Each case presents a real patient scenario with 6–7 linked clinical-judgment questions — exactly the NCSBN April 2026 NGN format. Bow-tie, matrix, cloze, trend, and extended-response items across all 6 CJMM layers.
The nurse reviews Mrs. Hayes' assessment findings. Which findings require IMMEDIATE nursing intervention?
The nurse is reviewing the patient's presentation to determine whether this represents a hypertensive EMERGENCY or hypertensive urgency. Select ALL findings from the patient's assessment that specifically indicate this is a hypertensive EMERGENCY rather than urgency.
The nurse is planning care for a patient admitted with severe acute pancreatitis (RANSON score 4). Which interventions are indicated?
The nurse is preparing to care for the burn patient immediately upon arrival.
The nurse is assessing a 24-year-old female with sickle cell disease (HbSS) admitted for vaso-occlusive crisis triggered by dehydration. Which clinical findings indicate the need for immediate priority nursing interventions?
The nurse is performing the initial assessment on arrival. Select ALL findings that confirm the opioid toxidrome and require immediate intervention.
The nurse is reviewing the patient's initial assessment findings.
The nurse completes the admission assessment of Marcus T. Select ALL findings that indicate decompensated liver failure with an active complication.
The nurse reviews Mr. M.'s clinical profile at 0300. Select ALL patient factors that contribute to his HIGH fall risk and require nursing action.
Dorothy Simmons is a 58-year-old female on POD2 after partial bowel resection for Stage II colon cancer. PMH: hypertension on hydrochlorothiazide 25 mg daily. She received bowel prep and was NPO pre-op. Post-op she has morphine PCA and ondansetron. Vital signs: BP 128/78, HR 92, Temp 37.6°C, SpO2 97
Tyler Morrison is a 19-year-old male with newly diagnosed Stage IV Burkitt lymphoma (bone marrow involvement). Started R-CODOX-M chemotherapy 18 hours ago. Allopurinol started only 12 hours before chemo (optimal 48-72 hours). Severe muscle cramps, nausea, anxiety. Vital signs: BP 108/72, HR 118, RR
Amanda Rodriguez is a 28-year-old female on TMP-SMX double-strength for UTI for 12 days. She presents with 5-day progressive painful skin lesions, sore throat, painful eyes, and difficulty swallowing. Vital signs: BP 108/72, HR 118, RR 22, Temp 38.6°C, SpO2 96% on RA. Exam: blistering/epidermal deta
Marcus Jennings is a 34-year-old male brought by EMS after a high-speed MVC. He was an unrestrained driver. GCS 12. Vital signs: BP 72/44, HR 138, RR 28, Temp 35.1°C (hypothermic), SpO2 94% on 15L NRB. Skin: pale, cool, mottled extremities. FAST exam: free fluid in Morrison's pouch, perisplenic, and
Sophia Martinez is a 9-year-old female diagnosed with polyarticular JIA (rheumatoid factor negative) 2 years ago. She has symmetric involvement of the small joints of both hands and feet, bilateral wrists, and bilateral knees. She is ANA positive. Current medications: methotrexate 15 mg/m² PO weekly
Taylor Nguyen is a 17-year-old female admitted to the inpatient eating disorders unit after her school counselor noted marked weight loss over 8 months. Her parents report she has been restricting all intake to <400 kcal/day for 4 weeks. Tallent: 5'5". Current weight: 41 kg. BMI: 13.8 kg/m² (severel
Patricia Evans is a 68-year-old female with a bioprosthetic mitral valve replacement 8 years ago complicated by multiple valve thromboses, leading to a mechanical valve replacement 4 years ago. She has been on warfarin 7.5 mg daily (target INR 2.5-3.5 for mechanical valve). She presents to the antic
Raymond Davis is a 56-year-old male who underwent 4-vessel CABG surgery 7 days ago for multivessel coronary artery disease. Post-operatively, he received unfractionated heparin (UFH) 5,000 units subcutaneous q8h for DVT prophylaxis. Post-op labs were monitored: platelets Day 1: 212,000; Day 3: 182,0
