Department 08 · 25 scenarios

Cardiology

See the risk. Understand the response.
Practise the reasoning you will carry to the bedside.

Plain English Primary sources Students & tutors

From routine safety to critical change

Learn the reasoning. Follow your local clinical pathway. These are fictional teaching cases, not patient-specific treatment instructions. Adult, pregnancy, pediatric and neonatal responses differ. Use the population-specific pathway and verified weight where required. Use current facility protocols, authorized orders and your scope of practice. Students work under supervision. In a real emergency, activate clinical help rather than consult this page.

How to use these cases Read the cues before opening the actions. Name your first priority, then compare your reasoning. The difficulty describes learning complexity; even an introductory case can involve a serious risk.

5 introductory5 intermediate5 difficult10 extremely difficult

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Learning complexity

25 of 25 scenarios

Open a scenario to explore its actions25 original cases

Heart failure & fluid balance

The fluid balance misses drinks brought by family

Introductory

The situation

A patient with heart failure appears to exceed the agreed intake plan, but the record excludes drinks brought by visitors. They are gaining weight and feel more breathless when lying flat.

What should catch your attention

Incomplete intake record
Weight trend
New orthopnea

Your immediate priority

Clarify all intake respectfully, assess congestion and communicate the trend to the clinical team.

01Incomplete intake record
02Clarify all intake respectfully, assess congestion and communicate the trend to the clinical team.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Clarify all intake respectfully, assess congestion and communicate the trend to the clinical team. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Check the accuracy of subsequent intake/output and response to the prescribed plan. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not blame the patient or independently impose a stricter fluid allowance. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: the fluid balance misses drinks brought by family. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

© 2026 RN Clarity · Lumiere Labs. All rights reserved. Original scenarios and diagrams are for personal learning. Do not copy, screenshot, print, repost, sell or reproduce them without written permission, except where applicable law permits. Cited guidance belongs to its respective owners.

Medication safety

The home medicine list contains two names for one drug

Introductory

The situation

During cardiac admission, a patient lists a brand name and generic name as separate medicines. They believe both should continue. The discharge list is being prepared.

What should catch your attention

Possible duplication
Different names same ingredient
Transition of care

Your immediate priority

Reconcile the ingredient, dose and intended regimen with pharmacy or the prescriber.

01Possible duplication
02Reconcile the ingredient, dose and intended regimen with pharmacy or the prescriber.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Reconcile the ingredient, dose and intended regimen with pharmacy or the prescriber. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
2
Pause and verify
Check two approved identifiers, the current order, allergy history, formulation, last dose and the actual medicine supplied. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
3
Clarify with the team
Contact the prescriber and pharmacist about the discrepancy. Explain urgent omitted-dose risks and obtain a documented safe plan. [1]
Why it matters Both giving the wrong medicine and delaying a time-critical medicine can harm the patient.
4
Close the loop
Record the resolved order, administration decision and monitoring plan; tell the receiving team about any remaining uncertainty. [1]
Why it matters A corrected chart must reach the bedside and the next handover to prevent repetition.

What to look for next

Use teach-back to confirm the final list and removal of unintended duplication. Watch for adverse effects or effects of a delayed dose according to the medicine. Escalate any deterioration rather than wait for routine pharmacy review.

Avoid this shortcut

Do not make a medication decision from the number of names alone. Do not guess a dose, crush an unsuitable formulation or silently copy conflicting medication lists.

A clear way to hand it over

“I am calling about this new concern: the home medicine list contains two names for one drug. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Reconciliation means comparing medicine lists and resolving differences.

Sources behind the actions 2 primary references

NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.
NICE · CG183: Drug allergy—recommendations
Confirm and document allergy history before drug administration; distinguish allergy from other adverse reactions.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Mobility & fall prevention

New dizziness during early cardiac rehabilitation

Introductory

The situation

An older patient becomes dizzy during the first supervised walk after several medicine changes. They are still speaking and the therapist stops immediately.

What should catch your attention

Activity-related dizziness
Recent medicine changes
Fall risk

Your immediate priority

Support safe rest, check symptoms and physiology and communicate the response before the next exercise attempt.

01Activity-related dizziness
02Support safe rest, check symptoms and physiology and communicate the response before the next exercise attempt.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Support safe rest, check symptoms and physiology and communicate the response before the next exercise attempt. [1]
Why it matters A fall can happen while staff are trying to finish an otherwise routine activity.
2
Make movement safe
Stay with the person, help them sit or lie safely and call for assistance. Use the assessed transfer equipment and assistance level. [1]
Why it matters A fall can happen while staff are trying to finish an otherwise routine activity.
3
Assess before restarting
Check symptoms, vital signs, medication timing and mobility compared with baseline. Escalate persistent faintness, injury or new neurological signs. [1]
Why it matters The cause may be illness or a medicine effect; an alarm alone does not address it.
4
Update the plan
Arrange an individualized falls and mobility review, explain how to request help and hand over the new assistance needs. [1]
Why it matters Matching supervision and equipment to the person reduces preventable repeat exposure.

What to look for next

Follow the revised mobilization and medicine review plan. Recheck symptoms and safe transfer ability before another attempt. New chest pain, breathlessness, bleeding or reduced alertness warrants urgent clinical help.

Avoid this shortcut

Do not push through symptoms to meet a rehabilitation target. Do not continue an unsafe walk, use a blanket restraint or assume dizziness always means dehydration.

A clear way to hand it over

“I am calling about this new concern: new dizziness during early cardiac rehabilitation. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Baseline means the person’s usual function before this change.

Sources behind the actions 2 primary references

NICE · NG249: Falls assessment and prevention (2025)
Individual inpatient fall assessment, dizziness, mobility and lying/standing blood pressure when appropriate.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

Daily weights are not comparable

Introductory

The situation

A patient with heart failure was weighed on different scales with different clothing over several days. A large apparent change triggers concern, but intake and symptoms also need review.

