Department 09 · 25 scenarios

Respiratory 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

Communication & discharge

The inhaler technique is ineffective

Introductory

The situation

A patient presses an inhaler repeatedly without coordinating inhalation. They believe the device is empty because symptoms have not improved. The prescribed inhaler type and spacer instructions need clarification.

What should catch your attention

Technique problem
Symptoms persist
Device-specific instruction needed

Your immediate priority

Demonstrate the prescribed device technique and ask the patient to show it back; arrange clinical review of persistent symptoms.

01Technique problem
02Demonstrate the prescribed device technique and ask the patient to show it back; arrange clinical review of persistent symptoms.
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
Demonstrate the prescribed device technique and ask the patient to show it back; arrange clinical review of persistent symptoms. [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 correct use and understanding of the individualized symptom plan. 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 substitute a different medicine or assume all inhalers use the same technique. 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 inhaler technique is ineffective. 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.

© 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.

Breathing & oxygen

Oxygen tubing is trapped under a bed wheel

Introductory

The situation

A patient on prescribed oxygen reports breathlessness after the bed was moved. The tubing is visibly trapped and delivery is reduced.

What should catch your attention

Mechanical delivery problem
New symptoms
Recent bed movement

Your immediate priority

Assess breathing and restore the prescribed oxygen flow/device setup while checking the entire connection.

01Mechanical delivery problem
02Assess breathing and restore the prescribed oxygen flow/device setup while checking the entire connection.
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 breathing and restore the prescribed oxygen flow/device setup while checking the entire connection. [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

Confirm response and a safe tubing arrangement. 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 only turn up the flow at the wall while the tubing remains obstructed. 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: oxygen tubing is trapped under a bed wheel. 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.

Pleural & ventilation emergency

The chest drain bottle is above chest level

Introductory

The situation

During room rearrangement, an underwater-seal drain bottle is placed high beside the bed. The patient is currently stable but the setup no longer follows its instructions.

What should catch your attention

Drain setup changed
Backflow risk
Preventable equipment problem

Your immediate priority

Restore the approved system position below the chest as required by the device policy, without pulling the insertion site.

01Drain setup changed
02Restore the approved system position below the chest as required by the device policy, without pulling the insertion site.
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
Restore the approved system position below the chest as required by the device policy, without pulling the insertion site. [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

Check connections, drainage and the patient's breathing after correction. Continuously reassess oxygenation, perfusion and drain findings; escalate deterioration immediately.

Avoid this shortcut

Do not disconnect the system unnecessarily or carry the bottle by the tubing. 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: the chest drain bottle is above chest level. 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.

Skin & pressure protection

A nasal device is damaging the skin

Introductory

The situation

A patient needing ongoing oxygen develops soreness and a non-blanching change beneath tubing at the ear. Removing all oxygen would be unsafe.

What should catch your attention

Device pressure
Ongoing oxygen need
Skin injury beginning

Your immediate priority

Relieve device pressure using an approved alternative/support while maintaining prescribed oxygen delivery.

01Device pressure
02Relieve device pressure using an approved alternative/support while maintaining prescribed oxygen delivery.
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 device pressure using an approved alternative/support while maintaining prescribed oxygen delivery. [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

Reassess skin across its natural colour and check the new device fit. 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 massage the area or trade essential oxygenation for unplanned device removal. 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: a nasal device is damaging 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.

Communication & discharge

The spirometry explanation causes confusion

Introductory

The situation

A patient preparing for a breathing test does not understand the instructions and repeatedly performs a different maneuver. They speak limited English and are becoming embarrassed.

What should catch your attention

Instruction not understood
Test reliability affected
Language support needed

Your immediate priority

Use competent language assistance and a brief demonstration within the testing protocol; check understanding without blame.

01Instruction not understood
02Use competent language assistance and a brief demonstration within the testing protocol; check understanding without blame.
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 competent language assistance and a brief demonstration within the testing protocol; check understanding without blame. [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 the appropriate test-quality review by the trained clinician. 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 label the patient uncooperative or interpret poor-quality measurements as definitive disease severity. 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 spirometry explanation causes 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 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.

