Department 02 · 25 scenarios

Long-Term 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

Mobility & fall prevention

The walking aid is out of reach

Introductory

The situation

A resident usually walks with a frame and one helper. At night they try to reach the toilet without the frame. They are unsteady but alert, and an unfamiliar agency worker assumes they walk independently.

What should catch your attention

Missing walking aid
Changed staffing
Urgent toileting need

Your immediate priority

Restore the documented assistance level and plan timely toileting rather than relying on the bell alone.

01Missing walking aid
02Restore the documented assistance level and plan timely toileting rather than relying on the bell 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
Restore the documented assistance level and plan timely toileting rather than relying on the bell alone. [1]
Why it matters A fall can happen while staff are trying to finish an otherwise routine activity.
2
Make movement safe
Stay with the person, help them sit or lie safely and call for assistance. Use the assessed transfer equipment and assistance level. [1]
Why it matters A fall can happen while staff are trying to finish an otherwise routine activity.
3
Assess before restarting
Check symptoms, vital signs, medication timing and mobility compared with baseline. Escalate persistent faintness, injury or new neurological signs. [1]
Why it matters The cause may be illness or a medicine effect; an alarm alone does not address it.
4
Update the plan
Arrange an individualized falls and mobility review, explain how to request help and hand over the new assistance needs. [1]
Why it matters Matching supervision and equipment to the person reduces preventable repeat exposure.

What to look for next

Check the transfer plan is visible to every shift. Recheck symptoms and safe transfer ability before another attempt. New chest pain, breathlessness, bleeding or reduced alertness warrants urgent clinical help.

Avoid this shortcut

Do not treat an alarm as a replacement for assistance. Do not continue an unsafe walk, use a blanket restraint or assume dizziness always means dehydration.

A clear way to hand it over

“I am calling about this new concern: the walking aid is out of reach. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

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

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

Sources behind the actions 2 primary references

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

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

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

© 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

Red skin beneath a continence pad

Introductory

The situation

A resident with limited movement has damp skin and new discomfort around the buttocks. One area lies over a bony point; another is exposed to urine. The skin findings were not described at the previous handover.

What should catch your attention

Moisture exposure
Pressure over bone
New discomfort

Your immediate priority

Ask the wound clinician to distinguish moisture damage from pressure injury and address both risks.

01Moisture exposure
02Ask the wound clinician to distinguish moisture damage from pressure injury and address both 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
Ask the wound clinician to distinguish moisture damage from pressure injury and address both risks. [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 skin comfort, dryness and whether pressure is relieved. 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 call every red patch a pressure ulcer or apply one treatment to all damage. 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: red skin beneath a continence pad. 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.

Medication safety

Two versions of a discharge medicine list

Introductory

The situation

A new resident arrives with a hospital list and an older home list. Both contain the same antihypertensive under different names. The evening round is due and no reconciliation has been completed.

What should catch your attention

Recent transfer
Different medicine names
Possible duplicate dose

Your immediate priority

Verify generic and brand names with pharmacy and resolve the duplicate before administration.

01Recent transfer
02Verify generic and brand names with pharmacy and resolve the duplicate before administration.
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 generic and brand names with pharmacy and resolve the duplicate before administration. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
2
Pause and verify
Check two approved identifiers, the current order, allergy history, formulation, last dose and the actual medicine supplied. [1]
Why it matters A familiar-looking package or copied list cannot establish the right medicine for this person.
3
Clarify with the team
Contact the prescriber and pharmacist about the discrepancy. Explain urgent omitted-dose risks and obtain a documented safe plan. [1]
Why it matters Both giving the wrong medicine and delaying a time-critical medicine can harm the patient.
4
Close the loop
Record the resolved order, administration decision and monitoring plan; tell the receiving team about any remaining uncertainty. [1]
Why it matters A corrected chart must reach the bedside and the next handover to prevent repetition.

What to look for next

Check the final chart and handover reflect the agreed regimen. Watch for adverse effects or effects of a delayed dose according to the medicine. Escalate any deterioration rather than wait for routine pharmacy review.

Avoid this shortcut

Do not combine both lists to be safe. Do not guess a dose, crush an unsuitable formulation or silently copy conflicting medication lists.

A clear way to hand it over

“I am calling about this new concern: two versions of a discharge medicine list. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

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

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

Sources behind the actions 2 primary references

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

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

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

Communication & discharge

The resident nods but cannot explain the plan

Introductory

The situation

A resident who speaks little English agrees to a new inhaler. When asked to demonstrate, they open the device incorrectly and say their daughter normally manages medicines. Discharge transport is already booked.