What should catch your attention

Measurement inconsistency
Trend may be misleading
Clinical findings still matter

Your immediate priority

Obtain a safe comparable measurement and assess congestion, perfusion and fluid records.

01Measurement inconsistency
02Obtain a safe comparable measurement and assess congestion, perfusion and fluid records.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Obtain a safe comparable measurement and assess congestion, perfusion and fluid records. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Document the conditions of measurement and interpret the trend with the team. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not alter treatment based on an obviously inconsistent weight alone. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: daily weights are not comparable. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Communication & discharge

The patient cannot explain when chest symptoms need help

Introductory

The situation

A patient preparing for cardiac discharge says they will wait until tomorrow if chest pressure returns because today's ECG was reassuring. Their home symptom-response plan is unclear.

What should catch your attention

Unsafe delay intention
Earlier test does not cover future symptoms
Discharge education gap

Your immediate priority

Explain the individualized urgent symptom plan in plain language and use teach-back, including local emergency contact instructions.

01Unsafe delay intention
02Explain the individualized urgent symptom plan in plain language and use teach-back, including local emergency contact instructions.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Explain the individualized urgent symptom plan in plain language and use teach-back, including local emergency contact instructions. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
2
Make the explanation accessible
Ask the person’s preferred language and communication needs. Use a qualified interpreter for clinical decisions when needed. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
3
Use a small teach-back
Explain one important step in plain language and ask the person to show or describe it in their own words. [1]
Why it matters This tests how clearly we explained the task without making the person feel examined.
4
Repair the gap
Rephrase, demonstrate and repeat the check. Provide an accessible written plan and a named contact for problems. [1]
Why it matters A usable plan supports safer decisions after the nurse is no longer beside the patient.

What to look for next

Confirm understanding and access to the written plan and prescribed medicines. Confirm the person can identify the next step and warning signs. Resolve missing equipment, support or follow-up before an unsafe discharge proceeds.

Avoid this shortcut

Do not promise that a reassuring current test prevents a later emergency. Do not rely on children to interpret or label a person noncompliant because of a language barrier.

A clear way to hand it over

“I am calling about this new concern: the patient cannot explain when chest symptoms need help. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Teach-back asks the person to explain the plan so staff can check their explanation.

Sources behind the actions 2 primary references

AHRQ · Teach-back: patient and family engagement
Check the clarity of an explanation by asking patients to describe the plan in their own words.
US HHS Office of Minority Health · National CLAS Standards: communication and language assistance
Competent language assistance; avoid using untrained people or children as interpreters.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

Increasing edema with reduced urine

Intermediate

The situation

A patient receiving ordered diuretics has worsening ankle edema but much less urine today. Pressure is lower and creatinine has risen. The visible swelling is not the only issue.

What should catch your attention

Congestion
Reduced perfusion possible
Kidney change

Your immediate priority

Seek review of the combined congestion, pressure and renal findings before routine escalation of fluid or diuretics.

01Congestion
02Seek review of the combined congestion, pressure and renal findings before routine escalation of fluid or diuretics.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek review of the combined congestion, pressure and renal findings before routine escalation of fluid or diuretics. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Follow ordered kidney, electrolyte and output monitoring after changes. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not use edema alone to choose treatment. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: increasing edema with reduced urine. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Rhythm & perfusion

New atrial fibrillation with tolerable symptoms

Intermediate

The situation

The monitor suggests a new irregular fast rhythm. The patient reports mild palpitations but is currently well perfused. Their onset time and anticoagulation history are uncertain.

What should catch your attention

New irregular rhythm
Current stability must be assessed
Timing and medicines affect decisions

Your immediate priority

Obtain prompt clinical assessment and diagnostic ECG, documenting symptom onset and relevant medication history.

01New irregular rhythm
02Obtain prompt clinical assessment and diagnostic ECG, documenting symptom onset and relevant medication history.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Obtain prompt clinical assessment and diagnostic ECG, documenting symptom onset and relevant medication history. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
2
Check patient and rhythm
Assess responsiveness, pulse, pressure, chest symptoms and breathing; verify the rhythm with reliable monitoring. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
3
Call and prepare
Activate emergency help for instability; begin CPR and AED or defibrillator care when indicated and prepare trained cardioversion or pacing support under protocol. [1]
Why it matters Different rhythms and pulse states require different treatments.
4
Review reversible causes
Assist the team with ECG, electrolytes, medicine review and ordered treatment, with continued monitoring. [1]
Why it matters Correcting the rhythm without addressing causes can lead to recurrence.

What to look for next

Watch for worsening perfusion and follow the authorized rate/rhythm and stroke-prevention plan. Trend pulse, pressure, consciousness and ECG after treatment. Report recurrence or post-treatment deterioration immediately.

Avoid this shortcut

Do not independently cardiovert or assume all irregular rhythms are atrial fibrillation. Do not give a rhythm drug from a monitor label alone or confuse synchronized cardioversion with an unsynchronized shock.

A clear way to hand it over

“I am calling about this new concern: new atrial fibrillation with tolerable symptoms. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An arrhythmia is an abnormal rhythm; perfusion describes whether the circulation supports the organs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Advanced Life Support
Pulse and perfusion assessment, rhythm-directed rescue and resuscitation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

A small catheter-site leak after angiography

Intermediate

The situation

After vascular access for a cardiac procedure, a dressing develops new oozing. The patient has antithrombotic exposure and reports local tenderness, but is currently stable.

What should catch your attention

Recent vascular procedure
New bleeding
Antithrombotic exposure

Your immediate priority

Assess the site and perfusion and use the procedure-specific hemostasis and escalation pathway.

