Department 03 · 25 scenarios

Intensive Care

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

Monitoring & clinical assessment

A low saturation alarm with a displaced sensor

Introductory

The situation

An awake ICU patient moves a cold hand and the saturation trace becomes weak. They speak normally and have no new breathing symptoms. The display shows a low value, but no one has checked the sensor.

What should catch your attention

Weak signal
Cold moving hand
No new symptoms

Your immediate priority

Check the patient and obtain a reliable measurement before changing treatment solely because of the number.

01Weak signal
02Check the patient and obtain a reliable measurement before changing treatment solely because of the number.
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
Check the patient and obtain a reliable measurement before changing treatment solely because of the number. [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

Recheck the reading after correcting the sensor. Recheck after correcting the measurement and after treatment; persistent clinical concern needs review even with a normal display.

Avoid this shortcut

Do not ignore symptoms if they later appear despite a corrected reading. 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: a low saturation alarm with a displaced sensor. 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.

© 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.

Skin & pressure protection

Pressure where a monitoring cable meets the skin

Introductory

The situation

During a turn, the nurse finds a painful indentation beneath a cable on a patient who cannot reposition independently. The skin is intact and the device is still required. Several hours of uninterrupted pressure may have occurred.

What should catch your attention

Device pressure
Limited movement
Painful intact skin

Your immediate priority

Relieve the cable pressure while preserving monitoring, and inspect other hidden device contact points.

01Device pressure
02Relieve the cable pressure while preserving monitoring, and inspect other hidden device contact points.
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
Relieve the cable pressure while preserving monitoring, and inspect other hidden device contact points. [1]
Why it matters Early damage can exist under intact skin and may not appear as bright redness.
2
Inspect skin and comfort
Assess pain, temperature, firmness, moisture and colour across pressure areas; compare with previous findings and skin tone. [1]
Why it matters Early damage can exist under intact skin and may not appear as bright redness.
3
Offload the area
Remove sustained pressure with suitable equipment and help reposition safely. Address pain and moisture so the plan is tolerable. [1]
Why it matters Continuing pressure can deepen tissue injury even before a wound becomes visible.
4
Arrange ongoing review
Document the finding, involve the wound team when indicated and agree individualized turning, support-surface and nutrition plans. [1]
Why it matters A single position change is only the start of preventing further damage.

What to look for next

Check the device no longer presses on the same area. Check that pressure stays relieved, equipment fits and skin or pain is not worsening. Report new blistering, purple discoloration or an open wound.

Avoid this shortcut

Do not remove essential monitoring without arranging a safe alternative. Do not rub damaged skin or impose one turning schedule regardless of clinical needs.

A clear way to hand it over

“I am calling about this new concern: pressure where a monitoring cable meets the skin. 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 Offloading means taking pressure off vulnerable tissue.

Sources behind the actions 1 primary references

NICE · CG179: Pressure ulcers—recommendations
Skin assessment across skin tones, non-blanching changes, pressure relief and prevention; no skin massage.

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.

Vascular access & infusion safety

An infusion label does not match the chart

Introductory

The situation

A stable patient’s infusion bag carries a concentration different from the current order. The pump label matches the old concentration. The nurse is about to change the rate after a verbal handover.

What should catch your attention

Conflicting concentration
Old pump label
Planned rate change

Your immediate priority

Pause the uncertain change and verify the actual drug, concentration, line and order with the team.

01Conflicting concentration
02Pause the uncertain change and verify the actual drug, concentration, line and order 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
Pause the uncertain change and verify the actual drug, concentration, line and order with the team. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
2
Trace and assess
Trace the line from patient to pump; check site, labels, concentration, rate and the current order. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
3
Escalate the unsafe finding
Stop an unsafe infusion when indicated by the emergency pathway and obtain urgent clinical and pharmacy help; protect time-critical support using the prescribed alternative. [1]
Why it matters Extravasation, disconnection and delivery error can harm tissue or destabilize circulation.
4
Close the safety loop
Arrange safe replacement or investigation, document exposure and verify every connection before restarting under the agreed plan. [1]
Why it matters Correcting one connection must not accidentally interrupt another essential treatment.

What to look for next

Confirm the corrected setup before treatment continues. Check the site, perfusion and clinical effect after correction; monitor for delayed tissue injury and report it.

Avoid this shortcut

Do not calculate from a remembered concentration. Do not flush an unknown line, bypass a pump alert or abruptly interrupt lifesaving support without emergency assessment.

A clear way to hand it over

“I am calling about this new concern: an infusion label does not match the chart. 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 Line tracing checks the entire route between medicine and patient.

Sources behind the actions 2 primary references

CDC · Intravascular catheter infection prevention: summary
Regular catheter-site assessment and removal of malfunctioning peripheral catheters.
NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.

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.

ICU comfort & arousal

The patient cannot ask for pain relief

Introductory

The situation

An intubated patient is awake enough to follow simple commands but cannot speak. They grimace during turning and point at a drain. Their sedation score alone is within the prescribed range.

What should catch your attention

Nonverbal pain signs
Activity-linked grimace
Normal sedation score

Your immediate priority

Use an appropriate nonverbal pain assessment and communication aid; review analgesia rather than assuming sedation means comfort.

01Nonverbal pain signs
02Use an appropriate nonverbal pain assessment and communication aid; review analgesia rather than assuming sedation means comfort.
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 an appropriate nonverbal pain assessment and communication aid; review analgesia rather than assuming sedation means comfort. [1]
Why it matters Movement may signal pain, delirium or a device problem; unresponsiveness can hide toxicity.
2
Assess before labeling
Use suitable pain and sedation tools, check physiological changes and compare with the agreed target. [1]
Why it matters Movement may signal pain, delirium or a device problem; unresponsiveness can hide toxicity.
3
Review the target and treatment
Request team review of analgesia, sedation, illness and sleep; titrate only within authorized orders and unit policy. [1]
Why it matters A goal appropriate for one stage of critical illness may be unsafe or excessive at another.
4
Support recovery safely
Coordinate communication aids, orientation, sleep and mobility with the team when physiologically appropriate. [1]
Why it matters Comfort and function depend on more than a sedative infusion.