David Park is a 58-year-old male who underwent emergency left-sided descending colostomy and Hartmann's procedure for perforated sigmoid diverticulitis with abscess formation (later found to be cancer). He had no pre-operative ostomy education due to the emergent nature of surgery. His wife is suppo
CASE 5 — Mr. Jerome Ellis, 34-year-old male with HbSS (sickle cell disease). Hydroxyurea 1,500 mg daily, folic acid. 3-day bilateral thigh/lumbar/knee pain 10/10. Today: chest pain, SOB, new fever, cough. BP 128/82, HR 114, RR 28, T 38.7C, SpO2 88% (room air). CXR: NEW bilateral lower lobe infiltrat
CASE 7 — Mr. Derek Lawson, 22-year-old male, collegiate football player. Diving into shallow pool → flexion-compression injury. BP 78/44, HR 48 (bradycardia), RR 14 (shallow), T 35.4C. SpO2 88% on 100% O2 via BVM. Complete motor and sensory paralysis all four limbs (quadriplegia). Loss of sensation
CASE 8 — Lily Chen, 4-year-old female. Incomplete vaccinations (parents declined Hib vaccine). 6-hour rapid progression: sore throat → drooling → high fever → difficulty swallowing → tripod position. T 40.1C, HR 168, RR 38, SpO2 93% on room air. Toxic appearance; tripod position (leaning forward, ha
Jerome Elliott is a 67-year-old male, POD #7 following 3-vessel CABG. He has been on UFH flush protocols and subcutaneous prophylactic UFH 5,000 units TID since surgery. Morning labs today: Platelets 62,000/mm³ (POD 0: 220,000 → POD 5: 148,000 → POD 6: 89,000 → POD 7: 62,000). New right arm swelling
Sofia Reyes is a 24-year-old female with no significant PMH who presents with a 5-day history of nausea, vomiting, jaundice, and confusion. Roommate found an empty bottle of extra-strength acetaminophen (500 tablets, recently purchased). Sofia is disoriented to time and place (GCS 12, E3V3M6). VS: B
Marcus Webb is a 29-year-old male with a C6 ASIA A (complete) spinal cord injury from a diving accident 6 weeks ago. He is in the rehabilitation unit using an indwelling Foley catheter. At 1430, the nurse finds him flushed and diaphoretic in his power wheelchair with a '10/10 headache' and nausea. V
Kevin Park is a 28-year-old male with no significant PMH presenting for elective ACL repair. Anesthesia was induced with propofol and succinylcholine, and maintenance was started with sevoflurane (an inhaled halogenated anesthetic). Approximately 25 minutes into the procedure: ETCO₂ has risen from 3
DeShawn Miller is a 34-year-old male with sickle cell disease (HbSS) admitted for an elective red blood cell exchange transfusion. A second unit is infusing (started 20 minutes ago at 125 mL/hr). With approximately 120 mL infused, DeShawn calls the nurse: 'Something is wrong — I have a crushing pain
Terrence Cole is a 16-year-old male brought to the ED at 2:15 AM. He woke from sleep 2.5 hours ago with sudden onset of severe right scrotal pain. He denies trauma, sexual activity, and urinary symptoms. He has had two prior episodes of sudden scrotal pain that resolved spontaneously. Assessment: VS
TREND ANALYSIS: Florence receives 3% hypertonic saline and benzodiazepine withdrawal protocol. Sodium correction trend: 0hr: Na 108, GCS 10, CIWA-Ar 16 4hr: Na 113, GCS 11, CIWA-Ar 12 (+5 mEq/L) 8hr: Na 116, GCS 13, CIWA-Ar 9 (+8 mEq/L) 12hr: Na 118, GCS 14, CIWA-Ar 7 (+10 mEq/L, infusion slowed) 24
Patricia Wells is a 51-year-old female with a 6-year history of idiopathic pulmonary arterial hypertension (iPAH), managed on ambrisentan (endothelin receptor antagonist, 10 mg daily) and tadalafil (PDE-5 inhibitor, 40 mg daily). She presents to her cardiology clinic reporting 3 weeks of worsening d
Emmett Rivera is a 28-year-old male with cystic fibrosis (homozygous F508del) on elexacaftor/tezacaftor/ivacaftor (Trikafta) for 14 months — FEV₁ improved from 52% to 71% predicted. He presents for hospital admission with 3 weeks of worsening dyspnea, increased green sputum production, decreased exe
[NURSE'S NOTES] Patient: Jerome Elliott, 67-year-old male Setting: Surgical Step-Down Unit, Post-Op Day 7 from CABG Clinical Context: Jerome is a 67-year-old male, POD #7 following 3-vessel CABG for triple-vessel coronary artery disease. He has been on unfractionated heparin (UFH) flush protocols an