What should catch your attention

Language barrier
Incorrect demonstration
Support role unclear

Your immediate priority

Arrange an interpreter and teach-back with the person and agreed carer; clarify who can safely help at home.

01Language barrier
02Arrange an interpreter and teach-back with the person and agreed carer; clarify who can safely help at home.
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 an interpreter and teach-back with the person and agreed carer; clarify who can safely help at home. [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 access to the correct device and follow-up contact. 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 infer understanding from nodding. 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 resident nods but cannot explain the plan. 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.

Hydration & frailty

Fluids remain untouched throughout the shift

Introductory

The situation

A resident’s drinks are full at evening handover. Their hands are painful and the cup is heavy. They have no swallowing symptoms and no fluid restriction, but staff have charted that drinks were offered.

What should catch your attention

Poor actual intake
Difficult cup
Intact swallowing

Your immediate priority

Offer an appropriate cup and direct help; record intake rather than the number of offers.

01Poor actual intake
02Offer an appropriate cup and direct help; record intake rather than the number of offers.
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
Offer an appropriate cup and direct help; record intake rather than the number of offers. [1]
Why it matters Reduced intake can have treatable causes, while symptoms alone do not measure the deficit.
2
Measure the change
Check intake, urine, weight, vital signs, mouth comfort and recent losses; compare with baseline. [1]
Why it matters Reduced intake can have treatable causes, while symptoms alone do not measure the deficit.
3
Match support to safety
Offer accessible oral fluids only when swallowing and the care plan permit. Seek a prescribed replacement plan when intake is inadequate or circulation is unstable. [1]
Why it matters Heart or kidney disease may limit how much fluid can safely be given.
4
Check response
Record all intake and losses, provide mouth care and review the cause with the team. [1]
Why it matters Replacement without addressing access, nausea, medicines or illness may not solve the problem.

What to look for next

Look for urine and alertness changes as well as improved access. Review urine, alertness, breathing and weight trends. Escalate shock, worsening confusion or signs of fluid overload.

Avoid this shortcut

Do not record an offered drink as consumed. Do not force oral drinks with unsafe swallowing or automatically give large fluid volumes.

A clear way to hand it over

“I am calling about this new concern: fluids remain untouched throughout the shift. 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 Fluid balance compares fluid entering and leaving the body.

Sources behind the actions 1 primary references

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.

Time-critical medicines

A usual tablet is now impossible to swallow

Intermediate

The situation

A resident with Parkinson disease coughs when swallowing and their levodopa is due. The nurse finds only a modified-release tablet and is asked to crush it so the medicine is not late.

What should catch your attention

Unsafe swallowing
Time-critical medicine
Modified-release tablet

Your immediate priority

Pause the unsafe oral attempt and urgently obtain a pharmacist and prescriber-approved route and formulation plan.

01Unsafe swallowing
02Pause the unsafe oral attempt and urgently obtain a pharmacist and prescriber-approved route and formulation 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 the unsafe oral attempt and urgently obtain a pharmacist and prescriber-approved route and formulation plan. [1]
Why it matters Parkinson treatment often depends on individual timing rather than a standard ward round.
2
Confirm the regimen
Check the patient’s exact medicine schedule, formulation and last dose with the current order and reconciliation record. [1]
Why it matters Parkinson treatment often depends on individual timing rather than a standard ward round.
3
Escalate route or supply problems
Contact the prescriber and pharmacist promptly if swallowing, fasting or availability prevents administration. [1]
Why it matters Sudden interruption can worsen movement and swallowing and may lead to severe complications.
4
Monitor and hand over
Use the authorized alternative plan and document symptoms, timing and follow-up; support safe mobility and swallowing. [1]
Why it matters A missed dose can affect several bedside risks and needs a coordinated response.

What to look for next

Monitor swallowing, stiffness and the actual delay. Review stiffness, mobility, swallowing, alertness and temperature. Marked rigidity, fever or instability needs urgent help.

Avoid this shortcut

Do not crush the modified-release tablet or simply omit every dose. Do not crush modified-release medicines or abruptly stop treatment without a specialist plan.

A clear way to hand it over

“I am calling about this new concern: a usual tablet is now impossible to swallow. 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 Time-critical means a delay can materially affect the medicine’s benefit or safety.

Sources behind the actions 2 primary references

NICE · NG71: Parkinson disease in adults
Individual medicine timing and avoiding abrupt interruption.
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.

Swallowing & aspiration

Repeated coughing at lunch

Intermediate

The situation

A resident recovering from pneumonia coughs on thin drinks and has a wet voice. Their usual swallow plan was written months ago, before this illness. A visitor continues feeding while the nurse checks the chart.