01Recent vascular procedure
02Assess the site and perfusion and use the procedure-specific hemostasis and escalation pathway.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Assess the site and perfusion and use the procedure-specific hemostasis and escalation pathway. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Track the size of any swelling and subsequent pressure, pulse and discomfort. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not ignore repeated oozing or improvise compression that compromises limb circulation. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: a small catheter-site leak after angiography. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Glucose safety

Low glucose before breakfast on the cardiac ward

Intermediate

The situation

A patient with diabetes received insulin but breakfast was delayed for a test. They become shaky and sweaty and the checked glucose is low. They can swallow safely.

What should catch your attention

Delayed meal
Insulin exposure
Confirmed low glucose

Your immediate priority

Use the authorized hypoglycemia treatment route and review the test/meal/medicine timing with the team.

01Delayed meal
02Use the authorized hypoglycemia treatment route and review the test/meal/medicine timing with the team.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Use the authorized hypoglycemia treatment route and review the test/meal/medicine timing with the team. [1]
Why it matters The brain needs glucose; giving food to an unconscious person risks aspiration.
2
Assess and act
Check glucose and consciousness. If the person can swallow safely, give the protocol’s rapid carbohydrate; if not, call urgent help and use the authorized non-oral rescue pathway. [1]
Why it matters The brain needs glucose; giving food to an unconscious person risks aspiration.
3
Check the response
Recheck glucose at the protocol interval, commonly 15 minutes after oral treatment, and repeat or escalate as directed. [1]
Why it matters A single treatment can fail, and symptoms alone do not show that glucose has recovered.
4
Prevent recurrence
Review meal interruption, insulin or other medicines, kidney function and the next nutrition plan with the team. [1]
Why it matters Correction without addressing the cause can lead to another episode soon afterwards.

What to look for next

Repeat glucose according to the protocol and monitor for recurrence. Continue prescribed glucose checks and observe alertness, swallowing and food intake. Some medicines can cause prolonged or recurrent hypoglycemia.

Avoid this shortcut

Do not postpone treatment until the test is finished. Do not give oral glucose to someone unable to swallow or change insulin orders independently.

A clear way to hand it over

“I am calling about this new concern: low glucose before breakfast on the cardiac ward. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hypoglycemia means blood glucose is too low for safe body function.

Sources behind the actions 2 primary references

NIDDK · Low blood glucose (hypoglycemia)
Rapid carbohydrate for a person who can swallow; reassessment after 15 minutes; severe episodes require emergency help.
American Diabetes Association · Diabetes Care in the Hospital: Standards of Care—2026
Nurse-initiated hospital hypoglycemia protocols, documentation, medication/meal review and prevention of recurrence.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Breathing & oxygen

Breathlessness and cough after a new oxygen need

Intermediate

The situation

A patient previously breathing comfortably now needs supplemental oxygen and coughs frequently. They have cardiac disease, but infection, edema and other causes remain possible.

What should catch your attention

Change in oxygen need
New respiratory symptoms
Cause not yet established

Your immediate priority

Assess work of breathing and perfusion, apply the prescribed oxygen plan and request clinical investigation.

01Change in oxygen need
02Assess work of breathing and perfusion, apply the prescribed oxygen plan and request clinical investigation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Assess work of breathing and perfusion, apply the prescribed oxygen plan and request clinical investigation. [1]
Why it matters A saturation number alone can miss exhaustion, carbon-dioxide retention or poor circulation.
2
Look at the patient
Assess work of breathing, respiratory rate, alertness, perfusion and oxygen saturation with a reliable signal. [1]
Why it matters A saturation number alone can miss exhaustion, carbon-dioxide retention or poor circulation.
3
Support and escalate
Use the prescribed oxygen target and delivery system. Call urgent respiratory help for increasing support needs, drowsiness or distress; prepare ordered blood gases. [1]
Why it matters Targeted oxygen treats low oxygen while blood gases and examination help guide ventilation decisions.
4
Check the equipment and response
Check supply, tubing, fit and connections; reassess symptoms and observations after changes and communicate the trend. [1]
Why it matters A disconnected system and worsening lung disease require different corrective actions.

What to look for next

Trend oxygen requirement and response to cause-specific ordered treatment. Watch alertness, respiratory effort and oxygen needs rather than saturation alone. A tiring patient can become quieter while becoming less safe.

Avoid this shortcut

Do not assume the diagnosis from the ward name. Do not withhold lifesaving oxygen in critical illness or assume every person with COPD has the same target.

A clear way to hand it over

“I am calling about this new concern: breathlessness and cough after a new oxygen need. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ventilation moves air; oxygenation transfers oxygen into blood.

Sources behind the actions 2 primary references

British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Cardiac ischemia

Recurrent chest pain after a coronary intervention

Difficult

The situation

Several hours after a coronary intervention, the patient develops renewed chest pressure and sweating. They describe it as similar to the original event. The access site looks stable.

What should catch your attention

Recurrent ischemic-type symptoms
Recent intervention
Access stability does not exclude cardiac complications

Your immediate priority

Activate urgent cardiac review, prepare ECG and communicate the procedure and medicine timeline.

01Recurrent ischemic-type symptoms
02Activate urgent cardiac review, prepare ECG and communicate the procedure and medicine timeline.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent cardiac review, prepare ECG and communicate the procedure and medicine timeline. [1]
Why it matters Heart ischemia does not always present as a classic crushing chest pain.
2
Recognize the pattern
Assess chest discomfort, breathlessness, sweating, nausea and circulation; call urgent clinical help for concerning or unstable symptoms. [1]
Why it matters Heart ischemia does not always present as a classic crushing chest pain.
3
Prepare time-sensitive assessment
Obtain a prompt ECG and ordered tests, monitoring and access using the local ACS pathway. [1]
Why it matters Early ECG and clinical review guide treatment; one normal tracing does not exclude all ACS.
4
Support ordered treatment
Check allergies, bleeding risk, current medicines and hemodynamics before protocol-directed medicines; prepare transfer if required. [1]
Why it matters Antiplatelet, nitrate and reperfusion decisions depend on diagnosis, contraindications and circulation.