[NURSE'S NOTES] Patient: Darnell Washington, 58-year-old male Setting: Medical Step-Down Unit Clinical Context: Darnell Washington is a 58-year-old male with a history of stage 3b CKD (baseline creatinine 2.8 mg/dL, baseline K+ 4.8 mEq/L), T2DM, and hypertension. He was admitted yesterday for manage
[NURSE'S NOTES] Patient: Sofia Reyes, 24-year-old female Setting: Emergency Department → Medical ICU Clinical Context: Sofia Reyes is a 24-year-old female with no significant past medical history who presents to the ED with a 5-day history of nausea, vomiting, jaundice, and confusion. Her roommate r
[NURSE'S NOTES] Patient: Marcus Webb, 29-year-old male Setting: Rehabilitation Unit Clinical Context: Marcus Webb is a 29-year-old male who sustained a C6 ASIA A (complete) spinal cord injury in a diving accident 6 weeks ago. He has no voluntary motor function or sensation below the C6 level. He is
[NURSE'S NOTES] Patient: Kevin Park, 28-year-old male Setting: Operating Room → ICU Clinical Context: Kevin Park is a 28-year-old male with no significant PMH presenting for elective anterior cruciate ligament (ACL) repair. He has no known allergies and no family history of anesthesia problems that
[NURSE'S NOTES] Patient: DeShawn Miller, 34-year-old male Setting: Medical-Surgical Unit Clinical Context: DeShawn Miller is a 34-year-old male with sickle cell disease (HbSS) who is admitted for an elective red blood cell exchange transfusion to reduce HbS from 82% to <30% before an upcoming laparo
[NURSE'S NOTES] Patient: Miriam Goldstein, 72-year-old female Setting: Emergency Department Clinical Context: Miriam Goldstein is a 72-year-old female who presents to the ED via private car with her husband. She appears in significant distress, holding her right eye. Chief complaint: "Terrible pain
[NURSE'S NOTES] Patient: Terrence Cole, 16-year-old male Setting: Emergency Department Clinical Context: Terrence Cole is a 16-year-old male brought to the ED by his mother at 2:15 AM. He woke from sleep 2.5 hours ago with sudden onset of severe right scrotal pain. He denies trauma, sexual activity,
[NURSE'S NOTES] Patient: Brianna Hayes, 34-year-old female Setting: Operating Room → PACU → Medical ICU Clinical Context: Brianna Hayes is a 34-year-old female with spina bifida (myelomeningocele, repaired at birth) undergoing elective laparoscopic bladder augmentation under general anesthesia. She
Marcus Thompson, 19-year-old male, presents to the ED with a 24-hour history of periumbilical pain that has migrated to the right lower quadrant. He rates pain 8/10, worse with movement. Assessment: T 38.3C, HR 102, BP 118/74, RR 18. Abdomen: rigid, rebound tenderness at McBurney's point, positive R
Mrs. Johansson, 44-year-old female with known Graves' disease, stopped her methimazole 3 weeks ago without consulting her provider. She presents to the ED brought by her husband who reports she has been 'acting strange' for 2 days. Assessment: T 39.8C, HR 148 (atrial fibrillation on monitor), BP 162
Ms. Osei, 31-year-old G3P2 at 34 weeks gestation with chronic hypertension on labetalol, presents to L&D triage with sudden onset severe abdominal pain described as 'board-like,' dark vaginal bleeding, and decreased fetal movement over the past hour. Assessment: T 37.1C, BP 158/102, HR 114, RR 20, u
Mr. Rivera, 55-year-old male, is on post-operative day 5 following left total knee replacement. He was ambulatory yesterday. Today he reports sudden onset shortness of breath that woke him from sleep. Assessment: SpO2 89% on room air, RR 28, HR 116 (sinus tachycardia), BP 108/72, T 37.4C, left calf
Mrs. Monroe, 72-year-old female with HFrEF (EF 30%), HTN, and atrial fibrillation on metoprolol, lisinopril, spironolactone, and digoxin, presents to the ED with 3-day worsening shortness of breath, 6-pound weight gain, and bilateral ankle swelling. Assessment: RR 26, SpO2 90% on room air, HR 96 (ir