What should catch your attention

New cough
Wet voice
Old swallow plan

Your immediate priority

Stop the current unsafe intake, explain the concern and request reassessment after the change in health.

01New cough
02Stop the current unsafe intake, explain the concern and request reassessment after the change in health.
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 current unsafe intake, explain the concern and request reassessment after the change in health. [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

Check breathing and the agreed medicine and hydration routes. Watch for respiratory change, wet voice, coughing, intake failure or dehydration. Reassess when alertness, illness or swallowing ability changes.

Avoid this shortcut

Do not let an old care plan override new symptoms. 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: repeated coughing at lunch. 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.

Infection control

Several residents develop diarrhea

Intermediate

The situation

Three residents in one corridor develop new diarrhea over two days. One recently received antibiotics. Staff share a commode and assume the outbreak is a mild stomach upset without notifying the infection lead.

What should catch your attention

Cluster of illness
Shared equipment
Recent antibiotic exposure

Your immediate priority

Start the facility outbreak pathway and arrange appropriate testing and cleaning while assessing each resident’s hydration.

01Cluster of illness
02Start the facility outbreak pathway and arrange appropriate testing and cleaning while assessing each resident’s hydration.
03Check response + communicate

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

What the RN should do—and why

1
Respond to the situation first
Start the facility outbreak pathway and arrange appropriate testing and cleaning while assessing each resident’s hydration. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
2
Apply the right precautions
Use standard precautions plus the indicated contact, droplet or airborne precautions; follow the facility’s placement and PPE pathway. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
3
Assess clinical severity
Check breathing, alertness, vital signs and hydration, and request diagnostic review when indicated. [1]
Why it matters Infection control cannot replace clinical treatment of a deteriorating patient.
4
Protect shared care
Use dedicated or cleaned equipment, appropriate hand hygiene and environmental cleaning; communicate precautions during transfer. [1]
Why it matters Organisms can spread through staff hands, equipment and unclear handovers.

What to look for next

Track new illness and any physiological decline. Watch for new cases, ongoing symptoms and deterioration. Recheck that precautions remain appropriate as the diagnosis or test results change.

Avoid this shortcut

Do not give one resident’s leftover antibiotics to another. Do not delay emergency care while seeking a perfect room or assume gloves replace hand hygiene.

A clear way to hand it over

“I am calling about this new concern: several residents develop diarrhea. 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 Transmission-based precautions add measures to routine infection prevention.

Sources behind the actions 2 primary references

CDC · Clinical safety: hand hygiene for healthcare workers
Gown/gloves and hand hygiene; soap and water when visibly soiled and as an additional precaution in C. diff outbreaks. Alcohol rub access should remain available.
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.

Bowel function & comfort

Loose stool after days without a formed bowel movement

Intermediate

The situation

A resident taking an opioid has small watery stools after several days without a normal bowel movement. They describe rectal pressure and reduced appetite. The chart labels this diarrhea and suggests an antidiarrheal.

What should catch your attention

Opioid exposure
No usual stool
Possible overflow

Your immediate priority

Seek assessment for impaction before treating the watery stool as uncomplicated diarrhea.

01Opioid exposure
02Seek assessment for impaction before treating the watery stool as uncomplicated diarrhea.
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 assessment for impaction before treating the watery stool as uncomplicated diarrhea. [1]
Why it matters Overflow stool can coexist with impaction, and a changed pattern needs assessment.
2
Check the pattern
Review stool frequency and consistency, pain, intake, mobility and medicines; assess abdomen and observations within competence. [1]
Why it matters Overflow stool can coexist with impaction, and a changed pattern needs assessment.
3
Identify urgent concerns
Escalate severe pain, vomiting, distension, blood or physiological decline before routine bowel treatment. [1]
Why it matters Obstruction or serious illness needs a different plan from uncomplicated constipation.
4
Follow the bowel plan
Use prescribed bowel measures, appropriate hydration and supported toileting; document response and request review if ineffective. [1]
Why it matters An individualized routine and medication review address contributing causes.

What to look for next

Recheck abdomen, comfort and stool after the prescribed plan. Review stool, comfort and abdominal change. Persistent symptoms or new red flags need prompt reassessment.

Avoid this shortcut

Do not automatically give an antidiarrheal. Do not repeatedly give laxatives or enemas when obstruction is suspected.

A clear way to hand it over

“I am calling about this new concern: loose stool after days without a formed bowel movement. 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 Impaction is a large retained stool mass; overflow is liquid stool leaking around it.