COPD & ventilatory failure

COPD symptoms worsen despite an acceptable oxygen number

Intermediate

The situation

A patient with COPD is increasingly sleepy and breathes shallowly. Their oxygen reading is within target, but ventilation and blood gases have not been reassessed.

What should catch your attention

New drowsiness
Shallow ventilation
Saturation alone incomplete

Your immediate priority

Obtain urgent review and indicated blood gases while maintaining the prescribed oxygen/ventilation plan.

01New drowsiness
02Obtain urgent review and indicated blood gases while maintaining the prescribed oxygen/ventilation 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
Obtain urgent review and indicated blood gases while maintaining the prescribed oxygen/ventilation plan. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
2
Assess beyond saturation
Check respiratory effort, alertness, fatigue and the prescribed oxygen target; obtain urgent review and ordered blood gases when indicated. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
3
Support targeted treatment
Give controlled oxygen and prescribed bronchodilator treatment; assist indicated non-invasive ventilation with trained staff. [1]
Why it matters Oxygen and ventilatory support address different parts of respiratory failure.
4
Monitor tolerance and response
Check the mask, breathing, consciousness and repeat assessment or blood gases according to the clinical plan. [1]
Why it matters Poor tolerance or worsening physiology can mean that the support strategy needs escalation.

What to look for next

Track consciousness and gas trends and prepare escalation if support fails. Monitor breathing effort, consciousness, oxygen target and prescribed gas trends, with immediate escalation of worsening ventilation.

Avoid this shortcut

Do not use the target saturation to dismiss worsening ventilation. Do not withhold life-saving oxygen from a critically hypoxic patient or assume more oxygen alone corrects ventilatory failure.

A clear way to hand it over

“I am calling about this new concern: cOPD symptoms worsen despite an acceptable oxygen number. 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 Hypercapnia means excess carbon dioxide in the blood; ventilation is movement of air in and out.

Sources behind the actions 2 primary references

NICE · NG115: COPD management
Blood-gas assessment and trained NIV for persistent hypercapnic respiratory failure.
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.

Acute airflow obstruction

Asthma wheeze becomes quieter as the patient tires

Intermediate

The situation

A patient being treated for an asthma attack is now less wheezy but can barely speak and appears exhausted. The change sounds superficially like improvement.

What should catch your attention

Reduced air movement possible
Speech limited
Exhaustion

Your immediate priority

Escalate immediately as possible life-threatening asthma and assist prescribed oxygen, bronchodilator and critical-care assessment.

01Reduced air movement possible
02Escalate immediately as possible life-threatening asthma and assist prescribed oxygen, bronchodilator and critical-care 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
Escalate immediately as possible life-threatening asthma and assist prescribed oxygen, bronchodilator and critical-care assessment. [1]
Why it matters A quieter chest or reduced effort can indicate exhaustion, not improvement.
2
Assess severity
Check speech, breathing effort, rate, consciousness, oxygenation and air entry; obtain peak flow only when suitable and safe. [1]
Why it matters A quieter chest or reduced effort can indicate exhaustion, not improvement.
3
Deliver authorized treatment
Prepare protocol-directed bronchodilators, oxygen and other prescribed acute treatment; call respiratory or resuscitation help for severe features. [1]
Why it matters Relieving bronchospasm and addressing inflammation are part of the medical pathway.
4
Reassess promptly
Compare symptoms, air entry, effort and observations after treatment and prepare escalation if response is poor. [1]
Why it matters An initial dose does not establish recovery or readiness for discharge.

What to look for next

Monitor effort, alertness, oxygenation and ordered gas results. Watch fatigue, altered consciousness, worsening oxygen need and poor response. Confirm an accessible relapse and medicine plan after stabilization.

Avoid this shortcut

Do not equate quieter wheeze with recovery when the patient is tiring. Do not assume absence of wheeze excludes danger or make a severely distressed patient perform a lengthy test.

A clear way to hand it over

“I am calling about this new concern: asthma wheeze becomes quieter as the patient tires. 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 Bronchospasm means tightening around the airways that makes airflow difficult.

Sources behind the actions 2 primary references

BTS / NICE / SIGN · Acute asthma management pathway
Separate adult and child acute-attack pathways; exhaustion and poor air movement require escalation.
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.

