explanation

The Code of Conduct requires honesty and open disclosure when things go wrong, and a nurse remains accountable for their own practice even when instructed otherwise. Concerns about an instruction that conflicts with professional standards are raised through the appropriate channels, including senior management and, if needed, an external authority.

Question 41Management of nursing care

According to the WHO 'My 5 Moments for Hand Hygiene', hand hygiene must be performed immediately before which activity?

  1. Touching a patient Correct answer.
  2. Collecting clean linen from the store room
  3. Documenting care in the clinical record
  4. Emptying a urinary drainage bag

Explanation

The WHO moments include hand hygiene before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings. Hand hygiene before patient contact protects the patient from organisms carried on the nurse's hands.

Question 42Management of nursing care

Which respiratory rate range is considered normal for a healthy adult at rest?

  1. 22 to 28 breaths per minute
  2. 12 to 20 breaths per minute Correct answer.
  3. 30 to 36 breaths per minute
  4. 4 to 10 breaths per minute

Explanation

A resting adult normally breathes about 12 to 20 times per minute. Rates outside this range, particularly a rising respiratory rate, are an early indicator of clinical deterioration.

Question 43Management of nursing care

A patient with a nasogastric tube has a prescribed enteric-coated tablet. What is the nurse's most appropriate action?

  1. Dissolve the tablet in sterile water and flush it down the tube
  2. Withhold the dose and request a crushable alternative Correct answer.
  3. Administer the tablet whole with a small volume of water
  4. Crush the tablet and mix it with water before administration

Explanation

Enteric-coated and modified-release tablets must not be crushed or dissolved because the coating controls where and how fast the drug is released. A liquid or immediate-release formulation should be obtained from the prescriber or pharmacist before the dose is given via the tube.

Question 44Management of nursing care

In a patient lying supine, which site is most at risk of developing a pressure injury?

  1. The anterior iliac crest
  2. The sacrum Correct answer.
  3. The lateral malleolus
  4. The patella

Explanation

In the supine position, body weight is concentrated over bony prominences such as the sacrum, occiput and heels. The sacrum is the most common site for pressure injury in this position.

Question 45Management of nursing care

An older patient with COPD has oxygen prescribed to a target SpO2 of 88–92%. The saturation is currently 96%. What should the nurse do?

  1. Increase the flow to keep the saturation above 95%
  2. Continue the current flow and recheck in four hours
  3. Stop the oxygen and record the reading as normal
  4. Reduce the oxygen flow and recheck the saturation Correct answer.

Explanation

For patients with chronic CO2 retention the prescribed target range is lower, usually 88–92%, because excessive oxygen can worsen hypercapnia. A reading above the target range means the flow should be reduced and the patient reassessed.

Question 46Management of nursing care

An older adult receiving intravenous fluids develops bibasal crackles, a raised respiratory rate and a 2 kg weight gain over 24 hours. These findings most suggest which problem?

  1. Dehydration
  2. Fluid overload Correct answer.
  3. Hypovolaemic shock
  4. Urinary retention

Explanation

Crackles at the lung bases, tachypnoea and a rapid weight gain point to excess circulating volume with developing pulmonary oedema. The nurse should slow or stop the infusion as prescribed and escalate promptly.

Question 47Management of nursing care

A patient has a respiratory rate of 28, SpO2 93% on room air, heart rate 118, blood pressure 105/60 mmHg, temperature 38.4°C and new confusion. Which interpretation is most accurate?

  1. These findings meet early-warning criteria and require urgent escalation Correct answer.
  2. The changes are most likely caused by pain and can be managed with analgesia
  3. These are expected findings in a patient recovering from surgery
  4. Only the temperature needs treating, because the other values are normal

Explanation

A rising respiratory rate, tachycardia, fever, hypotension and new confusion together form a deteriorating picture consistent with sepsis or another acute deterioration. This combination triggers early-warning escalation so assessment and treatment are not delayed.

Question 48Management of nursing care

When should a nurse record the care delivered to a patient?

  1. The following morning, before the medical round
  2. At the end of the shift, after handover is complete
  3. At the end of the shift, from memory
  4. As soon as practicable after the care is given Correct answer.

Explanation

Clinical records must be completed contemporaneously, meaning as soon as practicable after the event, while the details are accurate. Delayed or reconstructed entries undermine the record's reliability and legal standing.

Question 49Management of nursing care

Thirty minutes after receiving intravenous morphine, a patient is difficult to rouse, has a respiratory rate of 7 and pinpoint pupils. What is the nurse's priority action?

  1. Encourage the patient to walk to increase alertness
  2. Record the findings and reassess at the next round
  3. Give the next dose as prescribed and reassess in an hour
  4. Stop the opioid, support the airway and call for help Correct answer.

Explanation

Pinpoint pupils, reduced consciousness and a respiratory rate of 7 indicate opioid-induced respiratory depression, which is a medical emergency. The opioid must be withheld, the airway supported and urgent help summoned so naloxone can be considered.

Question 50Management of nursing care

Which technique is correct when collecting a wound swab for culture?

  1. Leave the swab sitting in pooled exudate at the wound edge
  2. Swab the surrounding intact skin as well as the exudate
  3. Swab the wound after it has been cleaned with chlorhexidine
  4. Swab viable tissue in the wound bed before cleansing Correct answer.

Explanation

A wound swab should be taken from clean, viable tissue in the wound bed before any cleansing or dressing, using a zig-zag motion over a defined area. Antiseptics and pooled exudate can suppress or contaminate the organisms being cultured.