What to look for next

Maintain rhythm/perfusion observation and record treatment response. Reassess pain, breathing, rhythm and perfusion. Report recurrence or evolving ECG changes even after symptoms settle.

Avoid this shortcut

Do not wait for routine morning tests or dismiss the pain as anxiety. Do not dismiss symptoms as anxiety, give nitrates despite a contraindication or promise a normal ECG rules out a heart attack.

A clear way to hand it over

“I am calling about this new concern: recurrent chest pain after a coronary intervention. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means tissue is not receiving enough blood and oxygen.

Sources behind the actions 2 primary references

AHA / ACC and collaborating societies · 2025 Acute Coronary Syndromes Guideline
Rapid ACS assessment and diagnostic/treatment pathways; antiplatelet and reperfusion decisions require clinical evaluation.
American Heart Association · Key patient messages: 2025 ACS Guideline
Chest discomfort, breathlessness, sweating and atypical symptoms warrant prompt assessment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

New back pain and hypotension after femoral access

Difficult

The situation

A patient after femoral arterial access develops back and abdominal pain, pallor and falling pressure. The groin dressing is dry and visible swelling is minimal.

What should catch your attention

Possible concealed bleeding
Recent arterial access
Dry dressing falsely reassuring

Your immediate priority

Activate urgent post-procedure bleeding assessment and provide the procedural and antithrombotic details.

01Possible concealed bleeding
02Activate urgent post-procedure bleeding assessment and provide the procedural and antithrombotic details.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent post-procedure bleeding assessment and provide the procedural and antithrombotic details. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Monitor circulation and prepare ordered investigations, products or intervention. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not rule out major bleeding because the skin site looks dry. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: new back pain and hypotension after femoral access. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

Heart failure symptoms worsen while the patient is lying flat

Difficult

The situation

A patient becomes distressed and cannot lie flat. They cough, use accessory muscles and need more oxygen. Their pressure remains high, but urine has declined.

What should catch your attention

Acute congestion symptoms
Increasing work of breathing
Not safe to await routine review

Your immediate priority

Arrange urgent cardiac/respiratory review and support positioning, prescribed oxygen or ventilation and ordered treatment.

01Acute congestion symptoms
02Arrange urgent cardiac/respiratory review and support positioning, prescribed oxygen or ventilation and ordered treatment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Arrange urgent cardiac/respiratory review and support positioning, prescribed oxygen or ventilation and ordered treatment. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Track breathing, pressure, urine and renal/electrolyte response. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not force a flat position or assume all breathlessness requires fluid. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: heart failure symptoms worsen while the patient is lying flat. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Rhythm & perfusion

Syncope with an intermittently slow rhythm

Difficult

The situation

A patient briefly loses consciousness and has a very slow rhythm on monitoring. They wake but remain pale and weak. A prior recording showed only occasional pauses.

What should catch your attention

Syncope
Intermittent rhythm can still be dangerous
Poor perfusion

Your immediate priority

Call emergency cardiac review, maintain monitoring and prepare the authorized bradycardia/pacing pathway.

01Syncope
02Call emergency cardiac review, maintain monitoring and prepare the authorized bradycardia/pacing pathway.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call emergency cardiac review, maintain monitoring and prepare the authorized bradycardia/pacing pathway. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
2
Check patient and rhythm
Assess responsiveness, pulse, pressure, chest symptoms and breathing; verify the rhythm with reliable monitoring. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
3
Call and prepare
Activate emergency help for instability; begin CPR and AED or defibrillator care when indicated and prepare trained cardioversion or pacing support under protocol. [1]
Why it matters Different rhythms and pulse states require different treatments.
4
Review reversible causes
Assist the team with ECG, electrolytes, medicine review and ordered treatment, with continued monitoring. [1]
Why it matters Correcting the rhythm without addressing causes can lead to recurrence.

What to look for next

Document the symptom-rhythm correlation and be ready for loss of pulse. Trend pulse, pressure, consciousness and ECG after treatment. Report recurrence or post-treatment deterioration immediately.

Avoid this shortcut

Do not regard recovery of consciousness as proof that the risk has passed. Do not give a rhythm drug from a monitor label alone or confuse synchronized cardioversion with an unsynchronized shock.

A clear way to hand it over

“I am calling about this new concern: syncope with an intermittently slow rhythm. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An arrhythmia is an abnormal rhythm; perfusion describes whether the circulation supports the organs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Advanced Life Support
Pulse and perfusion assessment, rhythm-directed rescue and resuscitation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Time-critical neurology

New facial weakness while waiting for cardiac discharge

Difficult

The situation

A patient suddenly has facial droop and trouble speaking while packing to leave. Their last normal conversation was witnessed by family and they recently had a cardiac procedure.

What should catch your attention

Sudden focal change
Witnessed timing
Recent procedure affects specialist decisions

Your immediate priority

Activate stroke response, obtain the witnessed last-known-well time and communicate procedure/medicine exposure.

01Sudden focal change
02Activate stroke response, obtain the witnessed last-known-well time and communicate procedure/medicine exposure.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate stroke response, obtain the witnessed last-known-well time and communicate procedure/medicine exposure. [1]
Why it matters Timing and an accurate baseline affect specialist assessment and potential treatment selection.
2
Record time and findings
Note last known well and new face, arm, speech, vision or balance changes; assess airway, breathing and glucose. [1]
Why it matters Timing and an accurate baseline affect specialist assessment and potential treatment selection.
3
Call the stroke pathway
Arrange immediate stroke-team review and urgent imaging; report anticoagulants, recent procedures and seizure history. [1]
Why it matters Imaging is needed to distinguish causes and guide reperfusion or bleeding management.
4
Protect ongoing care
Keep oral intake paused until an approved swallow assessment; follow ordered pressure, oxygen and transfer plans. [1]
Why it matters Aspiration and inappropriate treatment can add harm while the stroke pathway is underway.

