Registered Nurse Objective Structured Clinical Examination (NMC OSCE) Clinical Skills Stations Syllabus

List the common enteral and parenteral routes of medication administration with their abbreviations.

Enteral: oral (PO/per os), sublingual (SL), buccal, rectal (PR), and via enteral tubes (NG/PEG). Parenteral: intravenous (IV), intramuscular (IM), subcutaneous (SC/SubCut), and intradermal (ID). Other topical/local routes: transdermal, inhaled (INH), nebulised, ophthalmic, otic, nasal, and vaginal (PV).

Compare onset and typical use of intravenous (IV) versus subcutaneous (SC) routes.

IV delivers the drug directly into the bloodstream giving the most rapid onset and 100% bioavailability, used for emergencies and precise control. SC delivers into fatty tissue beneath the skin giving slow, sustained absorption, used for drugs such as insulin, heparin/LMWH, and some vaccines; only small volumes (usually $\leq 1\text{-}2\ \text{mL}$) can be given.

At which sites and angles are intramuscular and subcutaneous injections given?

IM injections are given at $90^{\circ}$ into muscle (e.g. deltoid, vastus lateralis, ventrogluteal). SC injections are given at $45^{\circ}$ to $90^{\circ}$ into a pinched skinfold (e.g. abdomen, outer thigh, upper outer arm), with the angle depending on needle length and the amount of subcutaneous tissue.

If a patient refuses a prescribed medication, what must the nurse do and document?

Respect the patient's right to refuse (assuming capacity), explain the purpose and risks of omission, do not coerce, inform the prescriber if appropriate, document the refusal and the reason, and use the correct omission/non-administration code on the chart. The refusal and any follow-up actions must be clearly recorded.

According to NMC standards, what are the key principles of good record-keeping (documentation)?

Records must be clear, accurate, legible, made as soon as possible (contemporaneous), factual and objective, signed/timed/dated, free from unexplained abbreviations and alterations, and never falsified. They should record decisions, actions, assessments and the care given, and be kept securely and confidentially.

How are signed-for medication entries and any errors corrected on a paper chart?

Errors are corrected with a single line through the entry so the original remains legible, then initialled, timed and dated; correction fluid is never used. Each administration is signed (and often co-signed for controlled drugs), and omissions are recorded with the appropriate reason code.

What are the clinical signs used to recognise cardiac arrest in an adult?

The patient is unresponsive and not breathing normally (apnoea or only occasional agonal gasps). Pulselessness may be present but a pulse check is not relied upon by lay/most responders; absence of normal breathing in an unresponsive person is treated as cardiac arrest. CPR is started immediately.

List the links in the adult 'Chain of Survival'.

1. Early recognition and call for help (to prevent arrest / activate emergency response). 2. Early CPR (to buy time). 3. Early defibrillation (to restart the heart). 4. Post-resuscitation care (to restore quality of life).

Describe the adult Basic Life Support sequence (DRS ABC).

Danger (check it is safe); Response (shake and shout); Shout for help; Airway (open with head-tilt/chin-lift); Breathing (look, listen, feel for up to 10 seconds for normal breathing); if absent, Call 999/2222 and get an AED; Compressions/CPR begin (30 compressions to 2 rescue breaths).

State the correct depth, rate, and compression-to-ventilation ratio for adult CPR.

Compress the centre of the chest to a depth of $5\text{-}6\ \text{cm}$ at a rate of $100\text{-}120$ compressions per minute, allowing full recoil between compressions, with a ratio of $30$ compressions to $2$ rescue breaths.

What does AED stand for, and what type of cardiac rhythms does it treat?

AED stands for Automated External Defibrillator. It delivers a shock only for 'shockable' rhythms: ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). It will not shock asystole or pulseless electrical activity (non-shockable rhythms).

Describe the safe steps for using an AED during a resuscitation attempt.

Turn the AED on as soon as it arrives and follow its voice prompts; expose and dry the chest; attach pads as pictured (one below the right clavicle, one in the left mid-axillary line); ensure no one touches the patient while it analyses; if a shock is advised, ensure everyone is clear (including oxygen removed) and deliver the shock; resume CPR immediately for 2 minutes until prompted again.

What safety precautions are required before delivering an AED shock?

Ensure no one is touching the patient ('stand clear'), remove or move oxygen away from the chest, avoid placing pads over jewellery, medication patches, or implanted devices (place at least $8\ \text{cm}$ away), and dry the chest and shave excessive hair if needed so pads adhere. Confirm 'clear' before pressing the shock button.

In a hospital, what number is typically called to summon the resuscitation team, and what information should be given?

The standard UK in-hospital emergency number is 2222. The caller states the type of emergency (e.g. cardiac arrest), the exact location (ward/bay/room), and any other relevant details so the resuscitation team and equipment can attend immediately.

What structured tool is recommended for handing over a patient after cardiac arrest (or any deterioration)?

SBAR: Situation (who/where and the immediate problem), Background (relevant history and events leading up), Assessment (current observations, ABCDE findings, what you think is wrong), and Recommendation (what you need or what should happen next).

What is urinalysis, and which dipstick parameters are routinely assessed?

Urinalysis is the physical, chemical and sometimes microscopic examination of urine. A reagent dipstick assesses pH, specific gravity, protein, glucose, ketones, blood, leucocytes, nitrites, bilirubin and urobilinogen, providing screening clues to infection, diabetes, renal and liver disease.