Sources behind the actions 2 primary references

NIDDK · Constipation: symptoms and causes
Constipation history and warning symptoms requiring prompt assessment.
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.

Urinary drainage

The drainage bag is empty and the lower abdomen hurts

Intermediate

The situation

A catheterized resident has increasing lower abdominal discomfort. The bag is empty although intake has continued. Tubing is trapped under the leg; the nurse can release it safely without disconnecting anything.

What should catch your attention

Painful bladder area
No drainage
Trapped tubing

Your immediate priority

Correct the kink first, then obtain review if pain or absent output persists.

01Painful bladder area
02Correct the kink first, then obtain review if pain or absent output persists.
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
Correct the kink first, then obtain review if pain or absent output persists. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
2
Check simple causes
Assess pain and bladder symptoms, tubing kinks, bag position and recent urine output; keep drainage unobstructed below bladder level. [1]
Why it matters Poor flow can be caused by tubing position, but low output can also reflect serious illness.
3
Escalate persistent problems
Follow the trained catheter assessment pathway for suspected obstruction, leakage, trauma or retention; obtain a clinical plan. [1]
Why it matters Repeated manipulation or unplanned irrigation can injure tissue and introduce infection.
4
Review the indication
Document output and catheter findings, provide appropriate hygiene and ask whether the catheter is still needed. [1]
Why it matters Removing unnecessary catheters reduces infection risk and supports mobility.

What to look for next

Measure actual output and symptom relief after correction. Check relief of bladder symptoms and restored drainage. Fever, bleeding, severe pain or continued low output needs prompt review.

Avoid this shortcut

Do not repeatedly irrigate a catheter without an authorized assessment plan. Do not disconnect the system to improve flow, routinely irrigate or treat cloudy urine alone as infection.

A clear way to hand it over

“I am calling about this new concern: the drainage bag is empty and the lower abdomen hurts. 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 closed system keeps the catheter connected to its drainage equipment.

Sources behind the actions 1 primary references

CDC · CAUTI prevention: summary of recommendations
Closed, unobstructed catheter drainage, appropriate indication and avoidance of routine bladder irrigation.

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.

Person-centred dementia care

Distress during every morning wash

Difficult

The situation

A resident with dementia becomes distressed when a new carer starts bathing. They point toward an arthritic shoulder and resist lifting that arm. Outside washing they appear settled and communicate with short phrases.

What should catch your attention

Activity-linked distress
Pain cue
New carer

Your immediate priority

Adapt washing to comfort, provide the prescribed pain plan and use a familiar approach with consent.

01Activity-linked distress
02Adapt washing to comfort, provide the prescribed pain plan and use a familiar approach with consent.
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
Adapt washing to comfort, provide the prescribed pain plan and use a familiar approach with consent. [1]
Why it matters Distress can be a way of communicating discomfort when words are difficult.
2
Listen and compare
Use a calm approach, ask familiar carers about baseline and assess pain, toileting, hunger, environment and sensory needs. [1]
Why it matters Distress can be a way of communicating discomfort when words are difficult.
3
Change the trigger
Offer appropriate pain review, quiet space, orientation, familiar routines and supported choices; assess sudden change for delirium. [1]
Why it matters Meeting the underlying need is safer than simply suppressing the response.
4
Agree a least-restrictive plan
Involve the person, carers and clinical team; document helpful approaches and review any proposed sedating medicine carefully. [1]
Why it matters Restraint or sedation can add falls, aspiration and other risks without addressing the cause.

What to look for next

Check whether the changed technique reduces distress. Check distress, comfort and function after changes. New physiological or cognitive decline needs medical assessment.

Avoid this shortcut

Do not call this aggression and proceed by force. Do not argue about a mistaken belief or label sudden deterioration as dementia progression.

A clear way to hand it over

“I am calling about this new concern: distress during every morning wash. 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 Person-centred care adapts to the person’s needs, preferences and usual abilities.

Sources behind the actions 2 primary references

NICE · NG97: Dementia care
Assess pain and causes of distress and provide person-centered support.
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.

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

An unusually quiet resident misses breakfast

Difficult

The situation

A resident normally chats at breakfast but now sleeps through it and cannot sustain attention. Their family says this is a sudden change. Temperature is not high, but breathing is faster and oral intake has fallen.

What should catch your attention

Acute attention change
Faster breathing
Family concern

Your immediate priority

Escalate the new baseline change promptly and assess infection, glucose, oxygenation and medicines.