Airborne infection precautions

Sputum collection is planned before isolation

Intermediate

The situation

A patient with a concerning cough and exposure history is asked to produce sputum in a shared bay before infection-control review. Other patients are nearby.

What should catch your attention

Potential airborne infection
Aerosol-producing activity
Shared environment

Your immediate priority

Arrange the indicated airborne isolation and specimen-collection pathway with infection control before non-emergency collection.

01Potential airborne infection
02Arrange the indicated airborne isolation and specimen-collection pathway with infection control before non-emergency collection.
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 the indicated airborne isolation and specimen-collection pathway with infection control before non-emergency collection. [1]
Why it matters Some respiratory infections require more than ordinary contact or droplet precautions.
2
Recognize a possible transmission risk
Report concerning respiratory symptoms and exposure history; arrange the indicated isolation pathway without delaying urgent clinical care. [1]
Why it matters Some respiratory infections require more than ordinary contact or droplet precautions.
3
Protect people during care
Use the specified room, fit-tested respiratory protection and transport precautions; explain the reason simply. [1]
Why it matters Appropriate engineering and personal protection reduce exposure to infectious airborne particles.
4
Coordinate investigation and follow-up
Prepare ordered specimens and specialist/public-health review and communicate precautions at every transfer. [1]
Why it matters Diagnosis, treatment and exposure follow-up require coordinated care.

What to look for next

Confirm transport and room precautions and maintain confidentiality. Review clinical deterioration and ensure precautions follow confirmed findings and local infection-control advice.

Avoid this shortcut

Do not collect in a shared space merely to obtain a faster result. Do not send the patient through shared spaces without the required transport precautions or announce private health information to unrelated people.

A clear way to hand it over

“I am calling about this new concern: sputum collection is planned before isolation. 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 Airborne precautions reduce exposure to infectious particles that can remain suspended in air.

Sources behind the actions 2 primary references

CDC · Tuberculosis infection control in health care
Prompt detection, airborne precautions and respiratory protection.
CDC · Transmission-based precautions
Organism-specific isolation, respiratory protection and safe transport precautions.

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.

Airway secretions & suction

Secretions increase after humidification is interrupted

Intermediate

The situation

A patient with an artificial airway has thicker secretions and more breathing effort after their humidification setup was interrupted. The RN is trained for this airway device.

What should catch your attention

Humidification change
Secretions may obstruct
Artificial airway

Your immediate priority

Assess airway patency, restore the approved humidification setup and perform indicated trained suction.

01Humidification change
02Assess airway patency, restore the approved humidification setup and perform indicated trained suction.
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 airway patency, restore the approved humidification setup and perform indicated trained suction. [1]
Why it matters A sound or alarm alone does not prove that suction is the correct intervention.
2
Check the patient and airway
Assess breathing, oxygenation, audible secretions, airway patency and the available ventilator information. [1]
Why it matters A sound or alarm alone does not prove that suction is the correct intervention.
3
Prepare a safe procedure
Use the device-specific suction method, prescribed preparation and infection-control technique within demonstrated competency. [1]
Why it matters Suction can cause hypoxemia or trauma when performed unnecessarily or incorrectly.
4
Reassess immediately
Check tolerance, breathing, oxygenation and airway function after the intervention; seek help for persistent obstruction. [1]
Why it matters Failure to improve requires a wider airway and ventilation assessment.

What to look for next

Monitor secretion burden and ventilatory response and escalate persistent difficulty. Track the response and stop/escalate if significant physiological deterioration occurs during the procedure.

Avoid this shortcut

Do not repeatedly suction without checking the cause of thickened secretions. Do not repeatedly suction an unexplained ventilation problem or routinely instill saline without an indicated protocol.

A clear way to hand it over

“I am calling about this new concern: secretions increase after humidification is interrupted. 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 Suction removes secretions; it does not correct every cause of difficult ventilation.

Sources behind the actions 2 primary references

AARC · Artificial Airway Suctioning guideline (2022)
Indicated trained suction, physiological monitoring and generally avoiding routine saline instillation.
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.

Swallowing & aspiration

A cough during meals after respiratory admission

Intermediate

The situation

A patient recovering from respiratory illness coughs after drinks and their voice sounds wet. They have become weaker during admission, but no swallow assessment has been completed.

