Best FIRST Intervention
BG = 52 mg/dL, patient awake and alert
Give 15 g fast-acting carbohydrate
Hypoglycemic patient becomes confused
Check glucose -> give 15 g carb ->recheck in 15 min
Fresh surgical incision care (What are you not supposed to do?)
Avoid heat application
After glucose treatment BG now 95
Answer: Intervention effective
Pain remains 7/10 after medication
Answer: Reassess and implement additional interventions
Leakage with coughing priority intervention
Answer: Teach Kegel exercises
RR 8 with COPD history and increasing drowsiness
Support airway & improve ventilation
COPD patient increasingly drowsy
Assess airway -> check ABGs -> apply oxygen as ordered
Hypoglycemic unconscious patient
Do NOT give oral glucose
After repositioning redness still blanchable
Answer: Skin intact and improving
SpO₂ unchanged after oxygen
Answer: Escalate respiratory support
Vomiting 3 days priority electrolyte imbalance
Answer: Metabolic alkalosis risk
Non-blanchable redness on sacrum
Reposition patient immediately (q2hr)
Pressure injury risk patient immobile
Reposition --> skin inspection --> moisture control --> nutrition support
Fluid overload patient with crackles
Avoid rapid IV fluids
After oxygen therapy SpO₂ increased from 88% to 95%
Answer: Intervention effective
Pressure injury worsens despite repositioning
Answer: Add pressure-relief surface
DKA patient breathing rapidly intervention priority
Answer: Administer insulin and fluids per protocol
400
Patient hyperventilating with tingling fingers
Slow breathing using coaching techniques
Suspected fluid deficit
Assess Vitals --> check urine output --> start fluids per order
Respiratory acidosis patient sedated
Answer: Avoid respiratory depressants
Avoid respiratory depressants
After analgesic patient pain decreased from 8 → 3
Answer: Expected outcome achieved
Confusion persists after glucose correction
Answer: Assess for alternative causes
COPD patient retaining CO₂ outcome expectation
Answer: Improved LOC after ventilation support
Post-op patient HR 104, RR 24 during repositioning
Treat pain before further mobility attempts
Post-op fever + tachycardia + shallow respirations
Answer: Assess incision → assess lungs → notify provider if worsening
Pressure injury risk patient immobile
Answer: Avoid massage over bony prominences
After fluids urine output increased from 20 mL/hr → 45 mL/hr
Answer: Fluid deficit improving
Urine output remains low after fluids
Answer: Notify provider immediately
Post-op immobile patient with Braden score 15 priority diagnosis
Post-op immobile patient with Braden score 15 priority diagnosis
Answer: Risk for impaired skin integrity