01Acute attention change
02Escalate the new baseline change promptly and assess infection, glucose, oxygenation and medicines.
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 the new baseline change promptly and assess infection, glucose, oxygenation and medicines. [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

Recheck alertness and observations during clinical review. Trend attention, alertness and physiological observations. Report further decline promptly even if the person is no longer restless.

Avoid this shortcut

Do not rule out illness because there is no fever. 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: an unusually quiet resident misses breakfast. 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.

Safeguarding & dignity

Bruising with a story that changes

Difficult

The situation

A resident has new bruises and appears frightened when one visitor answers questions. Alone, the resident says they do not want that visitor to manage their money. The cause of bruises is not yet established.

What should catch your attention

Unexplained findings
Fear around visitor
Private disclosure

Your immediate priority

Use a safe private conversation, document exact words and activate the safeguarding pathway without accusing anyone.

01Unexplained findings
02Use a safe private conversation, document exact words and activate the safeguarding pathway without accusing anyone.
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 a safe private conversation, document exact words and activate the safeguarding pathway without accusing anyone. [1]
Why it matters A person may not disclose abuse when the person causing harm is nearby.
2
Speak safely
Arrange a private conversation when safe, listen without blame and assess immediate injuries or threats. [1]
Why it matters A person may not disclose abuse when the person causing harm is nearby.
3
Use the safeguarding pathway
Contact the designated lead and urgent services when necessary; follow local reporting duties and preserve objective records. [1]
Why it matters Protection and information-sharing rules vary, and trained teams coordinate an appropriate response.
4
Keep care person-centred
Record exact words, observed findings and actions; arrange follow-up with appropriate consent or lawful justification. [1]
Why it matters Accurate records support continuity without turning suspicion into an unsupported accusation.

What to look for next

Confirm immediate safety and a named follow-up lead. Check ongoing safety and whether the agreed protective actions occurred; seek further help if risk continues.

Avoid this shortcut

Do not promise secrecy or confront the visitor alone. Do not promise absolute secrecy, confront the suspected abuser alone or photograph injuries outside policy.

A clear way to hand it over

“I am calling about this new concern: bruising with a story that changes. 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 Safeguarding means protecting a person from abuse or neglect while respecting their rights.

Sources behind the actions 1 primary references

NICE · NG189: Safeguarding adults in care homes
Recognition, factual documentation and appropriate safeguarding escalation.

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.

Goals of care & comfort

A resuscitation limit is mistaken for no treatment

Difficult

The situation

A resident has a documented do-not-resuscitate order but now has painful urinary retention. A worker suggests no clinician should be called because the resident is for comfort care. The resident asks for relief.

What should catch your attention

Painful reversible problem
Misread care limit
Expressed wish

Your immediate priority

Clarify the goals and arrange symptom relief; a CPR limit does not automatically exclude treatment of retention.

01Painful reversible problem
02Clarify the goals and arrange symptom relief; a CPR limit does not automatically exclude treatment of retention.
03Check response + communicate

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

What the RN should do—and why

1
Respond to the situation first
Clarify the goals and arrange symptom relief; a CPR limit does not automatically exclude treatment of retention. [1]
Why it matters A comfort-focused plan still requires active assessment and relief of suffering.
2
Assess and listen
Check pain, breathlessness, agitation and the person’s wishes; review the documented goals and emergency care plan. [1]
Why it matters A comfort-focused plan still requires active assessment and relief of suffering.
3
Clarify uncertainty
Contact the responsible clinician or palliative team when symptoms change or the plan is unclear; use the authorized emergency pathway if needed. [1]
Why it matters A resuscitation limit is not a blanket instruction to withhold all treatment.
4
Deliver the agreed care
Provide positioning, mouth care, presence and prescribed symptom medicines with monitoring; support family using clear explanations. [1]
Why it matters Individualized comfort care can reduce distress without making assumptions about prognosis.

What to look for next

Check comfort and the documented plan after intervention. Review symptom relief and medicine effects. Revisit uncertain deterioration or an ineffective plan with the team.

Avoid this shortcut

Do not withhold all treatment because CPR is limited. Do not equate a do-not-resuscitate order with do-not-treat or independently change the escalation plan.

A clear way to hand it over

“I am calling about this new concern: a resuscitation limit is mistaken for no treatment. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

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

In plain English Goals of care describe which treatments fit the person’s wishes and clinical situation.

Sources behind the actions 2 primary references

NICE · NG31: Care of dying adults
Individual goals, reversible causes, uncertainty and symptom care.
NICE · NG108: Decision-making and mental capacity
Supported decision-making and decision-specific assessment; legal rules must be adapted locally.

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.