What should catch your attention

Meal-related cough
Wet voice
New weakness

Your immediate priority

Pause unsafe oral intake and request the appropriate swallow assessment and interim nutrition/medicine plan.

01Meal-related cough
02Pause unsafe oral intake and request the appropriate swallow assessment and interim nutrition/medicine 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
Pause unsafe oral intake and request the appropriate swallow assessment and interim nutrition/medicine plan. [1]
Why it matters Continuing intake while swallowing is unsafe can put material into the airway.
2
Protect the airway
Stop the food, drink or oral medicine causing concern, sit the person appropriately and assess breathing. Call emergency help for airway compromise. [1]
Why it matters Continuing intake while swallowing is unsafe can put material into the airway.
3
Use the agreed pathway
Follow the approved screen only if trained and the person is suitable. Refer to the swallowing team and clarify safe medicine and nutrition routes. [1]
Why it matters A bedside observation cannot reliably exclude silent aspiration or prescribe a safe texture for everyone.
4
Make the plan visible
Communicate the agreed intake, positioning and supervision plan to all carers and monitor hydration, nutrition and mouth care. [1]
Why it matters A swallowing recommendation helps only when every meal and medicine round follows it.

What to look for next

Monitor breathing and follow the documented safe-intake recommendations. Watch for respiratory change, wet voice, coughing, intake failure or dehydration. Reassess when alertness, illness or swallowing ability changes.

Avoid this shortcut

Do not use absence of fever to exclude aspiration risk. Do not repeatedly test with water, thicken everything without assessment or assume no cough means no aspiration.

A clear way to hand it over

“I am calling about this new concern: a cough during meals after respiratory admission. 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 Aspiration means material enters the airway; silent aspiration may occur without coughing.

Sources behind the actions 1 primary references

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.

Pleural & ventilation emergency

New breathlessness after a pleural procedure

Difficult

The situation

After a pleural procedure, a patient develops unilateral pain and increasing dyspnea. They are not yet profoundly hypotensive, but the change is new and progressive.

What should catch your attention

Temporal procedure relationship
Unilateral symptoms
Progression

Your immediate priority

Seek urgent respiratory assessment and prepare ordered imaging while supporting prescribed oxygen and monitoring.

01Temporal procedure relationship
02Seek urgent respiratory assessment and prepare ordered imaging while supporting prescribed oxygen and monitoring.
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 urgent respiratory assessment and prepare ordered imaging while supporting prescribed oxygen and monitoring. [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

Escalate immediately if perfusion or ventilation deteriorates. Continuously reassess oxygenation, perfusion and drain findings; escalate deterioration immediately.

Avoid this shortcut

Do not wait for a dramatic saturation fall before reporting the change. 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: new breathlessness after a pleural 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 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.

Clot & breathing emergency

Sudden pleuritic pain during recovery from pneumonia

Difficult

The situation

A patient improving from pneumonia develops abrupt pleuritic pain and a new oxygen requirement. They have been immobile, and the new pattern differs from their earlier symptoms.

What should catch your attention

Abrupt new pattern
Immobility
Rising oxygen need

Your immediate priority

Arrange urgent assessment for PE and other causes, communicating the change from baseline and bleeding risks.

01Abrupt new pattern
02Arrange urgent assessment for PE and other causes, communicating the change from baseline and bleeding risks.
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 assessment for PE and other causes, communicating the change from baseline and bleeding risks. [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

Monitor perfusion and breathing through the diagnostic pathway. Trend breathing, oxygen needs and circulation; new syncope, hypotension or increasing distress requires further immediate escalation.

Avoid this shortcut

Do not assume every respiratory symptom is explained by the existing pneumonia. 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: sudden pleuritic pain during recovery from pneumonia. 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.

COPD & ventilatory failure

NIV causes distress and a poor seal

Difficult

The situation

A patient on NIV removes the mask repeatedly because it hurts and feels frightening. Their gas results still show respiratory failure. Reassurance alone is not correcting support.

What should catch your attention

Interface pain
Support interrupted
Ongoing respiratory failure

Your immediate priority

Seek trained respiratory review of fit, skin protection, communication and ventilator tolerance while assessing the patient's physiology.