What to look for next

Compare comfort before and after prescribed analgesia. Review arousal, breathing, circulation and pain after changes. Unexpected neurological findings need assessment rather than automatic sedation.

Avoid this shortcut

Do not confuse sedation scoring with pain assessment. Do not independently interrupt sedation during paralysis or deepen sedation merely to suppress an unexplained alarm.

A clear way to hand it over

“I am calling about this new concern: the patient cannot ask for pain relief. 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 Sedation target describes the intended level of wakefulness for the current treatment plan.

Sources behind the actions 2 primary references

SCCM · Focused PADIS guideline update (2025)
Pain, sedation, delirium and safe enhanced mobility in adult critical care.
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.

Rehabilitation & activity tolerance

Early sitting with several lines attached

Introductory

The situation

A recovering ICU patient is scheduled to sit at the edge of the bed. They have an arterial line, catheter and oxygen tubing. Their observations are stable, but only one worker is available for a transfer that requires two.

What should catch your attention

Multiple devices
Staffing mismatch
Planned activity

Your immediate priority

Wait for the planned staffing and organize line protection rather than attempting the transfer alone.

01Multiple devices
02Wait for the planned staffing and organize line protection rather than attempting the transfer alone.
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
Wait for the planned staffing and organize line protection rather than attempting the transfer alone. [1]
Why it matters Yesterday’s transfer ability does not establish safety during today’s illness.
2
Assess readiness
Review vital signs, symptoms, cognition, strength and support devices with the team before activity. [1]
Why it matters Yesterday’s transfer ability does not establish safety during today’s illness.
3
Use the planned assistance
Choose suitable equipment and staffing, secure lines and progress activity within the agreed plan. [1]
Why it matters Graded activity supports recovery without exposing the person to avoidable falls or device loss.
4
Stop for intolerance
Pause and assess new dizziness, distress, pain, abnormal rhythm or neurological change; escalate rather than push through. [1]
Why it matters Exercise-related symptoms may indicate deterioration rather than normal effort.

What to look for next

Document tolerance and device integrity after activity. Review recovery after stopping and agree the next safe activity level. Document both tolerance and assistance requirements.

Avoid this shortcut

Do not pull on lines or rush to meet a mobility target. Do not use a universal distance goal or pull a weak arm to complete a transfer.

A clear way to hand it over

“I am calling about this new concern: early sitting with several lines attached. 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 Activity tolerance is how safely the person responds to movement and effort.

Sources behind the actions 2 primary references

SCCM · Focused PADIS guideline update (2025)
Pain, sedation, delirium and safe enhanced mobility in adult critical care.
NICE · NG249: Falls assessment and prevention (2025)
Individual inpatient fall assessment, dizziness, mobility and lying/standing blood pressure when appropriate.

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.

Changing cognition

A new quiet change after sedation reduction

Intermediate

The situation

A patient was engaging with a communication board earlier but now cannot sustain attention. The sedation infusion was reduced, not increased. They have poor sleep, pain and a rising oxygen requirement.

What should catch your attention

Attention change
No increased sedation
Multiple causes

Your immediate priority

Request review for delirium and physiological deterioration rather than attributing the change to the sedation adjustment alone.

01Attention change
02Request review for delirium and physiological deterioration rather than attributing the change to the sedation adjustment alone.
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
Request review for delirium and physiological deterioration rather than attributing the change to the sedation adjustment alone. [1]
Why it matters A quiet, sleepy person can have delirium just as an agitated person can.
2
Find the change
Compare alertness, attention and function with the usual baseline; obtain family observations and assess vital signs and pain. [1]
Why it matters A quiet, sleepy person can have delirium just as an agitated person can.
3
Seek reversible causes
Escalate new confusion; check oxygenation, glucose when indicated, infection clues, medicines, retention, constipation and hydration. Use an appropriate validated assessment if trained. [1]
Why it matters Delirium often reflects illness or several interacting problems rather than worsening dementia alone.
4
Support orientation safely
Use calm explanations, glasses and hearing aids, familiar routines and an individualized safety plan. Involve the clinical team for persistent distress. [1]
Why it matters Supportive care reduces avoidable distress while the cause is investigated and treated.

What to look for next

Trend alertness and oxygen requirement together. Trend attention, alertness and physiological observations. Report further decline promptly even if the person is no longer restless.

Avoid this shortcut

Do not use agitation as the only sign of delirium. Do not dismiss sudden confusion as age, routinely restrain the person or sedate away the warning sign.

A clear way to hand it over

“I am calling about this new concern: a new quiet change after sedation reduction. 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 Delirium is a new disturbance in attention and awareness that can fluctuate.

Sources behind the actions 2 primary references

NICE · CG103: Delirium—recommendations (assessment updated 2023)
Recognize acute changes, assess causes, use a suitable validated tool by trained staff, reorient and address hypoxia, hydration and infection.
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.

Enteral tube safety

Tube position is uncertain after coughing

Intermediate

The situation

An intubated patient coughs forcefully and the external feeding-tube length changes. Feed is running and a staff member suggests listening over the stomach after pushing air to confirm placement.

What should catch your attention

Changed external length
Recent coughing
Feed running

Your immediate priority

Stop uncertain tube use and follow the validated placement-confirmation pathway before further feed or medicine.