Consent & supported decisions

Refusal of a recommended transfer

Difficult

The situation

A resident with chronic disease declines a non-emergency hospital assessment. They describe the risks accurately using an interpreter, but the family wants staff to force transfer. No immediate instability is present.

What should catch your attention

Clear explanation of choice
Family disagreement
No acute collapse

Your immediate priority

Support the resident’s decision and seek the lawful capacity pathway only if there is a genuine decision-specific concern.

01Clear explanation of choice
02Support the resident’s decision and seek the lawful capacity pathway only if there is a genuine decision-specific 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
Support the resident’s decision and seek the lawful capacity pathway only if there is a genuine decision-specific concern. [1]
Why it matters A communication barrier or an unwise choice does not by itself establish inability to decide.
2
Make understanding possible
Explain the decision in accessible language, address hearing or language needs and allow time when the situation permits. [1]
Why it matters A communication barrier or an unwise choice does not by itself establish inability to decide.
3
Escalate uncertainty appropriately
Ask the trained clinician to assess decision-specific capacity when there is concern; follow applicable local law and emergency policy. [1]
Why it matters Capacity can change with illness and relates to the particular decision, not a diagnostic label alone.
4
Document the authorized plan
Record the person’s wishes, supports provided and the lawful decision-maker or emergency basis if required. [1]
Why it matters Clear documentation helps the team respect autonomy while providing necessary, lawful care.

What to look for next

Document understanding, alternatives and when to seek urgent help. Review capacity when reversible illness or communication support changes. Escalate immediate safety concerns through the approved pathway.

Avoid this shortcut

Do not equate disagreement with incapacity. Do not assume relatives can automatically override an adult or use force merely because the patient disagrees.

A clear way to hand it over

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

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

In plain English Capacity is the ability to make a particular decision at the time it is needed; laws differ by location.

Sources behind the actions 2 primary references

NICE · NG108: Decision-making and mental capacity
Supported decision-making and decision-specific assessment; legal rules must be adapted locally.
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.

Glucose safety

Low glucose returns after initial improvement

Extremely difficult

The situation

A resident taking a sulfonylurea has low glucose, receives protocol treatment and initially improves. Two hours later they are drowsy again. Intake remains poor and kidney function has recently worsened.

What should catch your attention

Recurrent low glucose
Longer-acting medicine
Reduced clearance

Your immediate priority

Use the rescue pathway again and request urgent clinical review for prolonged recurrence risk and a safe medication plan.

01Recurrent low glucose
02Use the rescue pathway again and request urgent clinical review for prolonged recurrence risk and a safe 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
Use the rescue pathway again and request urgent clinical review for prolonged recurrence risk and a safe medication plan. [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 the full prescribed monitoring period, not only one normal result. Continue prescribed glucose checks and observe alertness, swallowing and food intake. Some medicines can cause prolonged or recurrent hypoglycemia.

Avoid this shortcut

Do not leave the resident after the first correction. Do not give oral glucose to someone unable to swallow or change insulin orders independently.

A clear way to hand it over

“I am calling about this new concern: low glucose returns after initial improvement. 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.

Head injury & anticoagulants

A fall followed by increasing sleepiness

Extremely difficult

The situation

A resident on anticoagulation had an unwitnessed fall overnight. They initially appeared unchanged but now vomit and need repeated prompting to stay awake. The external bruise is small and the incident form is already closed.

What should catch your attention

Anticoagulant
New vomiting
Reduced consciousness

Your immediate priority

Activate urgent clinical transfer assessment and provide fall time, neurological trend and anticoagulant details.

01Anticoagulant
02Activate urgent clinical transfer assessment and provide fall time, neurological trend and anticoagulant details.
03Check response + communicate

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

What the RN should do—and why

1
Respond to the situation first
Activate urgent clinical transfer assessment and provide fall time, neurological trend and anticoagulant details. [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

Monitor airway and neurological status while transport is arranged. Watch for worsening headache, vomiting, confusion, weakness or reduced consciousness. A previous normal assessment does not end monitoring.

Avoid this shortcut

Do not let the small bruise or closed incident form reassure you. 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 fall followed by increasing sleepiness. 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.

Sedation & ventilation

Breathlessness despite a normal-looking oxygen number

Extremely difficult

The situation

A frail resident with an opioid dose increase is difficult to wake and breathes slowly. They are receiving prescribed oxygen, so saturation remains reassuring. Their family thinks sleep means the pain treatment worked.

What should catch your attention

Slow breathing
Hard to wake
Recent opioid increase

Your immediate priority

Treat poor ventilation as urgent and tell the responder the dose, timing and oxygen support.

