NMC CBT exam guide and practice questions

Answer: 2 nebules

1 nebule is half of the required dose, therefore, 2 nebules are required.

Answer: Recognise the event, think before you act, decide on a course of action, test your decision, proceed with confidence

Before undertaking a procedure or event, it is important to consider the ethical impact of your action or the possible harm it could cause. See NMC Code Section 19: ‘Be aware of, and reduce as far as possible, any potential for harm associated with your practice. To achieve this, you must: 19.1 take measures to reduce as far as possible, the likelihood of mistakes, near misses, harm and the effect of harm if it takes place.’

Answer: Protection of the public through regulation of nurses and midwives

The NMC regulates nurses in England, Wales, Scotland & Northern Ireland. The NMC's values and mission are "to act in the interests of patients and the public in contributing to safe and effective care, and upholding confidence in the professions and regulation" (NMC 2015). It sets standards of education, training, conduct and performance so that nurses and midwives can deliver high-quality healthcare throughout their careers. The NMC maintains a register of nurses and midwives allowed to practise in the UK. The NMC require registered nurses to show evidence of relevant practice and continuing professional development in order to stay on the register every three years (known as revalidation). The NMC sets, monitors and oversees the professional standards of the profession.

Answer: Access the organisation's raising concerns/whistle-blowing policy and follow the advice given

As a nurse or midwife, you have a professional duty to put the interests of the people in your care first and to act to protect them if you consider they may be at risk (NMC 2015).

You should access the organisation's raising concerns/whistle-blowing policy and follow the advice given, because this policy has been designed to provide the appropriate steps that should be taken to protect the public from harm.

Reporting the incident to the NMC would not be the initial step to take. You should immediately raise your concern directly with the individual concerned or your line manager.

However, if the matter is not resolved and your concerns remain, your next step may involve notification to the NMC.

Discussing with other staff on the ward would be a breach of confidentiality regulations.

Waiting until the ward manager returns from annual leave would not be the correct step as action needs to be taken without delay to potentially prevent harm.

You should not do nothing because speaking up on behalf of people in your care and clients is part of your role and failing to report concerns is unacceptable (NMC 2015).

If you witness or suspect that there is a risk to the safety of people in your care and you consider that there is an immediate risk of harm, you should report your concerns straight away to the appropriate person or authority (NMC 2015).

Answer: Tell the doctor that s/he must see the patient in a private area

It is most important that a patient's dignity is maintained and you should challenge anyone who compromises this. Approaching the doctor and advising they see this patient in private would be the best answer. None of the remaining options would address the issue of the patient's dignity, nor confront the doctor about the problem.

Answer: Someone who does something on behalf of the patient

The role of an advocate is concerned with working on behalf of self and/or others to raise awareness of a concern and to promote solutions to an issue. It can include working as an advocate at an individual level but could also be at the level of an organisation, within the legal system, or other groups at the healthcare system's policy level working through formal, decision-making bodies.

Answer: Using appropriate hand hygiene, wearing gloves and aprons where necessary, disposing of used sharp instruments safely and providing care in a suitably clean environment to protect yourself and the patients

Standard Infection Control Precautions (SICP) are designed to prevent cross transmission from recognised and unrecognised sources of infection. These sources of (potential) infection include blood and other body fluid secretions or excretions (excluding sweat, non-intact skin or mucous membranes) and any equipment or items in the care environment which are likely to become contaminated.

Answer: Aseptic Non Touch Technique

The Aseptic Non Touch Technique (ANTT) is the method employed to maintain asepsis, protecting the patient from healthcare-associated infections and staff from contamination from the patient's blood, body fluids and toxic substances. This is a standardised approach used by all health care providers in the UK. Staff must undertake ANTT training and have an annual update.

Answer: They are immunosuppressed due to illness or subsequent treatment of an illness

Reverse barrier nursing is also known as protective isolation, whereby the patient is segregated from other patients to reduce their risk of catching an infection. If a patient is neutropenic or immunosuppressed due to particular types of cancers or treatments for cancers, they are at significant risk of acquiring infection and therefore need protecting from this.

All of the other patients described would require barrier nursing, also known as source isolation nursing, as they are the ones carrying the infection. Therefore other patients need the protection to ensure the infection does not spread from the initial patient to others.

Answer: Access the organisation's raising concerns/whistle-blowing policy and follow the advice given

As a nurse or midwife, you have a professional duty to put the interests of the people in your care first and to act to protect them if you consider they may be at risk (NMC 2015).

You should access the organisation's raising concerns/whistle-blowing policy and follow the advice given, because this policy has been designed to provide the appropriate steps that should be taken to protect the public from harm.

Reporting the incident to the NMC would not be the initial step to take. You should immediately raise your concern directly with the individual concerned or your line manager.

However, if the matter is not resolved and your concerns remain, your next step may involve notification to the NMC.

Discussing with other staff on the ward would be a breach of confidentiality regulations.