01Interface pain
02Seek trained respiratory review of fit, skin protection, communication and ventilator tolerance while assessing the patient's physiology.
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 trained respiratory review of fit, skin protection, communication and ventilator tolerance while assessing the patient's physiology. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
2
Assess beyond saturation
Check respiratory effort, alertness, fatigue and the prescribed oxygen target; obtain urgent review and ordered blood gases when indicated. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
3
Support targeted treatment
Give controlled oxygen and prescribed bronchodilator treatment; assist indicated non-invasive ventilation with trained staff. [1]
Why it matters Oxygen and ventilatory support address different parts of respiratory failure.
4
Monitor tolerance and response
Check the mask, breathing, consciousness and repeat assessment or blood gases according to the clinical plan. [1]
Why it matters Poor tolerance or worsening physiology can mean that the support strategy needs escalation.

What to look for next

Track response and recognize when NIV is failing or unsafe. Monitor breathing effort, consciousness, oxygen target and prescribed gas trends, with immediate escalation of worsening ventilation.

Avoid this shortcut

Do not use unprescribed sedation merely to force mask tolerance. Do not withhold life-saving oxygen from a critically hypoxic patient or assume more oxygen alone corrects ventilatory failure.

A clear way to hand it over

“I am calling about this new concern: nIV causes distress and a poor seal. 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 Hypercapnia means excess carbon dioxide in the blood; ventilation is movement of air in and out.

Sources behind the actions 2 primary references

NICE · NG115: COPD management
Blood-gas assessment and trained NIV for persistent hypercapnic respiratory failure.
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.

Tracheostomy & neck airway

A tracheostomy speaking valve is left on during distress

Difficult

The situation

A patient using a speaking valve becomes increasingly distressed. Their airway configuration and cuff status require immediate checking by trained staff.

What should catch your attention

Device-related airway concern
Distress
Cuff/anatomy matters

Your immediate priority

Activate the tracheostomy assessment pathway and remove the speaking valve according to the trained emergency protocol while checking ventilation and cuff instructions.

01Device-related airway concern
02Activate the tracheostomy assessment pathway and remove the speaking valve according to the trained emergency protocol while checking ventilation and cuff 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
Activate the tracheostomy assessment pathway and remove the speaking valve according to the trained emergency protocol while checking ventilation and cuff instructions. [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

Confirm improved airflow and review suitability before reuse. Keep reassessing airflow, chest movement, consciousness and oxygenation throughout the emergency and after tube management.

Avoid this shortcut

Do not attach or continue a speaking valve without the required airway/cuff assessment. 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: a tracheostomy speaking valve is left on during distress. 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.

Infection & shock

Respiratory infection progresses to shock without high fever

Difficult

The situation

A patient with respiratory infection becomes confused, tachypneic and hypotensive. Their temperature is not high, and they have immunosuppressive treatment.

What should catch your attention

Shock signs
Altered consciousness
Fever may be absent

Your immediate priority

Activate emergency sepsis/deterioration response and communicate immunosuppression and the respiratory source concern.

01Shock signs
02Activate emergency sepsis/deterioration response and communicate immunosuppression and the respiratory source concern.
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 sepsis/deterioration response and communicate immunosuppression and the respiratory source concern. [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 circulation, oxygen requirement and prescribed antimicrobial/resuscitation response. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not require a high fever before recognizing severe infection. 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: respiratory infection progresses to shock without high fever. 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.

Tracheostomy & neck airway

A blocked tracheostomy in a fresh stoma

Extremely difficult

The situation

A recently tracheostomized patient cannot breathe effectively and a suction catheter will not pass. A replacement tube is nearby but staff are unfamiliar with the fresh tract.

What should catch your attention

Possible obstruction/displacement
Fresh tract
Catheter cannot pass

Your immediate priority

Call the expert airway team and follow the anatomy-specific emergency algorithm with oxygenation support.

01Possible obstruction/displacement
02Call the expert airway team and follow the anatomy-specific emergency algorithm with oxygenation 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
Call the expert airway team and follow the anatomy-specific emergency algorithm with oxygenation support. [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

Confirm effective ventilation and a documented rescue plan after stabilization. Keep reassessing airflow, chest movement, consciousness and oxygenation throughout the emergency and after tube management.