On urinalysis, what do positive nitrites and leucocytes together suggest?

They suggest a urinary tract infection: nitrites indicate gram-negative bacteria (e.g. E. coli) that convert dietary nitrate to nitrite, and leucocytes indicate the presence of white cells/pyuria from infection. A urine sample (MSU) is usually sent for culture to confirm.

How is a midstream specimen of urine (MSU) correctly collected?

The patient cleans the genital area, begins voiding to flush the urethra, then catches the middle portion of the stream in a sterile container without touching the inside, and finishes voiding into the toilet. The sample is labelled, sent promptly, or refrigerated to avoid bacterial overgrowth.

Describe the procedure for capillary blood glucose monitoring.

Perform hand hygiene and gain consent; ensure the patient's hands are clean and warm; check the meter is calibrated and the strips are in date; prick the side of a fingertip with a single-use lancet; discard the first drop if advised; apply blood to the test strip; read and record the result; safely dispose of the lancet in a sharps bin; document and act on the reading.

State the normal fasting capillary blood glucose range and the thresholds defining hypoglycaemia.

A normal fasting blood glucose is roughly $4\text{-}7\ \text{mmol/L}$ (often quoted as $4\text{-}5.5\ \text{mmol/L}$ fasting). Hypoglycaemia is defined as a blood glucose below $4\ \text{mmol/L}$ ('four is the floor'), requiring prompt treatment with fast-acting carbohydrate.

How should hypoglycaemia in a conscious, able-to-swallow adult be treated, and what is the immediate goal?

Give $15\text{-}20\ \text{g}$ of fast-acting carbohydrate (e.g. $150\text{-}200\ \text{mL}$ pure fruit juice, or glucose tablets/gel), recheck blood glucose after $10\text{-}15$ minutes, and repeat up to 3 times if still $<4\ \text{mmol/L}$. Once above $4\ \text{mmol/L}$, give a long-acting carbohydrate snack to prevent recurrence.

Describe the correct technique for using a metered-dose inhaler (MDI).

Remove the cap and shake the inhaler; breathe out gently and fully; place the mouthpiece between the lips forming a seal; begin a slow deep inhalation while pressing the canister once; continue inhaling slowly and fully; hold the breath for about 10 seconds; breathe out gently; wait about 30 seconds before a second puff. A spacer improves delivery and coordination.

How is a peak flow meter used and what does it measure?

It measures Peak Expiratory Flow Rate (PEFR), the fastest rate of air a person can forcibly exhale, in litres per minute ($\text{L/min}$). The patient stands, sets the marker to zero, takes a full deep breath, seals the lips around the mouthpiece, and blows out as hard and fast as possible. The best of three attempts is recorded and compared with predicted/personal-best values.

Why should the mouth be rinsed after using an inhaled corticosteroid?

Rinsing the mouth (and spitting out) after an inhaled corticosteroid removes residual drug deposited in the mouth and throat, reducing the risk of oral thrush (oral candidiasis) and hoarseness/dysphonia.

Describe the key steps for administering a subcutaneous insulin (or anticoagulant) injection.

Check the prescription, drug, dose and expiry; confirm patient identity and consent; perform hand hygiene and don gloves; select and rotate the site (abdomen, thigh, upper arm); for insulin, do not aspirate or massage; pinch a skinfold; insert at $45\text{-}90^{\circ}$; inject slowly; wait a few seconds then withdraw; dispose of the needle in a sharps bin; document and observe.

Why is injection-site rotation important for subcutaneous insulin, and what occurs without it?

Rotating sites prevents lipohypertrophy (thickened, lumpy fatty tissue) and lipoatrophy. Repeatedly injecting the same spot causes lipohypertrophy, which leads to erratic, unpredictable insulin absorption and poor glycaemic control.

What is the purpose of catheter (urinary) care, and what are its key infection-prevention principles?

Catheter care maintains a clean, patent, closed drainage system to prevent catheter-associated urinary tract infection (CAUTI). Key principles: aseptic insertion, keep the system closed, perform daily meatal hygiene with soap and water, keep the bag below bladder level and off the floor, ensure free drainage, maintain hand hygiene, and review/remove the catheter as soon as no longer needed.

Describe the safe procedure for removing an indwelling urinary catheter.

Explain and gain consent; perform hand hygiene and don gloves/apron; attach a syringe to the balloon (inflation) port and aspirate/deflate the balloon fully to remove all the sterile water; ask the patient to relax/breathe and gently withdraw the catheter; check it is intact; provide hygiene; encourage fluids; and monitor and document the first void (time and volume), watching for retention.

What is a fluid balance chart and how is the overall balance calculated?

A fluid balance chart records all measured fluid intake (oral, IV, enteral) and all output (urine, vomit, drains, stoma, etc.) over a period, usually 24 hours. $$\text{Fluid balance} = \text{Total intake} - \text{Total output}$$ A positive balance means more in than out; a negative balance means more out than in.

What urine output indicates adequate renal perfusion in an adult, and what threshold signals oliguria/concern?

Adequate output is approximately $0.5\ \text{mL/kg/hour}$ or more (commonly around $30\text{-}50\ \text{mL/hour}$ for an average adult). Oliguria is an output below $0.5\ \text{mL/kg/hour}$ (or less than about $30\ \text{mL/hour}$) and should prompt assessment and escalation as it may indicate hypovolaemia or acute kidney injury.