Waiting until the ward manager returns from annual leave would not be the correct step as action needs to be taken without delay to potentially prevent harm.

You should not do nothing because speaking up on behalf of people in your care and clients is part of your role and failing to report concerns is unacceptable (NMC 2015).

If you witness or suspect that there is a risk to the safety of people in your care and you consider that there is an immediate risk of harm, you should report your concerns straight away to the appropriate person or authority (NMC 2015).

Answer: An irregularly irregular pulse

The heart normally beats in a regular rhythm between 60-100 beats per minute. In atrial fibrillation, the heart rate is irregular due to the heart's upper chambers (atria) contracting randomly. The heart rate can sometimes be considerably higher than 100 beats a minute and there may be a disordered pattern with an unpredictable beat.

Sometimes, atrial fibrillation doesn't cause any symptoms and the person is unaware that their heart rate isn't regular, but symptoms may include dizziness, shortness of breath and tiredness as well as heart palpitations.

Answer: Delusion

Schizophrenia is a type of psychosis. This means the person may not always be able to distinguish their own thoughts and ideas from reality. The symptoms of schizophrenia include disorders of thought, delusions of control, auditory hallucinations (third person, talking about the patient), delusions of belief and other types of hallucination. A patient needs to display only one of these symptoms clearly in order to be diagnosed with schizophrenia. For the purposes of this question:

• Hallucinations are perceptions - the patient 'experiences' something.
• Delusions are beliefs - strongly held, but nevertheless ideas and not experiences.
• If the patient had claimed to hear his neighbour talking about him (that is, voices in his head) this would be an hallucination.

Answer: Speech and language therapist

Nurses should refer patients to specialist members of the multidisciplinary team for additional support and specialist advice (NMC, 2015).

Speech and language therapists treat and develop personalised plans to support people who have eating and swallowing problems. None of the other options should be selected as although they will be included and involved in the care of a stroke patient, the speech and language therapist is the specialist in this particular aspect of care.

Answer: Written instructions to help you supply or administer medicines to patients, usually in planned circumstances

Patient group directions are specific written instructions for the supply or administration by nurses, pharmacists or other authorised named professionals of named medicines in an identified clinical situation, in the absence of a prescription.

Answer: The nurse in charge

The nurse in charge of an area is responsible for the safe and appropriate management of controlled drugs in that area. Certain tasks such as holding the keys can be delegated to a registered nurse, but the overall responsibility remains with the nurse in charge.

Answer: The student and the registered nurse

It is correct for both the student and the registered nurse to sign. ‘You must clearly countersign the signature of the student when supervising a student in the administration of medicines’ (NMC 2015). This is in line with the NMC standards for medicine management. The other options are incorrect. It is important that the student signs the chart if they administer the drug but this must always be under the supervision of a registered nurse. The registrant remains accountable and is required to countersign.

Answer: It should be established if the social worker’s nursing registration is currently valid and they are up to date with current medication practice

Some nurses do hold dual qualifications such as these and working with complex clients you see a number of nurses having more than one professional or nursing qualification. The issue is whether their qualifications are current and that they have kept up to date with their practice in each area. The administration of medication is often viewed as a nursing role but in some areas, with the right training, other professionals or care staff may carry out this function. Indeed many parents and carers perform this function with the right training and monitoring. In this instance there seems to be a policy which requires only a nurse to perform this function.

Answer: Inform your nursing officer on duty that you will require assistance to ensure the patients receive their medications as well as ensuring the other patients have essential care

As a registered nurse, according to the NMC Code Section 25.1, you must identify priorities, manage time, staff and resources effectively and deal with risk to make sure that the quality of care or service you deliver is maintained and improved, putting the needs of those receiving care or services first. Therefore, if you cannot do this then you must escalate this to your Senior. In this scenario you must ensure the patients get their medication on time, so you cannot wait until the day shift staff start work. You cannot delegate this task to a Health Care Support Worker, and it would be a risk to prepare the medication in advance. Therefore you must inform the Nursing Officer in charge that there is a risk to those receiving your care and that you require additional resources to manage this risk. This is also in accordance with Section 16 of the Code, which states that you must act without delay if you believe that there is a risk to patient safety or public protection. To achieve this, you must raise and, if necessary, escalate any concerns you may have about patient or public safety or the level of care people are receiving in your workplace or any other healthcare setting.

The NMC Standards for Medicine Management state in ‘Standard 14: Preparing medication in advance’ that: "Registrants must not prepare substances for injection in advance of their immediate use or administer medication drawn into a syringe or container by another practitioner when not in their presence."

Therefore you must not prepare these in advance and you must not ask anyone else to prepare the medications for you. You must never administer any medication that you personally have not prepared and you must only prepare and administer medication for one patient at a time.

Answer: Administer some simple medications

The senior student would be able to undertake all the other activities, based on the level of training and competence they would have had to already demonstrate in order to reach year 3 of the pre-registration nursing programmes in the UK (although please note that they can only take patients to theatre and cannot collect the patient from the theatre). However, you must not delegate administration of medications to any student or unregistered nurse, as this is not within their level of competence or role profile.