01Changed external length
02Stop uncertain tube use and follow the validated placement-confirmation pathway before further feed or medicine.
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
Stop uncertain tube use and follow the validated placement-confirmation pathway before further feed or medicine. [1]
Why it matters A feeding tube can be misplaced or migrate, and symptoms may be subtle.
2
Pause uncertain use
Stop use when placement or tolerance is in doubt; assess respiratory and abdominal symptoms. [1]
Why it matters A feeding tube can be misplaced or migrate, and symptoms may be subtle.
3
Verify by the approved method
Use the facility’s validated placement-confirmation pathway, trained interpretation and documentation; obtain specialist review if uncertain. [1]
Why it matters Air-injection sounds and tube appearance cannot reliably prove safe gastric placement.
4
Follow the nutrition plan
Restart only after confirmation and an authorized feeding or medication plan; check positioning, interactions and monitoring. [1]
Why it matters Correct placement does not remove aspiration, blockage or formulation risks.

What to look for next

Document the confirmed length and approved use. Recheck after relevant displacement events and monitor tolerance, hydration and respiratory changes according to policy.

Avoid this shortcut

Do not use an air-injection sound as proof of placement. Do not use a whoosh test as confirmation, give crushed modified-release medicines or force a blocked tube.

A clear way to hand it over

“I am calling about this new concern: tube position is uncertain after coughing. 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 Enteral means nutrition or medicine is delivered into the gastrointestinal tract.

Sources behind the actions 2 primary references

NHS England · Enduring nasogastric-tube placement safety standards
Validated placement checks; no whoosh test or unverified feeding/medicine delivery.
NICE · CG32: Nutrition support for adults
Nutrition assessment, refeeding risk, individualized support and monitoring.

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

Insulin continues after nutrition stops

Intermediate

The situation

A patient receiving an insulin infusion has enteral nutrition stopped for a procedure. The interruption is not communicated to the nurse managing glucose. The next glucose measurement is below the protocol threshold.

What should catch your attention

Insulin delivery
Feed interruption
Low measured glucose

Your immediate priority

Treat the low glucose and obtain the infusion and nutrition adjustment required by the authorized protocol.

01Insulin delivery
02Treat the low glucose and obtain the infusion and nutrition adjustment required by the authorized protocol.
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
Treat the low glucose and obtain the infusion and nutrition adjustment required by the authorized protocol. [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

Continue close glucose checks during and after the interruption. Continue prescribed glucose checks and observe alertness, swallowing and food intake. Some medicines can cause prolonged or recurrent hypoglycemia.

Avoid this shortcut

Do not assume the previous insulin rate remains appropriate. 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: insulin continues after nutrition stops. 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.

Vascular access & infusion safety

A damp arterial-line dressing

Intermediate

The situation

A patient’s arterial-line dressing becomes damp and the waveform changes. The patient is stable, but it is unclear whether the fluid is blood, flush solution or a disconnected sampling connection.

What should catch your attention

Damp access site
Changed waveform
Uncertain leak

Your immediate priority

Inspect and trace the arterial system using trained aseptic practice and obtain help for leakage or disconnection.

01Damp access site
02Inspect and trace the arterial system using trained aseptic practice and obtain help for leakage or disconnection.
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
Inspect and trace the arterial system using trained aseptic practice and obtain help for leakage or disconnection. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
2
Trace and assess
Trace the line from patient to pump; check site, labels, concentration, rate and the current order. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
3
Escalate the unsafe finding
Stop an unsafe infusion when indicated by the emergency pathway and obtain urgent clinical and pharmacy help; protect time-critical support using the prescribed alternative. [1]
Why it matters Extravasation, disconnection and delivery error can harm tissue or destabilize circulation.
4
Close the safety loop
Arrange safe replacement or investigation, document exposure and verify every connection before restarting under the agreed plan. [1]
Why it matters Correcting one connection must not accidentally interrupt another essential treatment.

What to look for next

Check bleeding, distal circulation and reliable monitoring after correction. Check the site, perfusion and clinical effect after correction; monitor for delayed tissue injury and report it.

Avoid this shortcut

Do not use the arterial line for routine medication administration. Do not flush an unknown line, bypass a pump alert or abruptly interrupt lifesaving support without emergency assessment.

A clear way to hand it over

“I am calling about this new concern: a damp arterial-line dressing. 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 Line tracing checks the entire route between medicine and patient.

Sources behind the actions 2 primary references

CDC · Intravascular catheter infection prevention: summary
Regular catheter-site assessment and removal of malfunctioning peripheral catheters.
NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.

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.

Kidney function & fluids

Urine output falls after a diuretic increase

Intermediate

The situation

A patient has falling urine output after a diuretic dose change. They still have edema, but pressure is lower and creatinine is rising. The next fluid order is due for review.

What should catch your attention

Low output
Lower pressure
Rising creatinine

Your immediate priority

Report both congestion and perfusion findings for a reassessed fluid and medication plan.

01Low output
02Report both congestion and perfusion findings for a reassessed fluid and medication 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
Report both congestion and perfusion findings for a reassessed fluid and medication plan. [1]
Why it matters A low urine total may reflect measurement error, obstruction or impaired kidney perfusion.
2
Check the trend
Compare measured urine, creatinine and vital signs with baseline; check collection accuracy and obstruction clues. [1]
Why it matters A low urine total may reflect measurement error, obstruction or impaired kidney perfusion.
3
Assess fluid status
Check intake, losses, weight, edema and breathing, and seek a clinician’s fluid and medication review. [1]
Why it matters Someone may be swollen yet poorly perfused; a reflex fluid bolus or diuretic can be unsafe.
4
Monitor the authorized plan
Track prescribed fluid balance, electrolytes and medicine changes, and escalate urgent complications such as hyperkalemia or pulmonary edema. [1]
Why it matters AKI can rapidly affect drug clearance, cardiac rhythm and fluid tolerance.

What to look for next

Trend urine, breathing and electrolytes after the agreed intervention. Look for improving perfusion and urine trends, stable electrolytes and no respiratory overload. Escalate worsening symptoms or urgent laboratory results.

Avoid this shortcut

Do not assume edema proves more diuretic is the right answer. Do not diagnose dehydration from urine alone or routinely treat AKI with loop diuretics.

A clear way to hand it over

“I am calling about this new concern: urine output falls after a diuretic increase. 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 AKI means an acute decrease in kidney function.