What to look for next

Prepare urgent imaging and specialist assessment with serial neurological observation. Trend neurological findings and consciousness, document changes with times and ensure the receiving team knows last known well.

Avoid this shortcut

Do not delay because discharge paperwork is complete. Do not give food to test swallowing, delay for a complete history or independently lower pressure.

A clear way to hand it over

“I am calling about this new concern: new facial weakness while waiting for cardiac discharge. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Last known well is the last time the person was known to be at their usual neurological baseline.

Sources behind the actions 2 primary references

American Heart Association / American Stroke Association · 2026 Guideline for early management of acute ischemic stroke
Time-sensitive stroke assessment, urgent imaging and specialist selection for reperfusion treatment.
American Speech-Language-Hearing Association · Swallowing screening
Stop a screen when dysphagia risk appears; refer for assessment. Bedside signs do not reliably exclude aspiration.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Heart failure & fluid balance

Cardiogenic shock with cool limbs and confusion

Extremely difficult

The situation

A patient with acute cardiac disease develops hypotension, cold extremities, confusion and reduced urine. Crackles are present. Additional fluid has been suggested simply because the pressure is low.

What should catch your attention

Shock signs
Congestion also present
Fluid response uncertain

Your immediate priority

Activate emergency cardiac/critical-care assessment and communicate both low perfusion and pulmonary congestion.

01Shock signs
02Activate emergency cardiac/critical-care assessment and communicate both low perfusion and pulmonary congestion.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate emergency cardiac/critical-care assessment and communicate both low perfusion and pulmonary congestion. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
2
Recognize the pattern
Compare breathlessness, oxygen need, edema, weight, pressure and urine with baseline and assess medication or fluid changes. [1]
Why it matters Congestion and impaired circulation can coexist, so one measurement cannot determine treatment.
3
Escalate the change
Seek urgent clinical review for respiratory distress, hypotension or poor perfusion and prepare the prescribed cardiac investigations. [1]
Why it matters Acute heart failure requires diagnosis and treatment matched to the current physiology.
4
Deliver and review the plan
Give ordered diuretics or respiratory support with the required kidney, electrolyte and output monitoring. [1]
Why it matters Treatment can improve congestion while also changing pressure, kidney function and electrolytes.

What to look for next

Follow the expert-directed hemodynamic and respiratory plan with close reassessment. Track work of breathing, perfusion, urine and laboratory trends after treatment; report deterioration rather than chasing urine volume alone.

Avoid this shortcut

Do not give repeated routine boluses without evaluating the response and congested lungs. Do not give a routine fluid bolus for low urine or a diuretic for every swollen patient without assessment and authorization.

A clear way to hand it over

“I am calling about this new concern: cardiogenic shock with cool limbs and confusion. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Congestion means fluid accumulation; perfusion means blood reaching organs.

Sources behind the actions 3 primary references

NICE · CG187: Acute heart failure—recommendations
Specialist assessment, ordered IV diuretics with renal/urine monitoring and ventilatory support for selected severe respiratory failure.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
British Thoracic Society · Oxygen use in adults in healthcare and emergency settings
Targeted oxygen therapy, urgent blood gases for hypercapnia risk and oxygen during critical illness without unsafe withholding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Rhythm & perfusion

A dangerous rhythm begins after electrolyte loss

Extremely difficult

The situation

Following heavy diuresis, a patient has sustained ventricular rhythm disturbance and dizziness. Recent laboratory results show electrolyte depletion, but the current pulse and pressure determine urgency.

What should catch your attention

Potential electrolyte trigger
Sustained rhythm disturbance
Perfusion at risk

Your immediate priority

Activate urgent rhythm management, verify pulse/perfusion and report the electrolyte results for prescribed correction.

01Potential electrolyte trigger
02Activate urgent rhythm management, verify pulse/perfusion and report the electrolyte results for prescribed correction.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent rhythm management, verify pulse/perfusion and report the electrolyte results for prescribed correction. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
2
Check patient and rhythm
Assess responsiveness, pulse, pressure, chest symptoms and breathing; verify the rhythm with reliable monitoring. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
3
Call and prepare
Activate emergency help for instability; begin CPR and AED or defibrillator care when indicated and prepare trained cardioversion or pacing support under protocol. [1]
Why it matters Different rhythms and pulse states require different treatments.
4
Review reversible causes
Assist the team with ECG, electrolytes, medicine review and ordered treatment, with continued monitoring. [1]
Why it matters Correcting the rhythm without addressing causes can lead to recurrence.

What to look for next

Monitor ECG and repeat ordered electrolytes through treatment. Trend pulse, pressure, consciousness and ECG after treatment. Report recurrence or post-treatment deterioration immediately.

Avoid this shortcut

Do not correct electrolytes alone while ignoring an unstable rhythm. Do not give a rhythm drug from a monitor label alone or confuse synchronized cardioversion with an unsynchronized shock.

A clear way to hand it over

“I am calling about this new concern: a dangerous rhythm begins after electrolyte loss. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An arrhythmia is an abnormal rhythm; perfusion describes whether the circulation supports the organs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Advanced Life Support
Pulse and perfusion assessment, rhythm-directed rescue and resuscitation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Rhythm & perfusion

An organized rhythm after collapse does not mean a pulse

Extremely difficult

The situation

During conversation, a patient collapses and gasps. The ECG remains organized. Trained rapid assessment does not find a pulse.

What should catch your attention

Sudden collapse
Abnormal breathing
Electrical activity without effective circulation

Your immediate priority

Start the arrest response and resuscitation immediately, with team-led assessment of reversible causes.

