Who to see first
Four patients arrive at the emergency department. Which patient requires immediate intervention: a patient with DKA and Kussmaul respirations, a patient with COPD and an oxygen saturation of 89% on their prescribed baseline oxygen, a patient with a new onset of stridor after thyroidectomy, or a patient with heart failure and bilateral crackles?
New-onset stridor after thyroidectomy.
A patient taking lisinopril develops swelling of the tongue and lips. What is the priority nursing action?
Stop lisinopril and initiate emergency airway management.
A patient with renal failure has a potassium of 6.8 mEq/L. Which ECG change is most concerning?
Peaked T waves.
A pregnant patient at 34 weeks reports severe headache, blurred vision, and right upper quadrant pain. What complication should the nurse suspect?
Severe preeclampsia.
A patient with schizophrenia states, "The government implanted a device in my brain." What is the most therapeutic response?
"That sounds frightening. I don't see evidence of an implanted device, but I want to understand what you're experiencing."
A nurse receives report on four patients. Which patient should be assessed first: a patient with potassium 6.1 mEq/L and peaked T waves, a patient with sodium 119 mEq/L and mild headache, a patient with hemoglobin 7.4 g/dL and fatigue, or a patient with BP 184/102 and no symptoms?
Potassium 6.1 mEq/L with peaked T waves.
A patient taking digoxin reports nausea, yellow-green halos, and weakness. Their potassium is 3.0 mEq/L. What complication is occurring, and why does the potassium level increase the risk?
Digoxin toxicity.
A patient with SIADH has a sodium of 116 mEq/L and begins having a seizure. What is the priority intervention?
Protect the airway and anticipate IV hypertonic 3% saline.
A patient receiving magnesium sulfate has absent deep tendon reflexes and a respiratory rate of 9/min. What should the nurse do first?
Stop magnesium sulfate immediately and prepare to administer calcium gluconate.
A patient taking an MAOI eats aged cheese and develops a severe headache, palpitations, and BP of 210/112. What complication should the nurse suspect?
Hypertensive crisis from an MAOI-tyramine interaction.
A postoperative patient suddenly becomes restless, tachycardic, and tachypneic. Their SpO₂ is 91%. The surgical dressing is dry. What complication should the nurse suspect, and what is the priority assessment?
Suspect pulmonary embolism.
A patient receiving heparin develops a platelet count decrease from 240,000 to 95,000/mm³. What adverse reaction should the nurse suspect, and what is the priority action?
Heparin-induced thrombocytopenia (HIT). Stop all heparin and notify the provider.
A patient with DKA has a glucose of 580 mg/dL, pH of 7.18, and potassium of 5.8 mEq/L. Why can the patient still have a total-body potassium deficit despite an elevated serum potassium?
Total-body potassium is depleted despite elevated serum potassium.
Immediately after delivery, a patient develops heavy vaginal bleeding. The uterus is boggy and displaced to the right. What is the priority nursing intervention?
Perform fundal massage.
A patient with borderline personality disorder tells the nurse, "If you leave me alone, I'll cut myself." What is the nurse's priority response?
Immediately assess suicide and self-harm risk and maintain safety.
Four hours after receiving morphine, a patient is difficult to arouse, has a respiratory rate of 7/min, and an oxygen saturation of 86%. What is the priority intervention?
Stop opioid administration, support ventilation, and administer naloxone as indicated.
A patient taking sertraline is prescribed linezolid. Several hours after administration, the patient develops agitation, hyperreflexia, diaphoresis, and inducible clonus. What is happening?
Serotonin syndrome.
A patient with acute kidney injury has a pH of 7.21, potassium of 6.5 mEq/L, and pulmonary edema. Which complication poses the most immediate threat, and what interventions should the nurse anticipate?
Hyperkalemia with ECG changes is an immediate threat.
A laboring patient receiving oxytocin develops recurrent late decelerations. What actions should the nurse take?
Stop oxytocin, reposition laterally, increase IV fluids as appropriate, and notify the provider
A patient with anorexia nervosa begins nutritional rehabilitation. Three days later, the patient develops weakness, confusion, and cardiac dysrhythmias. Which electrolyte imbalance should the nurse suspect?
Hypophosphatemia caused by refeeding syndrome
A nurse is caring for four patients: one with suspected bacterial meningitis and new petechiae, one with acute pancreatitis and calcium of 7.1 mg/dL, one with a GI bleed and BP 86/48, and one with a new unilateral facial droop that began 20 minutes ago. Which patient takes priority, and why?
GI bleed with BP 86/48.
A patient taking lithium develops diarrhea, coarse tremors, ataxia, and confusion. The lithium level is 2.1 mEq/L. Which intervention should the nurse anticipate, and why is neurological assessment essential?
Lithium toxicity. Hold lithium and notify the provider; anticipate IV fluids and possibly hemodialysis.
A patient with severe hypocalcemia develops laryngospasms, prolonged QT interval, and carpopedal spasms. Explain the pathophysiology behind these findings and identify the priority treatment
Severe symptomatic hypocalcemia.
A patient with severe preeclampsia develops sudden dyspnea, crackles, oxygen saturation of 84%, and pink frothy sputum. What life-threatening complication is occurring, and what is the priority response?
Acute pulmonary edema.
A patient with bipolar disorder taking lithium develops fever, muscle rigidity, altered mental status, and autonomic instability after haloperidol is added. Which two medication-related emergencies must the nurse differentiate, and what assessment findings help distinguish them?
Differentiate neuroleptic malignant syndrome (NMS) from serotonin syndrome.