Sources behind the actions 2 primary references

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.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

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.

Ventilator & artificial airway

Distress during a breathing trial

Difficult

The situation

During an authorized spontaneous breathing trial, a patient develops rapid breathing, sweating and distress. Saturation initially remains acceptable. The team’s trial-stopping criteria are available at the bedside.

What should catch your attention

Increased effort
Sweating
Trial intolerance

Your immediate priority

Notify the team and use the prescribed stopping and support pathway; report effort as well as saturation.

01Increased effort
02Notify the team and use the prescribed stopping and support pathway; report effort as well as saturation.
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
Notify the team and use the prescribed stopping and support pathway; report effort as well as saturation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
2
Call and assess
Check chest movement, oxygenation, tube position and the patient; summon the respiratory and medical team for acute distress or loss of ventilation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
3
Use the emergency airway pathway
Check visible connections and supply. Provide trained rescue ventilation when required, using the unit protocol and airway team guidance. [1]
Why it matters Maintaining ventilation takes priority over simply clearing an alarm message.
4
Find the cause and document
Assist prescribed blood gases, examination and imaging, then confirm secure airway, appropriate humidification and a monitored ventilation plan. [1]
Why it matters Restoring a connection is not enough if another airway or lung problem persists.

What to look for next

Reassess comfort, ventilation and the reason for intolerance. Trend chest movement, respiratory effort, saturation, capnography when used and the ordered blood gases. Escalate persistent failure immediately.

Avoid this shortcut

Do not continue a failed trial to improve the duration recorded. Do not blindly increase pressures, routinely instill saline before suction or attempt unfamiliar airway procedures.

A clear way to hand it over

“I am calling about this new concern: distress during a breathing trial. 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 ventilator moves air into the lungs; capnography measures exhaled carbon dioxide.

Sources behind the actions 3 primary references

AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.
AARC · Artificial Airway Suctioning guideline (2022)
Indicated trained suction, physiological monitoring and generally avoiding routine saline instillation.
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.

Ventilator & artificial airway

Agitation starts when ventilator pressure rises

Difficult

The situation

A ventilated patient becomes agitated at the same time as high-pressure alarms begin. Secretions are visible and chest movement is less effective. A request arrives to deepen sedation before checking the airway.

What should catch your attention

Pressure alarm
Reduced chest movement
Visible secretions

Your immediate priority

Assess the airway, circuit and patient with respiratory help before treating unexplained distress only with sedation.

01Pressure alarm
02Assess the airway, circuit and patient with respiratory help before treating unexplained distress only with sedation.
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 airway, circuit and patient with respiratory help before treating unexplained distress only with sedation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
2
Call and assess
Check chest movement, oxygenation, tube position and the patient; summon the respiratory and medical team for acute distress or loss of ventilation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
3
Use the emergency airway pathway
Check visible connections and supply. Provide trained rescue ventilation when required, using the unit protocol and airway team guidance. [1]
Why it matters Maintaining ventilation takes priority over simply clearing an alarm message.
4
Find the cause and document
Assist prescribed blood gases, examination and imaging, then confirm secure airway, appropriate humidification and a monitored ventilation plan. [1]
Why it matters Restoring a connection is not enough if another airway or lung problem persists.

What to look for next

Watch ventilation after the identified cause is managed. Trend chest movement, respiratory effort, saturation, capnography when used and the ordered blood gases. Escalate persistent failure immediately.

Avoid this shortcut

Do not assume every high-pressure alarm means the patient needs more sedative. Do not blindly increase pressures, routinely instill saline before suction or attempt unfamiliar airway procedures.

A clear way to hand it over

“I am calling about this new concern: agitation starts when ventilator pressure rises. 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 ventilator moves air into the lungs; capnography measures exhaled carbon dioxide.

Sources behind the actions 3 primary references

AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.
AARC · Artificial Airway Suctioning guideline (2022)
Indicated trained suction, physiological monitoring and generally avoiding routine saline instillation.
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.

Head injury & anticoagulants

A new unequal pupil after head injury

Difficult

The situation

A patient with traumatic brain injury develops an unequal pupil and reduced responsiveness. The sedation dose has not changed. Their pressure and ventilation are being managed to a prescribed neurocritical-care plan.

What should catch your attention

New pupil difference
Declining response
Stable sedation dose

Your immediate priority

Activate urgent neurological and airway review, record the change time and maintain the prescribed physiological support while preparing imaging or intervention.

01New pupil difference
02Activate urgent neurological and airway review, record the change time and maintain the prescribed physiological support while preparing imaging or intervention.
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 neurological and airway review, record the change time and maintain the prescribed physiological support while preparing imaging or intervention. [1]
Why it matters A seemingly minor fall can cause serious injury, especially with anticoagulant use.
2
Assess safely
Check airway, breathing, circulation, consciousness, pupils and injury history; avoid unnecessary movement if spinal injury is possible. [1]
Why it matters A seemingly minor fall can cause serious injury, especially with anticoagulant use.
3
Arrange urgent review
Report the mechanism, loss of consciousness, vomiting, neurological changes and anticoagulant details; follow imaging and observation orders. [1]
Why it matters Treatment decisions depend on symptoms, risk factors and examination, not the size of a visible bump.
4
Track the trend
Record neurological observations and times, provide the prescribed monitoring and escalate deterioration immediately. [1]
Why it matters A change after an initially reassuring assessment may indicate evolving injury.

What to look for next

Repeat neurological and circulatory observations during escalation. Watch for worsening headache, vomiting, confusion, weakness or reduced consciousness. A previous normal assessment does not end monitoring.

Avoid this shortcut

Do not delay by calling the change a sedation effect. Do not let an unexplained fall or increasing sleepiness pass without review.

A clear way to hand it over

“I am calling about this new concern: a new unequal pupil after head injury. 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 Neurological observations check how the brain and nerves are functioning.

