What Should the Nurse Do?
Your post-op patient is suddenly restless, tachycardic, and complaining of chest pain and shortness of breath
What is suspect a pulmonary embolism and initiate rapid response?
The patient develops slurred speech and unilateral weakness.
What is activate stroke protocol and notify the provider immediately?
A patient on telemetry develops a wide QRS with absent P waves and HR 180.
What is assess for ventricular tachycardia and prepare for code/defibrillation?
A patient with COPD becomes drowsy and has a PaCO₂ of 75.
What is notify provider; prepare for non-invasive ventilation or intubation?
An NG tube suddenly stops draining and the patient becomes distended.
What is check for kinks or displacement and irrigate per protocol?
Your patient receiving TPN suddenly becomes febrile with chills.
What is stop the TPN, assess for sepsis, and notify the provider?
A head trauma patient has clear fluid leaking from the nose.
What is suspect CSF leak and test fluid for glucose (Halo sign), elevate HOB, and notify provider?
A patient with chest pain has ST elevations in leads II, III, and aVF.
What is notify provider immediately; suspect inferior wall MI?
A trach patient is showing signs of respiratory distress, and breath sounds are absent on one side.
What is suspect dislodgement or obstruction and assess airway patency immediately?
A patient newly started on an ACE inhibitor reports swelling of lips and tongue.
What is suspect angioedema and stop the drug; secure the airway?
A patient’s blood pressure drops to 80/50 during a blood transfusion.
What is stop the transfusion, maintain IV access with NS, monitor vitals, and call the provider?
The patient is increasingly confused, vomiting, and has bradycardia.
What is suspect increased ICP and prepare for possible imaging and provider notification?
A patient with known CHF gains 5 lbs in 2 days and reports difficulty breathing.
What is assess for fluid overload, elevate HOB, and notify provider?
A patient receiving 100% O₂ suddenly becomes confused with low PaO₂.
What is suspect ARDS; notify provider and prepare for intubation?
The patient with diabetes is diaphoretic, shaky, and confused.
What is check blood glucose and administer rapid-acting carb?
A patient with a new trach is coughing violently and the trach tube dislodges.
What is insert the obturator and attempt to reinsert the trach; if unable, bag-valve mask over stoma and call for help?
A spinal cord injury patient suddenly develops hypertension, bradycardia, and flushing.
What is assess for triggers (e.g., bladder distention), raise HOB, and treat autonomic dysreflexia?
A patient post-cardiac cath complains of back pain and flank bruising.
What is suspect retroperitoneal bleeding and notify provider?
A burn patient develops hoarseness, drooling, and stridor.
What is anticipate airway compromise and prepare for intubation?
A patient with a hip replacement reports calf pain and has a positive Homan’s sign.
What is suspect DVT and notify provider immediately?
During a PCA pump check, the nurse finds the patient overly sedated with a RR of 6.
What is stop the PCA, assess airway, administer naloxone, and notify the provider?
Patient post-craniotomy has a unilateral fixed and dilated pupil.
What is suspect brain herniation and initiate emergency neuro response?
A patient on IV heparin has hematuria, bleeding gums, and an aPTT >100.
What is stop heparin and prepare to administer protamine sulfate?
A patient with chest trauma has tracheal deviation and absent breath sounds on one side.
What is suspect tension pneumothorax and prepare for needle decompression?
A patient on vancomycin develops flushing of face and neck during infusion.
What is slow the infusion rate and monitor for Red Man Syndrome?