Mrs. Kowalski, 84-year-old female, is post-operative day 2 following right hip hemiarthroplasty for a femoral neck fracture. She has T2DM (Hgb A1c 9.2%), malnutrition (albumin 2.4 g/dL), urinary incontinence, and is minimally mobile. The nurse performs a Braden Scale assessment: Sensory Perception 2
Mr. Mendoza, 71-year-old male with known 5.8cm abdominal aortic aneurysm (AAA), hypertension, and 40-pack-year smoking history, is brought to the ED by ambulance after sudden onset severe tearing abdominal pain radiating to his back. He reports feeling 'like something ripped.' Assessment: BP 82/44 m
Ms. Torres, 35-year-old female, is transported to the burn center after a house fire. She was rescued after approximately 10 minutes in the burning structure. Assessment: Airway patent, voice hoarse, facial hair singed, soot around nares and mouth, carbonaceous sputum. Burns: face and neck (partial
Mr. Park, 32-year-old male with no significant past medical history, is 20 minutes into an elective left knee arthroscopy under general anesthesia with sevoflurane and succinylcholine for intubation. The circulating nurse notes the following sudden changes: EtCO2 rising to 78 mmHg (was 38), temperat
Ms. Nair, 28-year-old female, is brought to the ED by her roommate 8 hours after reportedly ingesting 'the entire bottle' of acetaminophen (approximately 25g). She appears anxious but alert. Assessment: T 37.1C, HR 108, BP 118/74, RR 18, SpO2 99%. She reports nausea and right upper quadrant discomfo
Ms. Williams, 24-year-old female with HbSS sickle cell disease, presents to the ED with a 2-day history of severe bilateral leg pain (8/10) and lower back pain (9/10). She reports she has been sick with a URI for the past week. Assessment: T 38.4C, HR 112, BP 108/68, RR 22, SpO2 94% on room air. She
Ms. Patel, 29-year-old female with known Crohn's disease (terminal ileum involvement), presents with a 10-day history of worsening right lower quadrant pain, 8-10 bloody stools per day, fever, and 12-pound weight loss. She ran out of her infliximab infusion 6 weeks ago. Assessment: T 38.6C, HR 118,
Ms. Chen, 32-year-old otherwise healthy female, presents with a 1-week history of easy bruising, petechiae on bilateral lower extremities and trunk, and one episode of epistaxis lasting 20 minutes. She reports a viral URI 3 weeks ago that resolved. No medications, no alcohol. Assessment: BP 118/74,
Mr. Hayes, 34M with bee sting allergy, develops anaphylaxis with stridor, shock, and angioedema despite initial EpiPen. Requires repeat epinephrine, airway management, and biphasic observation.
Baby Noah, 6-week-old male with projectile non-bilious vomiting, weight loss, and hypochloremic hypokalemic metabolic alkalosis. Requires IV NS+KCl resuscitation before laparoscopic pyloromyotomy.
Mr. Rashid, 22M with closed tibial fracture developing ACS — opioid-resistant pain, tense compartment, paresthesia. Requires splint removal, emergency fasciotomy, rhabdomyolysis monitoring.
Mrs. Barton, 67F with acute eye pain after dark theater. IOP 58 mmHg, mid-dilated pupil. Requires pilocarpine, IV acetazolamide, and laser peripheral iridotomy.
Mr. Whitfield, 72M on warfarin (INR 3.8) with left basal ganglia hemorrhage. Requires 4F-PCC reversal, IV nicardipine, dysphagia assessment.
Mrs. Jefferson, 74F with EF 32%, BNP 1240, bilateral crackles, JVD, edema. Requires IV furosemide, sodium restriction, GDMT initiation with ACEi/BB/MRA.
Mr. Hassan, 55M POD2 after hemicolectomy with basilar atelectasis progressing to HAP. IS coaching, multimodal analgesia, pulmonary hygiene bundle.
Mr. Carter, 52M with new Stage 2 HTN, smoking, obesity, sedentary. Lisinopril + lifestyle education, ACE cough, NSAID interaction.
Ms. Kim, 42F with TSH 18.4, low T4, positive TPO-Ab. Levothyroxine titration, empty-stomach administration, calcium interaction.
Mr. Allen, 56M with hematemesis and melena from NSAID/aspirin PUD. Resuscitation, urgent EGD, H. pylori testing.