Sources behind the actions 2 primary references

NICE · NG232: Head injury assessment and management
Age-specific assessment, neurological deterioration and anticoagulant-related risk.
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.

Infection & shock

Fluids improve pressure but breathing worsens

Difficult

The situation

A patient with septic shock receives prescribed resuscitation. Pressure improves briefly, but oxygen needs and crackles increase. They have heart failure and remain poorly perfused despite the initial response.

What should catch your attention

Persistent shock
Increasing oxygen need
Limited fluid tolerance

Your immediate priority

Report the mixed response before further fluid; support the team’s individualized hemodynamic reassessment.

01Persistent shock
02Report the mixed response before further fluid; support the team’s individualized hemodynamic reassessment.
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
Report the mixed response before further fluid; support the team’s individualized hemodynamic reassessment. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
2
Escalate early
Assess airway, breathing, circulation and mental state; activate the local emergency or sepsis response for shock or rapid decline. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
3
Support the prescribed bundle
Prepare cultures and lactate testing, urgent antimicrobials and individualized fluid or vasopressor treatment as ordered; do not delay urgent therapy for a difficult sample. [1]
Why it matters Identifying infection and supporting circulation address different parts of the same emergency.
4
Reassess after each step
Trend blood pressure, breathing, alertness, urine and response to treatment; report overload or persistent poor perfusion. [1]
Why it matters Fluids and medicines must be adjusted to response and comorbidity, rather than repeated automatically.

What to look for next

Track perfusion and respiratory effects after each subsequent intervention. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not repeat fluid boluses automatically because the first temporarily improved pressure. Do not wait for fever, laboratory confirmation or a score threshold when clinical shock is evident.

A clear way to hand it over

“I am calling about this new concern: fluids improve pressure but breathing worsens. 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 Perfusion means blood flow delivering oxygen to organs.

Sources behind the actions 2 primary references

SCCM / ESICM · Surviving Sepsis Campaign adult guidelines—2026
Immediate emergency response, cultures/lactate, prompt antimicrobials in shock and individualized resuscitation with reassessment.
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.

Infection & shock

Fever and hypotension after a central-line access

Difficult

The situation

A patient with multiple lines develops fever and falling pressure after line access. The nurse notes a concerning access site but other infection sources are also possible. A vasopressor is already prescribed.

What should catch your attention

New fever
Circulatory decline
Potential device source

Your immediate priority

Activate the sepsis pathway and report all possible sources; obtain the team’s culture and source-control plan.

01New fever
02Activate the sepsis pathway and report all possible sources; obtain the team’s culture and source-control 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
Activate the sepsis pathway and report all possible sources; obtain the team’s culture and source-control plan. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
2
Escalate early
Assess airway, breathing, circulation and mental state; activate the local emergency or sepsis response for shock or rapid decline. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
3
Support the prescribed bundle
Prepare cultures and lactate testing, urgent antimicrobials and individualized fluid or vasopressor treatment as ordered; do not delay urgent therapy for a difficult sample. [1]
Why it matters Identifying infection and supporting circulation address different parts of the same emergency.
4
Reassess after each step
Trend blood pressure, breathing, alertness, urine and response to treatment; report overload or persistent poor perfusion. [1]
Why it matters Fluids and medicines must be adjusted to response and comorbidity, rather than repeated automatically.

What to look for next

Trend support needs and perfusion after treatment. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not independently remove every line before preserving necessary access and obtaining a source-control plan. Do not wait for fever, laboratory confirmation or a score threshold when clinical shock is evident.

A clear way to hand it over

“I am calling about this new concern: fever and hypotension after a central-line 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 Perfusion means blood flow delivering oxygen to organs.

Sources behind the actions 2 primary references

SCCM / ESICM · Surviving Sepsis Campaign adult guidelines—2026
Immediate emergency response, cultures/lactate, prompt antimicrobials in shock and individualized resuscitation with reassessment.
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.

Ventilator & artificial airway

The ventilator disconnects during a turn

Extremely difficult

The situation

During turning, a ventilator circuit connection separates and the patient’s chest stops moving effectively. Saturation is falling. One team member continues the turn while another searches through the alarm menu.

What should catch your attention

Visible disconnection
Loss of ventilation
Falling saturation

Your immediate priority

Stop the maneuver, call airway help and restore or provide trained rescue ventilation immediately under the unit pathway.

01Visible disconnection
02Stop the maneuver, call airway help and restore or provide trained rescue ventilation immediately under the unit 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
Stop the maneuver, call airway help and restore or provide trained rescue ventilation immediately under the unit pathway. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
2
Call and assess
Check chest movement, oxygenation, tube position and the patient; summon the respiratory and medical team for acute distress or loss of ventilation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
3
Use the emergency airway pathway
Check visible connections and supply. Provide trained rescue ventilation when required, using the unit protocol and airway team guidance. [1]
Why it matters Maintaining ventilation takes priority over simply clearing an alarm message.
4
Find the cause and document
Assist prescribed blood gases, examination and imaging, then confirm secure airway, appropriate humidification and a monitored ventilation plan. [1]
Why it matters Restoring a connection is not enough if another airway or lung problem persists.

What to look for next

Confirm chest movement and monitoring after reconnection. Trend chest movement, respiratory effort, saturation, capnography when used and the ordered blood gases. Escalate persistent failure immediately.

Avoid this shortcut

Do not spend the emergency only navigating an alarm screen. Do not blindly increase pressures, routinely instill saline before suction or attempt unfamiliar airway procedures.

A clear way to hand it over

“I am calling about this new concern: the ventilator disconnects during a turn. 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 ventilator moves air into the lungs; capnography measures exhaled carbon dioxide.

Sources behind the actions 3 primary references

AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.
AARC · Artificial Airway Suctioning guideline (2022)
Indicated trained suction, physiological monitoring and generally avoiding routine saline instillation.
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.