01Slow breathing
02Treat poor ventilation as urgent and tell the responder the dose, timing and oxygen 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
Treat poor ventilation as urgent and tell the responder the dose, timing and oxygen support. [1]
Why it matters Profound sedation and inadequate breathing can lead to arrest even when supplemental oxygen keeps saturation high.
2
Assess breathing immediately
Check responsiveness and normal breathing, stop further opioid delivery and activate emergency support. Start CPR if indicated by the resuscitation assessment. [1]
Why it matters Profound sedation and inadequate breathing can lead to arrest even when supplemental oxygen keeps saturation high.
3
Ventilate and reverse by protocol
Provide airway positioning and trained ventilation support; give naloxone under the authorized pathway without delaying resuscitation. [1]
Why it matters Naloxone can reverse opioid effects, but oxygen alone does not move enough air into the lungs.
4
Watch for recurrence
Continue monitoring and obtain a safe pain and opioid plan from the treating team. [1]
Why it matters The opioid may act longer than naloxone; improvement can be temporary.

What to look for next

Watch for recurrent sedation after reversal. Recheck respiratory effort, consciousness, oxygenation and recurrent sedation. Keep observation and escalation active after an initial response.

Avoid this shortcut

Do not judge safety from saturation alone. Do not leave a drowsy patient alone, rely only on saturation or let naloxone delay CPR.

A clear way to hand it over

“I am calling about this new concern: breathlessness despite a normal-looking 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 Respiratory depression means breathing is too slow or shallow to provide adequate ventilation.

Sources behind the actions 2 primary references

American Heart Association · 2025 Resuscitation Guidelines: special circumstances
Prioritize airway/ventilation in opioid respiratory emergencies, give naloxone and monitor for recurrent respiratory depression.
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

Shock during a presumed urinary infection

Extremely difficult

The situation

A resident with a catheter becomes confused, cold and clammy. Blood pressure falls and breathing accelerates. The urine smells strong, but the nurse has no confirmed source. The resident has heart failure and an agreed active treatment plan.

What should catch your attention

Falling pressure
Acute confusion
Limited fluid tolerance

Your immediate priority

Activate emergency assessment and hand over possible sources and heart failure before individualized resuscitation.

01Falling pressure
02Activate emergency assessment and hand over possible sources and heart failure before individualized resuscitation.
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 assessment and hand over possible sources and heart failure before individualized resuscitation. [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 overload after prescribed fluids. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not assume urine smell identifies the source or give repeated unassessed boluses. 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: shock during a presumed urinary infection. 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.

Time-critical neurology

New weakness while staff debate dementia

Extremely difficult

The situation

A resident with dementia suddenly drops a cup and speaks unclearly. One side of the face is different from the morning photograph in the care record. They take an anticoagulant and their usual communication is limited.

What should catch your attention

Sudden focal change
Known morning baseline
Anticoagulant use

Your immediate priority

Activate the stroke pathway using observed last-known-well time and baseline communication from carers.

01Sudden focal change
02Activate the stroke pathway using observed last-known-well time and baseline communication from carers.
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 stroke pathway using observed last-known-well time and baseline communication from carers. [1]
Why it matters Timing and an accurate baseline affect specialist assessment and potential treatment selection.
2
Record time and findings
Note last known well and new face, arm, speech, vision or balance changes; assess airway, breathing and glucose. [1]
Why it matters Timing and an accurate baseline affect specialist assessment and potential treatment selection.
3
Call the stroke pathway
Arrange immediate stroke-team review and urgent imaging; report anticoagulants, recent procedures and seizure history. [1]
Why it matters Imaging is needed to distinguish causes and guide reperfusion or bleeding management.
4
Protect ongoing care
Keep oral intake paused until an approved swallow assessment; follow ordered pressure, oxygen and transfer plans. [1]
Why it matters Aspiration and inappropriate treatment can add harm while the stroke pathway is underway.

What to look for next

Keep oral intake paused pending appropriate screening. Trend neurological findings and consciousness, document changes with times and ensure the receiving team knows last known well.

Avoid this shortcut

Do not attribute a new one-sided deficit to dementia. Do not give food to test swallowing, delay for a complete history or independently lower pressure.

A clear way to hand it over

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

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

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

Sources behind the actions 2 primary references

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

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

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

Bleeding & circulation

Coffee-ground vomit and faintness

Extremely difficult

The situation

A resident on an anticoagulant vomits dark material and becomes pale and faint. They recently started an anti-inflammatory medicine. Pulse rises and pressure falls, while the first blood count has not returned.

What should catch your attention

Possible GI bleeding
Medicine interaction
Circulatory decline

Your immediate priority

Activate the bleeding response and report both medicines and last doses for urgent source and reversal review.

