PRIORITY DECISION MAKING
A patient with a history of lung cancer presents with confusion, Na⁺ 118, and low urine output. What is the priority nursing action?
Initiate fluid restriction and monitor for SIADH-related hyponatremia.
A stroke patient initially improves, then suddenly develops headache and vomiting after thrombolytic therapy. What is occurring?
Intracranial hemorrhage.
A patient receiving Alteplase begins bleeding from IV sites. What is the underlying mechanism?
Systemic fibrinolysis breaking down clots.
Lung cancer → SIADH → hyponatremia → what neurologic complication?
Seizures.
A seizure patient stops seizing but is unresponsive. What is the next priority?
Assess airway and breathing.
A patient with pancreatitis becomes hypotensive (BP 86/50), tachycardic, and has decreased urine output. What is the FIRST intervention?
Initiate aggressive IV fluid resuscitation (Lactated Ringers).
A spinal cord injury patient develops sudden hypertension, bradycardia, and severe headache during catheterization. What is happening?
Autonomic dysreflexia.
A patient with ICP elevation is given Mannitol. Why must kidney function be monitored?
Risk of renal failure from osmotic diuresis.
SCI → bladder distention → autonomic dysreflexia → what life-threatening risk?
Stroke from severe hypertension.
A patient receiving chemo develops a fever. What is the FIRST action?
Notify provider and initiate neutropenic protocol.
A TBI patient becomes restless with ICP rising from 15 to 24 mm Hg. What is the priority action?
Reduce stimulation and ensure proper positioning (HOB elevated, head midline).
A meningitis patient becomes increasingly lethargic with unequal pupils. What complication is developing?
Increased ICP with possible brain herniation.
A chemotherapy patient receiving Vincristine develops numbness in hands and feet. Why?
Neurotoxicity causing peripheral neuropathy.
Pancreatitis → fluid shifts → what type of shock?
Hypovolemic shock.
A stroke patient’s BP is 210/110 prior to thrombolytics. What is the next step?
Administer Labetalol to lower BP safely.
A leukemia patient develops a fever of 101°F with ANC <500. What is the priority?
Treat as neutropenic fever — initiate antibiotics immediately.
A pancreatitis patient suddenly has decreased pain but worsening vitals and confusion. What does this indicate?
Pancreatic necrosis.
A patient with cirrhosis on Spironolactone develops hyperkalemia. Why?
Potassium retention due to aldosterone blockade.
Leukemia → neutropenia → what complication?
Severe infection/sepsis.
A patient with ascites has increasing abdominal pressure and dyspnea. What is the next step?
Prepare for paracentesis.
A patient with cirrhosis becomes acutely confused with asterixis. What is the priority intervention?
Administer Lactulose to reduce ammonia levels.
A liver failure patient becomes progressively drowsy and difficult to arouse. What stage are they progressing toward?
Hepatic coma.
A patient with seizures receives Lorazepam followed by Phenytoin. Why both?
Lorazepam stops acute seizure; phenytoin prevents recurrence.
Cirrhosis → portal hypertension → what life-threatening bleeding risk?
Esophageal varices rupture.
A TBI patient’s ICP spikes suddenly. What is the FIRST immediate intervention?
Reposition head (midline, elevate HOB) to improve venous drainage.