The Code states:

‘You must be accountable for your decisions to delegate tasks and duties to other people.

To achieve this, you must:

• 11.1 only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand your instructions
• 11.2 make sure that everyone you delegate tasks to is adequately supervised and supported so they can provide safe and compassionate care, and
• 11.3 confirm that the outcome of any task you have delegated to someone else meets the required standard.’

Answer: Encourage him to seek help and if he does not then report him to his line manager

The NMC (2015) is clear in that you must work cooperatively with colleagues in whatever setting you find yourself. The code specifically states that you must:

‘8.7 be supportive of colleagues who are encountering health or performance problems. However, this support must never compromise or be at the expense of patient or public safety’.

Therefore in this situation you have very little choice but to offer support and encourage them to seek medical help from their GP or occupational health department. If they refuse or delay in doing this then you have no choice in reporting the matter to their line manager as patient safety could be compromised.

Answer: Ensure the patient is safe and then report the incident without delay

Your first concern is always the health and wellbeing of the people in your care, therefore in this instance, you must ensure that there is no further risk to the patient and injuries are dealt with. As soon as possible the incident must be reported to your line manager and appropriate action taken. The code (section 16) specifically states that you must:

• 2.1 Act without delay if you believe that there is a risk to patient safety or public protection.
• 2.3 Raise and, if necessary, escalate (take further action on) any concerns you may have about patient or public safety, or the level of care people are receiving at your workplace or any other healthcare setting and use the channels available to you in line with our guidance and your local working practices’.

You will need to read both NMC documents in the reference section below for further guidance.

Answer: Structure communication to ensure sharing of concise and focused information and foster a culture of patient safety

SBAR or ISBAR stands for identify, situation, background, assessment, recommendation. It is a means of enhancing effective communication (NHS Institute for Innovation and Improvement 2008, adapted by Marshall et al (2009)). The ISBAR tool provides a means to structure communication that ensures the sharing of concise and focused information and fosters a culture of patient safety.

Answer: Clinical audit

This describes an audit, where you decide to evaluate the care being delivered versus a standard, in this case it is the national guideline. Audit is a particularly important part of clinical delivery and is intended to improve care. Once the data has been collected and compared, recommendations can be implemented to ensure that this evidence-based care is either maintained or improved.

The definition of a clinical audit from the National Institute for Clinical Excellence (NICE) is: ‘A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit standards and the implementation of change.’

Answer: Provides guidance for health and social care

The best description of NICE is that it is a body that evaluates use of healthcare resources and aims to improve healthcare by making guidelines and evaluating treatments. NICE has developed many guidelines on treating patients and is perceived as one of the best bodies for health improvement.

Answer: A body that monitors safety and quality of healthcare services

The CQC is the independent regulator for safety and quality of healthcare services delivered by any healthcare provider in England. Other countries of the UK have equivalent organisations.

Answer: Rehabilitation care

Intermediate care is rehabilitation care, helping the patient to be as independent as possible after discharge from hospital, and is usually provided by a multidisciplinary team.

It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.

Answer: First point of contact in the health care system

Primary care is the first point of contact with the healthcare system. Primary health care, primary care, general practice and family medicine are terms which are often used interchangeably. Here are short descriptions of how each is defined by WHO. Primary health care (PHC) refers to the concept elaborated in the 1978 Declaration of Alma-Ata, which is based on the principles of equity, participation, intersectoral action, appropriate technology and a central role played by the health system. Primary care (PC) is the first point of contact and also provides accessible, continued, comprehensive and coordinated care. PC is a subset of PHC.

General practice is synonymous with primary care and family medicine. Family medicine (FM) or primary care teams can vary between countries and in size: the core team usually is the general practitioner and a nurse, but can comprise a multidisciplinary team of up to 30 professionals including community nurses, midwives, feldshers, dentists, physiotherapists, social workers, psychiatrists, speech therapists, dietitians, pharmacists, administrative staff and managers. In 2003, WHO defined a primary care team as a group of 'fellow professionals with complementary contributions to make in patient care'/

Answer: Payment is required for social care but not for nursing care

In the UK, social care is provided by Local Authorities who make a charge for services, and nursing care is provided by the National Health Service which is at no cost to the patient at the point of delivery.

Answer: A hospital setting

Hospital settings are rarely very therapeutic areas for the treatment of people with autistic spectrum disorders. Indeed the Department of Health (2015) Mental Health Act 1983: Code of practice states that:

‘20.20 Compulsory treatment in a hospital setting is rarely likely to be helpful for a person with autism, who may be very distressed by even minor changes in routine and is likely to find detention in hospital anxiety-provoking. Sensitive, person-centred support in a familiar setting will usually be more helpful. Wherever possible, less restrictive alternative ways of providing the treatment or supporting a person should be found. The specialist expertise and skills of staff should be regularly audited, particularly the ability to recognise social and health needs, and specialist communication skills’.