01Sudden collapse
02Start the arrest response and resuscitation immediately, with team-led assessment of reversible causes.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Start the arrest response and resuscitation immediately, with team-led assessment of reversible causes. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
2
Check patient and rhythm
Assess responsiveness, pulse, pressure, chest symptoms and breathing; verify the rhythm with reliable monitoring. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
3
Call and prepare
Activate emergency help for instability; begin CPR and AED or defibrillator care when indicated and prepare trained cardioversion or pacing support under protocol. [1]
Why it matters Different rhythms and pulse states require different treatments.
4
Review reversible causes
Assist the team with ECG, electrolytes, medicine review and ordered treatment, with continued monitoring. [1]
Why it matters Correcting the rhythm without addressing causes can lead to recurrence.

What to look for next

Record response and transitions in rhythm and circulation. Trend pulse, pressure, consciousness and ECG after treatment. Report recurrence or post-treatment deterioration immediately.

Avoid this shortcut

Do not delay compressions because the monitor looks organized. Do not give a rhythm drug from a monitor label alone or confuse synchronized cardioversion with an unsynchronized shock.

A clear way to hand it over

“I am calling about this new concern: an organized rhythm after collapse does not mean a pulse. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An arrhythmia is an abnormal rhythm; perfusion describes whether the circulation supports the organs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Advanced Life Support
Pulse and perfusion assessment, rhythm-directed rescue and resuscitation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Severe allergic reaction

A severe contrast-associated reaction during a cardiac procedure

Extremely difficult

The situation

During a cardiac investigation, the patient develops rapidly worsening breathing, swelling and hypotension after contrast exposure. The reaction is affecting several systems.

What should catch your attention

Acute exposure
Airway compromise
Shock

Your immediate priority

Activate anaphylaxis resuscitation and assist the authorized first-line epinephrine and airway/circulatory support.

01Acute exposure
02Activate anaphylaxis resuscitation and assist the authorized first-line epinephrine and airway/circulatory support.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate anaphylaxis resuscitation and assist the authorized first-line epinephrine and airway/circulatory support. [1]
Why it matters A rash may be absent; life-threatening allergy is identified by organ compromise.
2
Recognize severe compromise
Stop the suspected trigger when possible; call emergency help for sudden airway, breathing or circulation problems after an exposure. [1]
Why it matters A rash may be absent; life-threatening allergy is identified by organ compromise.
3
Use the emergency protocol
Give intramuscular epinephrine/adrenaline under the authorized pathway, support airway and oxygenation, and position safely without standing the patient. [1]
Why it matters Epinephrine addresses dangerous airway and circulatory effects; antihistamines do not replace it.
4
Prepare continued care
Arrange ordered fluids, repeat treatment and observation; report the exposure, symptoms and treatment times. [1]
Why it matters Symptoms can persist or recur, requiring monitored follow-up rather than immediate reassurance.

What to look for next

Monitor response and recurrence, documenting the exact product and timing. Continuously review breathing, perfusion and response. Escalate ongoing compromise and arrange allergy documentation and follow-up after stabilization.

Avoid this shortcut

Do not wait to prove an immune mechanism before emergency treatment. Do not wait for a rash, use antihistamines as sole emergency treatment or let a hypotensive person walk.

A clear way to hand it over

“I am calling about this new concern: a severe contrast-associated reaction during a cardiac procedure. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Anaphylaxis is a serious systemic allergic reaction; adrenaline and epinephrine are two names for the same medicine.

Sources behind the actions 1 primary references

Resuscitation Council UK · Emergency treatment of anaphylactic reactions
IM adrenaline/epinephrine first-line, positioning, emergency support and observation; antihistamines do not treat airway or circulatory compromise.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

Major bleeding after antithrombotic treatment

Extremely difficult

The situation

A cardiac patient develops hematemesis and marked hypotension after antithrombotic therapy. Preventing thrombosis remains important, but the current bleeding is life-threatening.

What should catch your attention

Visible major bleeding
Shock
Competing thrombosis/bleeding risk

Your immediate priority

Activate major-bleeding and cardiac specialist review together and identify all antithrombotic drugs and times.

01Visible major bleeding
02Activate major-bleeding and cardiac specialist review together and identify all antithrombotic drugs and times.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate major-bleeding and cardiac specialist review together and identify all antithrombotic drugs and times. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Track resuscitation, blood products and the documented specialist plan for interruption/reversal and later reassessment. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not independently stop or restart the entire regimen without an urgent authorized plan. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: major bleeding after antithrombotic treatment. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Electrolyte & rhythm safety

Severe hyperkalemia masquerades as another cardiac event

Extremely difficult

The situation

A patient with kidney impairment develops weakness and new broad conduction changes. A critical potassium result arrives while the team is also evaluating chest discomfort.

What should catch your attention

Critical potassium
ECG change
Multiple possible cardiac threats

Your immediate priority

State the potassium emergency immediately and assist the authorized cardiac protection, potassium-lowering and removal plan.

01Critical potassium
02State the potassium emergency immediately and assist the authorized cardiac protection, potassium-lowering and removal plan.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
State the potassium emergency immediately and assist the authorized cardiac protection, potassium-lowering and removal plan. [1]
Why it matters Severe potassium elevation can cause fatal rhythm changes, sometimes without dramatic symptoms.
2
Assess cardiac risk
Check symptoms, monitoring and ECG promptly; report the potassium result, kidney function and sample concerns without delaying care for an unstable patient. [1]
Why it matters Severe potassium elevation can cause fatal rhythm changes, sometimes without dramatic symptoms.
3
Support ordered stabilization
Prepare protocol-directed calcium when indicated and potassium-shifting or removal treatment; follow independent medicine checks. [1]
Why it matters Calcium protects the heart temporarily but does not remove potassium from the body.
4
Monitor treatment complications
Track repeat potassium and ECG, and glucose checks after insulin-based treatment, following the full monitoring period. [1]
Why it matters Potassium can rebound and treatment can cause delayed hypoglycemia.