Ventilator & artificial airway

An endotracheal tube moves outward

Extremely difficult

The situation

An intubated patient coughs during oral care. Tube markings change and exhaled carbon dioxide drops. Chest movement is poor despite an apparently connected circuit, and oxygenation is declining.

What should catch your attention

Changed tube depth
Reduced exhaled carbon dioxide
Poor chest movement

Your immediate priority

Call immediate expert airway help and follow the airway-displacement rescue pathway; avoid blindly advancing the tube.

01Changed tube depth
02Call immediate expert airway help and follow the airway-displacement rescue pathway; avoid blindly advancing the tube.
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 immediate expert airway help and follow the airway-displacement rescue pathway; avoid blindly advancing the tube. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
2
Call and assess
Check chest movement, oxygenation, tube position and the patient; summon the respiratory and medical team for acute distress or loss of ventilation. [1]
Why it matters An alarm may reflect equipment failure, displacement, obstruction or rapidly changing lung disease.
3
Use the emergency airway pathway
Check visible connections and supply. Provide trained rescue ventilation when required, using the unit protocol and airway team guidance. [1]
Why it matters Maintaining ventilation takes priority over simply clearing an alarm message.
4
Find the cause and document
Assist prescribed blood gases, examination and imaging, then confirm secure airway, appropriate humidification and a monitored ventilation plan. [1]
Why it matters Restoring a connection is not enough if another airway or lung problem persists.

What to look for next

Verify airway and ventilation with the specialist team after rescue. Trend chest movement, respiratory effort, saturation, capnography when used and the ordered blood gases. Escalate persistent failure immediately.

Avoid this shortcut

Do not push the tube inward based only on the old marking. Do not blindly increase pressures, routinely instill saline before suction or attempt unfamiliar airway procedures.

A clear way to hand it over

“I am calling about this new concern: an endotracheal tube moves outward. 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 ventilator moves air into the lungs; capnography measures exhaled carbon dioxide.

Sources behind the actions 3 primary references

AARC · Clinical practice guidelines: patient-ventilator assessment
Trained patient, airway, circuit and ventilator assessment.
AARC · Artificial Airway Suctioning guideline (2022)
Indicated trained suction, physiological monitoring and generally avoiding routine saline instillation.
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.

Tracheostomy & neck airway

The suction catheter will not pass through a tracheostomy

Extremely difficult

The situation

A patient with a tracheostomy develops distress and little airflow. A trained nurse cannot pass the suction catheter through the tube. The stoma is recent and the upper-airway information is documented.

What should catch your attention

Poor airflow
Catheter cannot pass
Recent stoma

Your immediate priority

Activate the neck-airway algorithm and expert help immediately, using the documented anatomy and trained patency steps.

01Poor airflow
02Activate the neck-airway algorithm and expert help immediately, using the documented anatomy and trained patency steps.
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 neck-airway algorithm and expert help immediately, using the documented anatomy and trained patency steps. [1]
Why it matters A laryngectomy disconnects the mouth and nose from the lungs, so face-mask oxygen alone cannot work.
2
Identify the airway
Call expert help and check the bedside airway information, breathing and stoma. Distinguish tracheostomy from total laryngectomy. [1]
Why it matters A laryngectomy disconnects the mouth and nose from the lungs, so face-mask oxygen alone cannot work.
3
Follow the trained algorithm
Apply oxygen through the appropriate route and check tube patency using the emergency algorithm within competence; if anatomy is uncertain, follow the algorithm’s face-and-stoma approach. [1]
Why it matters Blocked or displaced tubes require a structured response rather than repeated forced suction or ventilation.
4
Prepare ongoing support
Bring the person’s emergency equipment, assist the airway team and confirm the updated tube and ventilation plan. [1]
Why it matters Tube changes, new stomas and difficult anatomy need specialist decisions and a clear handover.

What to look for next

Continuously check effective ventilation during rescue. Keep reassessing airflow, chest movement, consciousness and oxygenation throughout the emergency and after tube management.

Avoid this shortcut

Do not repeatedly force the catheter or blindly reinsert a fresh-stoma tube. Do not give face-mask-only oxygen to a known laryngectomy or blindly force a displaced tube into a fresh stoma.

A clear way to hand it over

“I am calling about this new concern: the suction catheter will not pass through a tracheostomy. 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 stoma is the neck opening; a tracheostomy and a total laryngectomy have different airway anatomy.

Sources behind the actions 1 primary references

National Tracheostomy Safety Project · Emergency tracheostomy and laryngectomy care
Anatomy-specific emergency algorithms and recognition of obstruction or displacement.

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.

Vascular access & infusion safety

Shock continues while vasopressor fluid leaks into tissue

Extremely difficult

The situation

A patient receiving a vasopressor through an approved peripheral route has new swelling and pale skin at the site. Pressure falls despite rate escalation. The concentration and pump settings are correct.

What should catch your attention

Vasopressor exposure
Pale swollen site
Persistent shock

Your immediate priority

Activate the drug-specific extravasation response, stop delivery through the unsafe access and arrange an authorized alternative urgently; do not flush the affected line.

01Vasopressor exposure
02Activate the drug-specific extravasation response, stop delivery through the unsafe access and arrange an authorized alternative urgently; do not flush the affected line.
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 drug-specific extravasation response, stop delivery through the unsafe access and arrange an authorized alternative urgently; do not flush the affected line. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
2
Trace and assess
Trace the line from patient to pump; check site, labels, concentration, rate and the current order. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
3
Escalate the unsafe finding
Stop an unsafe infusion when indicated by the emergency pathway and obtain urgent clinical and pharmacy help; protect time-critical support using the prescribed alternative. [1]
Why it matters Extravasation, disconnection and delivery error can harm tissue or destabilize circulation.
4
Close the safety loop
Arrange safe replacement or investigation, document exposure and verify every connection before restarting under the agreed plan. [1]
Why it matters Correcting one connection must not accidentally interrupt another essential treatment.

What to look for next

Track tissue perfusion and restored drug effect through safe access. Check the site, perfusion and clinical effect after correction; monitor for delayed tissue injury and report it.