Avoid this shortcut

Do not blindly force the spare tube into a fresh tract. 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: a blocked tracheostomy in a fresh stoma. 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.

Tracheostomy & neck airway

A total laryngectomy patient receives face-mask ventilation

Extremely difficult

The situation

A breathless patient has a permanent neck stoma after total laryngectomy. A face mask is being used, but the lungs are not connected to the mouth or nose.

What should catch your attention

Separate airway anatomy
Incorrect ventilation route
Urgent hypoxia risk

Your immediate priority

State the anatomy clearly and direct trained oxygenation/ventilation through the stoma under the laryngectomy response.

01Separate airway anatomy
02State the anatomy clearly and direct trained oxygenation/ventilation through the stoma under the laryngectomy response.
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 anatomy clearly and direct trained oxygenation/ventilation through the stoma under the laryngectomy response. [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

Verify chest movement and effective ventilation through the correct route. Keep reassessing airflow, chest movement, consciousness and oxygenation throughout the emergency and after tube management.

Avoid this shortcut

Do not confuse total laryngectomy with every type of tracheostomy. 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: a total laryngectomy patient receives face-mask 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 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.

Pleural & ventilation emergency

Tension pneumothorax during ventilatory support

Extremely difficult

The situation

A ventilated patient suddenly develops severe hypoxia and hypotension with new unilateral chest findings. A time-critical pressure problem is possible.

What should catch your attention

Sudden respiratory/circulatory collapse
Positive-pressure support
Unilateral findings

Your immediate priority

Activate immediate emergency/critical-care assessment and prepare urgent decompression by appropriately trained authorized staff when indicated.

01Sudden respiratory/circulatory collapse
02Activate immediate emergency/critical-care assessment and prepare urgent decompression by appropriately trained authorized staff when indicated.
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 immediate emergency/critical-care assessment and prepare urgent decompression by appropriately trained authorized staff when indicated. [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

Monitor ventilation and perfusion through rescue and subsequent drain management. Continuously reassess oxygenation, perfusion and drain findings; escalate deterioration immediately.

Avoid this shortcut

Do not delay an unstable suspected tension emergency solely to obtain routine imaging. 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: tension pneumothorax during ventilatory 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 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.

Bleeding & circulation

A large airway bleed threatens ventilation

Extremely difficult

The situation

A patient coughs substantial fresh blood and becomes unable to clear the airway effectively. Oxygenation falls and the bleeding side is not yet known.

What should catch your attention

Airway threatened by blood
Hypoxia
Source uncertain

Your immediate priority

Activate the airway/major-bleeding response and prepare suction and specialist respiratory support, using team-directed positioning and treatment.

01Airway threatened by blood
02Activate the airway/major-bleeding response and prepare suction and specialist respiratory support, using team-directed positioning and 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
Activate the airway/major-bleeding response and prepare suction and specialist respiratory support, using team-directed positioning and treatment. [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 airway clearance, perfusion and the measured bleeding pattern. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not leave the patient alone or independently choose a bleeding-side position when the source is unknown. 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 large airway bleed threatens 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 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.

Severe allergic reaction

Anaphylaxis during an IV respiratory medicine

Extremely difficult

The situation

Soon after an IV medicine begins, a patient develops wheeze, swelling and hypotension. Their known asthma makes the respiratory sound easy to misattribute.

What should catch your attention

New medicine exposure
Multiple systems affected
Shock

Your immediate priority

Activate anaphylaxis treatment immediately and stop the suspected trigger while supporting the authorized epinephrine and airway response.

01New medicine exposure
02Activate anaphylaxis treatment immediately and stop the suspected trigger while supporting the authorized epinephrine and airway response.
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 treatment immediately and stop the suspected trigger while supporting the authorized epinephrine and airway response. [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 recurrence and document the product and exposure times. Continuously review breathing, perfusion and response. Escalate ongoing compromise and arrange allergy documentation and follow-up after stabilization.

Avoid this shortcut

Do not treat this as asthma alone or rely on antihistamines for shock. 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: anaphylaxis during an IV respiratory medicine. 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.