What to look for next

Continue rhythm and glucose monitoring and verify repeat potassium. Escalate ECG deterioration, recurrent high potassium or low glucose. Confirm the plan for potassium removal and medicine review.

Avoid this shortcut

Do not let an ACS label obscure dangerous electrolyte toxicity. Do not assume a normal ECG excludes danger or that calcium has corrected the potassium level.

A clear way to hand it over

“I am calling about this new concern: severe hyperkalemia masquerades as another cardiac event. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hyperkalemia means potassium in blood is too high.

Sources behind the actions 1 primary references

UK Kidney Association · Management of hyperkalaemia in adults (updated July 2026)
Urgent ECG/monitoring, calcium for indicated cardiac toxicity, potassium-lowering treatment and glucose monitoring after insulin.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Monitoring & clinical assessment

The patient suddenly deteriorates after cardiac surgery

Extremely difficult

The situation

A patient recovering from cardiac surgery develops falling pressure, increasing breathlessness and poor perfusion. Chest drain output has unexpectedly fallen. A surgical complication is possible despite little visible loss.

What should catch your attention

Post-cardiac surgery
Shock
Drain trend changed

Your immediate priority

Call the cardiac surgical emergency team immediately, communicate the drain and physiological trends and prepare urgent expert assessment.

01Post-cardiac surgery
02Call the cardiac surgical emergency team immediately, communicate the drain and physiological trends and prepare urgent expert assessment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call the cardiac surgical emergency team immediately, communicate the drain and physiological trends and prepare urgent expert assessment. [1]
Why it matters Artifact can trigger alarms, but a real deterioration may also be present.
2
Assess actual physiology
Check consciousness, pulse, breathing and symptoms directly; compare observations with the display. [1]
Why it matters Artifact can trigger alarms, but a real deterioration may also be present.
3
Check the measurement
Inspect sensors, connections and the approved setup; obtain an alternative valid measurement when needed. [1]
Why it matters A treatment based on an inaccurate value can harm the patient.
4
Keep monitoring useful
Escalate a confirmed abnormality and document the reliable trend; restore appropriate alarm limits and hand over any fault. [1]
Why it matters Alarms support assessment only when they are audible, correctly configured and acted on.

What to look for next

Track response and maintain the prescribed monitoring and rescue readiness. Recheck after correcting the measurement and after treatment; persistent clinical concern needs review even with a normal display.

Avoid this shortcut

Do not manipulate or strip a drain independently or wait for a large drainage volume. Do not silence repeated alarms without assessing the patient or independently recalibrate an unfamiliar device.

A clear way to hand it over

“I am calling about this new concern: the patient suddenly deteriorates after cardiac surgery. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Artifact means a misleading signal produced by something other than the patient’s true physiology.

Sources behind the actions 1 primary references

NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Clot & breathing emergency

Possible PE complicates recovery from a cardiac procedure

Extremely difficult

The situation

A patient with reduced mobility develops sudden pleuritic pain, hypoxia and hypotension. They also have a recent vascular access site and antithrombotic therapy.

What should catch your attention

Acute respiratory/circulatory change
Thrombotic risk
Procedure-related bleeding risk

Your immediate priority

Activate urgent PE/cardiac assessment and communicate the complete procedure and medicine history.

01Acute respiratory/circulatory change
02Activate urgent PE/cardiac assessment and communicate the complete procedure and medicine history.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent PE/cardiac assessment and communicate the complete procedure and medicine history. [1]
Why it matters A clot in the lung circulation can reduce oxygen transfer and overload the heart.
2
Assess and call
Assess breathing, chest symptoms, saturation, pulse and pressure; obtain immediate help for collapse or shock. [1]
Why it matters A clot in the lung circulation can reduce oxygen transfer and overload the heart.
3
Prepare urgent investigation
Follow the local PE pathway for monitoring, access and ordered imaging or tests; report surgery, immobility and bleeding risk. [1]
Why it matters Clinical assessment determines which tests and treatments are appropriate.
4
Support prescribed treatment
Prepare anticoagulation or emergency specialist treatment as directed, using medicine and bleeding checks. [1]
Why it matters Treating clot risk must be balanced with bleeding and the person’s hemodynamic state.

What to look for next

Maintain respiratory and perfusion monitoring and prepare ordered diagnostics/rescue. Trend breathing, oxygen needs and circulation; new syncope, hypotension or increasing distress requires further immediate escalation.

Avoid this shortcut

Do not choose anticoagulation solely from a suspected diagnosis without the bleeding assessment. Do not massage a suspected clot, make the breathless patient walk or delay shock care for routine testing.

A clear way to hand it over

“I am calling about this new concern: possible PE complicates recovery from a cardiac procedure. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An embolus is material, often a blood clot, that travels and blocks a blood vessel.

Sources behind the actions 2 primary references

NICE · NG158: Venous thromboembolic diseases—recommendations
Urgent PE diagnostic pathway, ordered anticoagulation and emergency management of hemodynamic instability.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Safe critical-care transfer

Acute deterioration during a planned diagnostic transfer

Extremely difficult

The situation

A cardiac patient becomes hypotensive and severely breathless just as transport arrives for imaging. Their previous handover described them as stable.

What should catch your attention

Condition changed before transport
Old stability assessment
Transfer resources may be inadequate

Your immediate priority

Pause the transfer, activate urgent review and reassess destination, escort and monitoring requirements.

01Condition changed before transport
02Pause the transfer, activate urgent review and reassess destination, escort and monitoring requirements.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Pause the transfer, activate urgent review and reassess destination, escort and monitoring requirements. [1]
Why it matters A location change can interrupt lifesaving support and may require a different escort or stabilization first.
2
Check readiness
Review current instability, airway, oxygen or infusion needs and why transfer is needed; involve the responsible clinician. [1]
Why it matters A location change can interrupt lifesaving support and may require a different escort or stabilization first.
3
Prepare equipment and people
Confirm enough oxygen, charged devices, medicines, secure lines, emergency equipment and a trained escort for the person’s support needs. [1]
Why it matters The transport environment has fewer backup resources than the original clinical area.
4
Hand over the real status
Communicate trends, orders, treatment limits, device settings and contingency plans to the accepting team. [1]
Why it matters A destination and referral alone do not provide continuity of critical care.