Avoid this shortcut

Do not increase the pump rate to overcome suspected tissue leakage. Do not flush an unknown line, bypass a pump alert or abruptly interrupt lifesaving support without emergency assessment.

A clear way to hand it over

“I am calling about this new concern: shock continues while vasopressor fluid leaks into tissue. 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 Line tracing checks the entire route between medicine and patient.

Sources behind the actions 3 primary references

eviQ / Cancer Institute NSW · Extravasation management: clinical procedure
For suspected tissue-damaging drug leakage: stop, do not flush, retain access initially for a drug-specific plan.
CDC · Intravascular catheter infection prevention: summary
Regular catheter-site assessment and removal of malfunctioning peripheral catheters.
NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.

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 potassium elevation with weak circulation

Extremely difficult

The situation

An ICU patient with AKI has a critical potassium result, widening ECG complexes and falling pressure. Insulin-based treatment is ordered, but their glucose is already low and dialysis review is pending.

What should catch your attention

Critical potassium
ECG change
Low glucose before treatment

Your immediate priority

Call immediate renal and resuscitation help; verify the prescribed glucose-support and monitoring plan before insulin treatment.

01Critical potassium
02Call immediate renal and resuscitation help; verify the prescribed glucose-support and monitoring plan before insulin 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
Call immediate renal and resuscitation help; verify the prescribed glucose-support and monitoring plan before insulin treatment. [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

Check recurrent potassium and glucose problems through the full protocol period. Escalate ECG deterioration, recurrent high potassium or low glucose. Confirm the plan for potassium removal and medicine review.

Avoid this shortcut

Do not let potassium treatment obscure the risk of hypoglycemia. 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 potassium elevation with weak circulation. 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.

Pleural & ventilation emergency

Sudden shock on positive-pressure ventilation

Extremely difficult

The situation

A ventilated patient suddenly becomes hypoxemic and hypotensive with a marked new difference in chest findings. A recent central-line procedure is noted. Portable imaging has been requested but has not arrived.

What should catch your attention

Abrupt hypoxemia
Shock
Recent chest-related procedure

Your immediate priority

Activate emergency bedside assessment for possible tension pneumothorax and prepare trained decompression support without delaying unstable care for imaging.

01Abrupt hypoxemia
02Activate emergency bedside assessment for possible tension pneumothorax and prepare trained decompression support without delaying unstable care for imaging.
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 bedside assessment for possible tension pneumothorax and prepare trained decompression support without delaying unstable care for imaging. [1]
Why it matters Air trapped around a lung can reduce ventilation and, under tension, impair circulation.
2
Recognize acute change
Assess breathing, chest symptoms, air entry, oxygenation and circulation; activate emergency response for distress or shock. [1]
Why it matters Air trapped around a lung can reduce ventilation and, under tension, impair circulation.
3
Prepare urgent treatment
Support oxygenation and trained ventilation as indicated; prepare the clinician’s emergency decompression or drain equipment. [1]
Why it matters An unstable suspected tension pneumothorax requires immediate clinical management, not routine waiting for imaging.
4
Monitor the drainage plan
After intervention, observe breathing, circulation and the prescribed chest-drain system; report obstruction, disconnection or ongoing instability. [1]
Why it matters Treatment can fail if the drain is not functioning or the underlying leak persists.

What to look for next

Track circulation and ventilation during and after intervention. Continuously reassess oxygenation, perfusion and drain findings; escalate deterioration immediately.

Avoid this shortcut

Do not wait for a radiograph before escalating shock. Do not clamp an air-leaking drain routinely or attempt needle decompression outside your competence and authorization.

A clear way to hand it over

“I am calling about this new concern: sudden shock on positive-pressure ventilation. 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 Pneumothorax means air in the space around a lung; tension describes pressure that compromises the heart and circulation.

Sources behind the actions 2 primary references

Agency for Clinical Innovation NSW · Pleural drains in adults
Patient and system assessment, trained troubleshooting and drain-specific escalation.
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.

Vascular access & infusion safety

Proning exposes a disconnected critical line

Extremely difficult

The situation

During a coordinated prone turn, a line carrying vasoactive medicine becomes disconnected. Pressure falls and the patient has severe lung disease. The airway is still secure but access is difficult in the new position.

What should catch your attention

Critical infusion interruption
Falling pressure
Restricted access while prone

Your immediate priority

Tell the whole team immediately, protect ventilation and follow the planned emergency access and infusion-restoration pathway.

01Critical infusion interruption
02Tell the whole team immediately, protect ventilation and follow the planned emergency access and infusion-restoration 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
Tell the whole team immediately, protect ventilation and follow the planned emergency access and infusion-restoration pathway. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
2
Trace and assess
Trace the line from patient to pump; check site, labels, concentration, rate and the current order. [1]
Why it matters A correct pump display does not prove the right drug is connected to the right access.
3
Escalate the unsafe finding
Stop an unsafe infusion when indicated by the emergency pathway and obtain urgent clinical and pharmacy help; protect time-critical support using the prescribed alternative. [1]
Why it matters Extravasation, disconnection and delivery error can harm tissue or destabilize circulation.
4
Close the safety loop
Arrange safe replacement or investigation, document exposure and verify every connection before restarting under the agreed plan. [1]
Why it matters Correcting one connection must not accidentally interrupt another essential treatment.

What to look for next

Verify every connection and the hemodynamic response after the turn is stabilized. Check the site, perfusion and clinical effect after correction; monitor for delayed tissue injury and report it.

Avoid this shortcut

Do not reconnect an unidentified open line without the approved safety and asepsis checks. Do not flush an unknown line, bypass a pump alert or abruptly interrupt lifesaving support without emergency assessment.

A clear way to hand it over

“I am calling about this new concern: proning exposes a disconnected critical line. 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 Line tracing checks the entire route between medicine and patient.