COPD & ventilatory failure

Carbon-dioxide retention worsens during transport preparation

Extremely difficult

The situation

A patient with acute ventilatory failure becomes more obtunded while waiting to travel for imaging. Their gas results are worsening despite current support.

What should catch your attention

Worsening consciousness
Gas deterioration
Transport could reduce rescue access

Your immediate priority

Request urgent critical-care review and postpone unsafe transfer until the support and escort plan match current needs.

01Worsening consciousness
02Request urgent critical-care review and postpone unsafe transfer until the support and escort plan match current needs.
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 urgent critical-care review and postpone unsafe transfer until the support and escort plan match current needs. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
2
Assess beyond saturation
Check respiratory effort, alertness, fatigue and the prescribed oxygen target; obtain urgent review and ordered blood gases when indicated. [1]
Why it matters Oxygen saturation alone does not show whether carbon dioxide is accumulating.
3
Support targeted treatment
Give controlled oxygen and prescribed bronchodilator treatment; assist indicated non-invasive ventilation with trained staff. [1]
Why it matters Oxygen and ventilatory support address different parts of respiratory failure.
4
Monitor tolerance and response
Check the mask, breathing, consciousness and repeat assessment or blood gases according to the clinical plan. [1]
Why it matters Poor tolerance or worsening physiology can mean that the support strategy needs escalation.

What to look for next

Monitor ventilation and airway protection continuously. Monitor breathing effort, consciousness, oxygen target and prescribed gas trends, with immediate escalation of worsening ventilation.

Avoid this shortcut

Do not switch off necessary support merely to make the transport equipment fit. Do not withhold life-saving oxygen from a critically hypoxic patient or assume more oxygen alone corrects ventilatory failure.

A clear way to hand it over

“I am calling about this new concern: carbon-dioxide retention worsens during transport preparation. 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 Hypercapnia means excess carbon dioxide in the blood; ventilation is movement of air in and out.

Sources behind the actions 2 primary references

NICE · NG115: COPD management
Blood-gas assessment and trained NIV for persistent hypercapnic respiratory failure.
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.

Ventilator & artificial airway

An artificial-airway obstruction does not resolve with suction

Extremely difficult

The situation

A ventilated patient remains difficult to ventilate after appropriately performed suction. The circuit and tube position may be involved, and saturation is falling.

What should catch your attention

Persistent ventilation failure
Suction did not resolve
Equipment or airway cause

Your immediate priority

Call airway experts immediately and assist the device/circuit/patient checks and emergency ventilation plan.

01Persistent ventilation failure
02Call airway experts immediately and assist the device/circuit/patient checks and emergency ventilation 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
Call airway experts immediately and assist the device/circuit/patient checks and emergency ventilation plan. [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 effective ventilation after every intervention and record the suspected cause. Trend chest movement, respiratory effort, saturation, capnography when used and the ordered blood gases. Escalate persistent failure immediately.

Avoid this shortcut

Do not repeat suction indefinitely while deterioration continues. 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 artificial-airway obstruction does not resolve with suction. 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.

Acute airflow obstruction

Severe asthma with altered consciousness

Extremely difficult

The situation

A patient with severe asthma becomes confused and increasingly exhausted despite initial prescribed treatment. They cannot complete sentences and their respiratory effort is changing.

What should catch your attention

Altered consciousness
Exhaustion
Failure of initial treatment

Your immediate priority

Activate senior respiratory/critical-care rescue and prepare escalation of ventilatory support while continuing authorized treatment.

01Altered consciousness
02Activate senior respiratory/critical-care rescue and prepare escalation of ventilatory support while continuing authorized 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
Activate senior respiratory/critical-care rescue and prepare escalation of ventilatory support while continuing authorized treatment. [1]
Why it matters A quieter chest or reduced effort can indicate exhaustion, not improvement.
2
Assess severity
Check speech, breathing effort, rate, consciousness, oxygenation and air entry; obtain peak flow only when suitable and safe. [1]
Why it matters A quieter chest or reduced effort can indicate exhaustion, not improvement.
3
Deliver authorized treatment
Prepare protocol-directed bronchodilators, oxygen and other prescribed acute treatment; call respiratory or resuscitation help for severe features. [1]
Why it matters Relieving bronchospasm and addressing inflammation are part of the medical pathway.
4
Reassess promptly
Compare symptoms, air entry, effort and observations after treatment and prepare escalation if response is poor. [1]
Why it matters An initial dose does not establish recovery or readiness for discharge.