Mrs. Vega, 66F with new AFib, CHA2DS2-VASc 4. Apixaban, metoprolol, medication access barriers.
Ms. Santos, 34F vegetarian with menorrhagia. Oral iron technique, vitamin C, calcium interaction, GI side effects.
Mr. Chen, 38M with GAD-7 16. Sertraline + CBT, alcohol self-medication, relaxation techniques.
Ms. Walsh, 26F with classic UTI. First-line antibiotics, phenazopyridine, recurrence prevention strategies.
Mr. Bennett, 62M with recurrent gout. Low-dose colchicine, ULT timing, HCTZ→losartan, dietary modification.
Mr. Santos, 41M with lipase 4820, SIRS. Aggressive LR, hypocalcemia monitoring, infected necrosis, step-up approach.
Mr. Reeves, 32M heroin OD. Naloxone titration, COWS-guided buprenorphine, naloxone rescue kit, MAT engagement.
Mrs. Kim, 64F T-score -2.8 on steroids. Bisphosphonate technique, calcium timing, AFF warning signs.
Mr. Foster, 58M pre-op TKR. NPO violation, metformin this morning, surgical site verification, post-op atelectasis.
Mrs. Okafor, 55F chronic LBP on oxycodone. Unexpected benzodiazepine, multimodal revision, combined overdose.
Mr. Park, 29M C5 SCI with AD from Foley obstruction. Upright position, trigger removal, atropine contraindicated.
Mrs. Foster, 34F with TSI-positive Graves. Methimazole + propranolol, three treatment options, agranulocytosis emergency.
Ms. Diane Okafor is a 48-year-old African American female with stage III ER/PR-positive, HER2-negative invasive ductal carcinoma of the left breast. S...
Mrs. Gloria Hernandez is a 78-year-old Hispanic female admitted 2 days ago for an elective right total hip arthroplasty (THA) following a 2-year histo...
Mr. Earl Watkins is an 81-year-old African American male brought to the primary care clinic by his daughter, Cheryl. She reports that her father has f...
Mrs. Keiko Tanaka is a 52-year-old Japanese American female who underwent a total thyroidectomy 18 hours ago for papillary thyroid carcinoma. She is o...
Ms. Priya Patel, a 28-year-old female, presents to her primary care provider reporting fatigue, weight gain of 15 pounds over 4 months despite no chan...
Mrs. Eleanor Witten, an 82-year-old female, is admitted to the orthopedic unit after undergoing right hip hemiarthroplasty (femoral head replacement) ...
A community health nurse is running a free blood pressure screening clinic at a local community center in a low-income neighborhood. The clinic serves...
Mr. Anthony Bello, a 55-year-old male, returns to the surgical unit from the PACU (Post-Anesthesia Care Unit) following an uncomplicated elective lapa...
A 34-year-old female with a 3-year history of Graves' disease presents to the ED 9 days after self-discontinuing methimazole 20 mg BID due to cost. Chief complaints: palpitations, diaphoresis, agitation, and vomiting x 24 hours. Vitals on arrival: T 40.2°C (104.4°F), HR 168 irregular, BP 162/58, RR 32, SpO2 94% room air. Exam: diffuse goiter with thrill and bruit, mild bilateral proptosis, tremor, warm moist skin. Burch-Wartofsky Point Scale is being calculated. Labs pending include TSH, free T4
A 42-year-old male with a documented penicillin allergy (reported as rash) is on the pre-operative surgical unit awaiting elective cholecystectomy. Two minutes after cefazolin 2g IV infusion begins for surgical prophylaxis, the nurse performs a rapid head-to-toe assessment. Vital signs: BP 72/40 mmHg, HR 128 bpm, RR 28 breaths/min, SpO2 94% on room air.
Complete the Bow-Tie clinical reasoning diagram for a 29-year-old male in status epilepticus. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 22-year-old female with acute acetaminophen toxicity. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 19-year-old male with suspected compartment syndrome. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Admission assessment: BP 178/112 mmHg (repeated 15 minutes later 176/110), HR 98, RR 20, T 37.0 C, SpO2 97% on room air. The patient reports a severe occipital headache rated 8/10 that is unrelieved by acetaminophen, and describes intermittent blurred vision and 'spots' in her visual fields. Urine dip 3+ protein, spot protein/creatinine ratio 0.45. Labs: platelets 89,000/uL, AST 186 U/L (baseline 18), ALT 142 U/L (baseline 15), serum creatinine 1.1 mg/dL (baseline 0.6), LDH 312 U/L, uric acid 7.