Sources behind the actions 2 primary references

CDC · Intravascular catheter infection prevention: summary
Regular catheter-site assessment and removal of malfunctioning peripheral catheters.
NICE · NG5: Medicines optimisation
Reconciliation, medicine safety, communication and individual review.

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.

ICU comfort & arousal

Paralysis hides a stopped sedation infusion

Extremely difficult

The situation

A ventilated patient receiving a neuromuscular blocker has a sedation pump alarm. They cannot move or communicate. Tachycardia begins, and a handover note implies no pain assessment is possible during paralysis.

What should catch your attention

Paralysis
Interrupted sedation delivery
Possible awareness or distress

Your immediate priority

Verify analgesia and sedation delivery immediately with the ICU team; paralysis does not provide comfort or unconsciousness.

01Paralysis
02Verify analgesia and sedation delivery immediately with the ICU team; paralysis does not provide comfort or unconsciousness.
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
Verify analgesia and sedation delivery immediately with the ICU team; paralysis does not provide comfort or unconsciousness. [1]
Why it matters Movement may signal pain, delirium or a device problem; unresponsiveness can hide toxicity.
2
Assess before labeling
Use suitable pain and sedation tools, check physiological changes and compare with the agreed target. [1]
Why it matters Movement may signal pain, delirium or a device problem; unresponsiveness can hide toxicity.
3
Review the target and treatment
Request team review of analgesia, sedation, illness and sleep; titrate only within authorized orders and unit policy. [1]
Why it matters A goal appropriate for one stage of critical illness may be unsafe or excessive at another.
4
Support recovery safely
Coordinate communication aids, orientation, sleep and mobility with the team when physiologically appropriate. [1]
Why it matters Comfort and function depend on more than a sedative infusion.

What to look for next

Use the unit’s monitoring strategy and reassess after delivery is restored. Review arousal, breathing, circulation and pain after changes. Unexpected neurological findings need assessment rather than automatic sedation.

Avoid this shortcut

Do not infer adequate sedation from absence of movement. Do not independently interrupt sedation during paralysis or deepen sedation merely to suppress an unexplained alarm.

A clear way to hand it over

“I am calling about this new concern: paralysis hides a stopped sedation infusion. 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 Sedation target describes the intended level of wakefulness for the current treatment plan.

Sources behind the actions 2 primary references

SCCM · Focused PADIS guideline update (2025)
Pain, sedation, delirium and safe enhanced mobility in adult critical care.
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.

Bleeding & circulation

Fresh surgical bleeding during organ support

Extremely difficult

The situation

A patient returning from major surgery has rapidly increasing drain blood, cooling extremities and falling pressure. They also need mechanical ventilation and renal support. The first postoperative hemoglobin is not yet available.

What should catch your attention

Increasing blood loss
Poor perfusion
Several support systems

Your immediate priority

Activate major-bleeding review and coordinate airway, access and transfer support while reporting surgery and anticoagulant exposure.

01Increasing blood loss
02Activate major-bleeding review and coordinate airway, access and transfer support while reporting surgery and anticoagulant 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 major-bleeding review and coordinate airway, access and transfer support while reporting surgery and anticoagulant exposure. [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

Record losses and resuscitation without losing track of devices. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not wait for the first hemoglobin before responding to shock. 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: fresh surgical bleeding during organ support. 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.

Safe critical-care transfer

An ICU transfer is proposed despite escalating support

Extremely difficult

The situation

A patient needs urgent imaging outside ICU, but vasopressor and oxygen requirements have increased. The portable oxygen cylinder is partly used and the receiving area has not confirmed readiness. Imaging could change treatment.

What should catch your attention

Escalating support
Limited oxygen reserve
Unconfirmed destination

Your immediate priority

Request the responsible clinician’s risk-benefit decision, appropriate stabilization, trained escort and full equipment contingency before leaving.

01Escalating support
02Request the responsible clinician’s risk-benefit decision, appropriate stabilization, trained escort and full equipment contingency before leaving.
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
Request the responsible clinician’s risk-benefit decision, appropriate stabilization, trained escort and full equipment contingency before leaving. [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

Monitor continuously and confirm support immediately on arrival. Monitor during travel and reassess immediately on arrival; verify all connections, prescribed settings and continuing treatments.

Avoid this shortcut

Do not treat a booked scan as proof that routine transport is safe. 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: an ICU transfer is proposed despite escalating support. 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.

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

Intensive Care

A low saturation alarm with a displaced sensor

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess actual physiology

Check the measurement

Keep monitoring useful

What to look for next

Avoid this shortcut

A clear way to hand it over

Pressure where a monitoring cable meets the skin

What should catch your attention

What the RN should do—and why

Respond to the situation first

Inspect skin and comfort

Offload the area

Arrange ongoing review

What to look for next

Avoid this shortcut

A clear way to hand it over

An infusion label does not match the chart

What should catch your attention

What the RN should do—and why

Respond to the situation first

Trace and assess

Escalate the unsafe finding

Close the safety loop

What to look for next

Avoid this shortcut

A clear way to hand it over

The patient cannot ask for pain relief

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess before labeling

Review the target and treatment

Support recovery safely

What to look for next

Avoid this shortcut

A clear way to hand it over

Early sitting with several lines attached

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess readiness

Use the planned assistance

Stop for intolerance

What to look for next

Avoid this shortcut

A clear way to hand it over

A new quiet change after sedation reduction

What should catch your attention

What the RN should do—and why

Respond to the situation first

Find the change

Seek reversible causes

Support orientation safely

What to look for next

Avoid this shortcut

A clear way to hand it over

Tube position is uncertain after coughing

What should catch your attention

What the RN should do—and why

Respond to the situation first

Pause uncertain use

Verify by the approved method

Follow the nutrition plan

What to look for next

Avoid this shortcut

A clear way to hand it over

Insulin continues after nutrition stops

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess and act

Check the response

Prevent recurrence

What to look for next

Avoid this shortcut