What to look for next

Resume only with a documented safe transport/rescue plan appropriate to current support needs. Monitor during travel and reassess immediately on arrival; verify all connections, prescribed settings and continuing treatments.

Avoid this shortcut

Do not let a booked scan determine clinical readiness. Do not send an unstable supported patient with an unprepared escort or assume devices will keep working because they did on the ward.

A clear way to hand it over

“I am calling about this new concern: acute deterioration during a planned diagnostic transfer. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A contingency plan specifies what to do if the person or equipment deteriorates during transfer.

Sources behind the actions 2 primary references

WHO · Clinical checklists: emergency and transfer care
Structured handover and verification of support during emergency/transfer care.
AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Rhythm & perfusion

Resuscitation status is unclear during collapse

Extremely difficult

The situation

A patient collapses and has no effective breathing or pulse. Family members give conflicting accounts of treatment wishes, and no applicable current limitation is immediately available.

What should catch your attention

Arrest
Conflicting informal information
Verified care plan not available

Your immediate priority

Activate the emergency response and follow local law and policy for resuscitation while a designated team member urgently verifies any applicable documented limitation.

01Arrest
02Activate the emergency response and follow local law and policy for resuscitation while a designated team member urgently verifies any applicable documented limitation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate the emergency response and follow local law and policy for resuscitation while a designated team member urgently verifies any applicable documented limitation. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
2
Check patient and rhythm
Assess responsiveness, pulse, pressure, chest symptoms and breathing; verify the rhythm with reliable monitoring. [1]
Why it matters The urgency depends on circulation and symptoms, not the monitor label alone.
3
Call and prepare
Activate emergency help for instability; begin CPR and AED or defibrillator care when indicated and prepare trained cardioversion or pacing support under protocol. [1]
Why it matters Different rhythms and pulse states require different treatments.
4
Review reversible causes
Assist the team with ECG, electrolytes, medicine review and ordered treatment, with continued monitoring. [1]
Why it matters Correcting the rhythm without addressing causes can lead to recurrence.

What to look for next

Communicate the verified plan to the resuscitation lead and document the evidence and decisions. Trend pulse, pressure, consciousness and ECG after treatment. Report recurrence or post-treatment deterioration immediately.

Avoid this shortcut

Do not let an unverified family disagreement replace the applicable legal and clinical process. Do not give a rhythm drug from a monitor label alone or confuse synchronized cardioversion with an unsynchronized shock.

A clear way to hand it over

“I am calling about this new concern: resuscitation status is unclear during collapse. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English An arrhythmia is an abnormal rhythm; perfusion describes whether the circulation supports the organs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Advanced Life Support
Pulse and perfusion assessment, rhythm-directed rescue and resuscitation.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

CONNECT UNDERSTANDING TO EXAM PRACTICE

The explanation is clear.
The exam asks you to choose.

Here, we explain the nursing response directly. In an NCLEX®-style question, several options may sound reasonable. You must weigh the cues, priority, timing and safety—not just recognize a familiar phrase.

Practise applying the reasoning, read why alternatives are less appropriate and review your decisions before exam day.

Build question-bank judgmentStudy by topic or system; review the rationale

Work through NGN casesConnect changing cues across a case

Explore standalone NGN itemsPractise decisions in different item formats

Rehearse a full mockPractise pacing and review your decisions

Try adaptive practiceA CAT-style learning simulator

For tutors & preceptors

Turn a scenario into a conversation.

Pause at the cues. Ask learners to identify the change from baseline and the immediate risk.
Explain the action. Ask what is independent nursing care and what requires a protocol or order.
Change one detail. Explore how unsafe swallowing, low pressure or kidney disease alters the plan.
Rehearse the handover. Compare with local policy, check the source and name what must be reassessed.

Explore the free teaching toolkit

Cardiology

The fluid balance misses drinks brought by family

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize the pattern

Escalate the change

Deliver and review the plan

What to look for next

Avoid this shortcut

A clear way to hand it over

The home medicine list contains two names for one drug

What should catch your attention

What the RN should do—and why

Respond to the situation first

Pause and verify

Clarify with the team

Close the loop

What to look for next

Avoid this shortcut

A clear way to hand it over

New dizziness during early cardiac rehabilitation

What should catch your attention

What the RN should do—and why

Respond to the situation first

Make movement safe

Assess before restarting

Update the plan

What to look for next

Avoid this shortcut

A clear way to hand it over

Daily weights are not comparable

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize the pattern

Escalate the change

Deliver and review the plan

What to look for next

Avoid this shortcut

A clear way to hand it over

The patient cannot explain when chest symptoms need help

What should catch your attention

What the RN should do—and why

Respond to the situation first

Make the explanation accessible

Use a small teach-back

Repair the gap

What to look for next

Avoid this shortcut

A clear way to hand it over

Increasing edema with reduced urine

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize the pattern

Escalate the change

Deliver and review the plan

What to look for next

Avoid this shortcut

A clear way to hand it over

New atrial fibrillation with tolerable symptoms

What should catch your attention

What the RN should do—and why

Respond to the situation first

Check patient and rhythm

Call and prepare

Review reversible causes

What to look for next

Avoid this shortcut

A clear way to hand it over

A small catheter-site leak after angiography

What should catch your attention

What the RN should do—and why

Respond to the situation first

Call and assess

Prepare safe resuscitation

Track treatment and source control

What to look for next

Avoid this shortcut