What to look for next

Follow gas, consciousness and circulation trends, with continuous supervision. Watch fatigue, altered consciousness, worsening oxygen need and poor response. Confirm an accessible relapse and medicine plan after stabilization.

Avoid this shortcut

Do not wait for complete respiratory arrest before seeking airway support. Do not assume absence of wheeze excludes danger or make a severely distressed patient perform a lengthy test.

A clear way to hand it over

“I am calling about this new concern: severe asthma with altered consciousness. 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 Bronchospasm means tightening around the airways that makes airflow difficult.

Sources behind the actions 2 primary references

BTS / NICE / SIGN · Acute asthma management pathway
Separate adult and child acute-attack pathways; exhaustion and poor air movement require escalation.
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.

Clot & breathing emergency

Possible PE with collapse and recent intracranial bleeding

Extremely difficult

The situation

A patient develops sudden profound dyspnea and circulatory collapse after prolonged immobility. Their history includes recent intracranial bleeding, which critically affects rescue decisions.

What should catch your attention

Life-threatening cardiopulmonary change
Thrombotic risk
Major bleeding contraindication concern

Your immediate priority

Activate emergency specialist assessment and prominently communicate the intracranial-bleeding timeline before any antithrombotic/reperfusion decision.

01Life-threatening cardiopulmonary change
02Activate emergency specialist assessment and prominently communicate the intracranial-bleeding timeline before any antithrombotic/reperfusion decision.
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 specialist assessment and prominently communicate the intracranial-bleeding timeline before any antithrombotic/reperfusion decision. [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/perfusion support and prepare ordered diagnostics or intervention. Trend breathing, oxygen needs and circulation; new syncope, hypotension or increasing distress requires further immediate escalation.

Avoid this shortcut

Do not independently select anticoagulation or thrombolysis from the suspected diagnosis alone. 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 with collapse and recent intracranial bleeding. 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

Several respiratory threats occur during an evacuation

Extremely difficult

The situation

During an urgent relocation, a ventilated patient needs portable support, a chest drain and a continuous infusion. Oxygen reserves and the receiving location's rescue capability are uncertain.

What should catch your attention

Multiple essential systems
Limited transport supplies
Destination readiness unknown

Your immediate priority

Coordinate a trained transport team, verify each essential support and sufficient reserves and identify a safe receiving destination.

01Multiple essential systems
02Coordinate a trained transport team, verify each essential support and sufficient reserves and identify a safe receiving destination.
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
Coordinate a trained transport team, verify each essential support and sufficient reserves and identify a safe receiving destination. [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

Continuously observe ventilation/perfusion and have a clear deterioration and return plan. Monitor during travel and reassess immediately on arrival; verify all connections, prescribed settings and continuing treatments.

Avoid this shortcut

Do not move first and discover missing support at the destination. 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: several respiratory threats occur during an evacuation. 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

Respiratory Care

The inhaler technique is ineffective

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

Oxygen tubing is trapped under a bed wheel

What should catch your attention

What the RN should do—and why

Respond to the situation first

Look at the patient

Support and escalate

Check the equipment and response

What to look for next

Avoid this shortcut

A clear way to hand it over

The chest drain bottle is above chest level

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize acute change

Prepare urgent treatment

Monitor the drainage plan

What to look for next

Avoid this shortcut

A clear way to hand it over

A nasal device is damaging 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

The spirometry explanation causes confusion

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

COPD symptoms worsen despite an acceptable oxygen number

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess beyond saturation

Support targeted treatment

Monitor tolerance and response

What to look for next

Avoid this shortcut

A clear way to hand it over

Asthma wheeze becomes quieter as the patient tires

What should catch your attention

What the RN should do—and why

Respond to the situation first

Assess severity

Deliver authorized treatment

Reassess promptly

What to look for next

Avoid this shortcut

A clear way to hand it over

Sputum collection is planned before isolation

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize a possible transmission risk

Protect people during care

Coordinate investigation and follow-up

What to look for next

Avoid this shortcut