The patient was pulled from a house fire approximately 45 minutes ago. Primary survey is complete; she is hemodynamically borderline (HR 128, BP 100/72) and normothermic after external rewarming. The burn team is performing a systematic depth and TBSA assessment using the American Burn Association (ABA) Rule of Nines and Lund-Browder chart for documentation. On exam: the ENTIRE anterior thorax and abdomen (9% + 9% = 18%) show dry, leathery, charred-white eschar that is insensate to pinprick and
Complete the Bow-Tie clinical reasoning diagram for a 58-year-old male with acute gastrointestinal hemorrhage. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 45-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 48-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 24-year-old patient. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 72-year-old male with hyperosmolar hyperglycemic state. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 34-year-old male with tension pneumothorax. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 44-year-old male with acute severe epigastric pain, elevated pancreatic enzymes, and hemodynamic instability. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
A 74-year-old female is transferred from a skilled nursing facility to the hospital after staff noted acute confusion, lethargy, and refusal to eat over the past 6 hours. She has a 3-day history of dysuria and urinary frequency. On arrival, BP does not improve after initial assessment. The ED physician activates the SEP-1 protocol.
Complete the Bow-Tie clinical reasoning diagram for a 30-year-old primigravida at term presenting with spontaneous rupture of membranes and acute fetal bradycardia. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 26-year-old at 10 weeks gestation with severe nausea and vomiting. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for an unresponsive adult found on a park bench. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this community health patient with infectious disease. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this leadership and delegation scenario. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this patient safety and transfusion scenario. Select the condition, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for this complex prioritization and delegation scenario. Select the patient requiring immediate assessment, TWO priority nursing actions, and TWO parameters to monitor.
It is 0700 change of shift on a 28-bed medical-surgical unit. You are the charge nurse. Staffing for the 0700-1900 shift includes: yourself (RN, 8 years experience), two staff RNs (one with 3 years experience, one newly licensed 4 months out of orientation), one LPN/LVN (6 years experience), and two UAPs (unlicensed assistive personnel, both experienced). The unit has 22 clients at the start of shift. The outgoing night charge nurse gives you the following SBAR summary of assignment consideratio
You are a staff RN on a 0700-1900 shift on a medical-surgical unit. At 0945, you enter the room of a 58-year-old client who was admitted yesterday for cellulitis and started on IV vancomycin. You note that the client's IV pump is running. You look at the pump settings to confirm the next dose is infusing correctly, and you realize with alarm that the pump is programmed at 2000 mg/hour for a vancomycin dose of 2000 mg — meaning the full dose is being infused over 1 hour instead of the ordered 2-
A 78-year-old woman with a UTI and multiple fall risk factors is admitted for treatment. The nurse must establish the fall prevention plan.
The oncoming nurse is receiving hand-off on a post-thyroidectomy client who recently received IV opioid analgesia.
An intubated ICU client has already partially self-extubated once and continues to reach for his endotracheal tube despite less restrictive interventions.
The client admitted for cellulitis related to IV drug use expresses anticipated judgment from healthcare providers.
The family of a dying client requests that specific religious and cultural practices be observed during and after death.
A nurse observes another staff member speak harshly to a confused older client who appears distressed by the interaction.
A 66-year-old right-handed woman is brought to the emergency department by her husband at 1145. Her husband states she was working in the garden when she suddenly sat down, and when he approached she could not speak clearly and her right arm went limp. He reports the last time she was clearly her normal self was at 1045, when they had coffee together — putting 'last known well' at one hour before arrival. Past medical history: hypertension, hyperlipidemia, atrial fibrillation (on warfarin, INR
A 58-year-old man arrives at the emergency department at 0815 by private vehicle, accompanied by his wife. He reports sudden onset of chest pain that began approximately 45 minutes ago while he was getting ready for work. He describes the pain as "crushing pressure, like someone standing on my chest," radiating to his left arm and jaw. Associated symptoms: shortness of breath, nausea, and sweating. He denies prior similar episodes. Past medical history: hypertension (on lisinopril), hyperlipide
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