01Possible GI bleeding
02Activate the bleeding response and report both medicines and last doses for urgent source and reversal review.
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 bleeding response and report both medicines and last doses for urgent source and reversal review. [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 ongoing loss and perfusion during transfer. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not wait for anemia confirmation or give oral drinks during instability. 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: coffee-ground vomit and faintness. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

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

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

Sources behind the actions 2 primary references

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

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

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

Electrolyte & rhythm safety

High potassium after a missed dialysis session

Extremely difficult

The situation

A resident misses dialysis because transport fails. They now have weakness and a critical potassium result with a new abnormal ECG. Their fluid limit remains in place, and they are frightened of another transfer.

What should catch your attention

Missed dialysis
Critical potassium
ECG change

Your immediate priority

Arrange emergency renal and cardiac assessment; support consent and communicate the access and last dialysis details.

01Missed dialysis
02Arrange emergency renal and cardiac assessment; support consent and communicate the access and last dialysis details.
03Check response + communicate

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

What the RN should do—and why

1
Respond to the situation first
Arrange emergency renal and cardiac assessment; support consent and communicate the access and last dialysis details. [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

Follow glucose and potassium monitoring after prescribed treatment. Escalate ECG deterioration, recurrent high potassium or low glucose. Confirm the plan for potassium removal and medicine review.

Avoid this shortcut

Do not use a normal earlier ECG as reassurance. 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: high potassium after a missed dialysis session. 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.

Airway obstruction

Choking while the person cannot communicate

Extremely difficult

The situation

A resident with previous stroke suddenly cannot cough or speak while eating. Their carer knows the usual swallowing plan but gave a larger bite. The resident is becoming unresponsive and cannot describe the problem.

What should catch your attention

Silent ineffective cough
Meal-related onset
Declining responsiveness

Your immediate priority

Activate emergency choking response immediately and use the current trained algorithm appropriate to the person.

01Silent ineffective cough
02Activate emergency choking response immediately and use the current trained algorithm appropriate to the person.
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 choking response immediately and use the current trained algorithm appropriate to the person. [1]
Why it matters Effective coughing and a severely blocked airway require different responses.
2
Recognize severity
Assess whether the person can speak, breathe or cough effectively. Encourage effective coughing and summon emergency help for severe obstruction. [1]
Why it matters Effective coughing and a severely blocked airway require different responses.
3
Use trained first aid
Follow the current age-appropriate choking algorithm and your training; if unresponsive, begin the indicated resuscitation sequence and obtain an AED. [1]
Why it matters Prompt mechanical relief and resuscitation can restore airflow while advanced help arrives.
4
Arrange assessment afterwards
Ensure clinical review after a severe event and review swallowing, feeding and injury concerns. [1]
Why it matters Relief of the obstruction does not exclude retained material, injury or future aspiration risk.

What to look for next

Arrange post-event airway and swallowing review even if the obstruction clears. Keep checking breathing and responsiveness. Recurrent obstruction or persistent respiratory symptoms needs urgent assessment.

Avoid this shortcut

Do not wait for an interpreter during a life-threatening airway emergency. Do not perform blind finger sweeps or give water to wash down an obstructing object.

A clear way to hand it over

“I am calling about this new concern: choking while the person cannot communicate. 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 severe airway obstruction stops enough air from moving into the lungs.

Sources behind the actions 1 primary references

AHA · 2025 Adult Basic Life Support
Recognition of arrest and age-appropriate trained obstruction/resuscitation 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.

Kidney function & fluids

Swelling, low urine and worsening breathing

Extremely difficult

The situation

A resident with chronic kidney disease has little urine, swollen ankles and new breathlessness. They also had diarrhea and poor intake. Staff propose extra fluids because the urine is low, but pressure and perfusion need assessment.

What should catch your attention

Mixed fluid clues
Renal disease
New respiratory change

Your immediate priority

Request urgent fluid-status and medication review instead of automatically treating either dehydration or overload.

01Mixed fluid clues
02Request urgent fluid-status and medication review instead of automatically treating either dehydration or overload.
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 fluid-status and medication review instead of automatically treating either dehydration or overload. [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

Measure balance and reassess breathing after each authorized 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 infer the correct fluid treatment from edema or urine alone. 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: swelling, low urine and worsening breathing. 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.

Goals of care & comfort

Severe breathlessness with an unclear emergency plan

Extremely difficult

The situation

A resident with advanced lung disease becomes severely breathless. The written plan mentions no ICU but does not specify other treatments. Their family gives conflicting accounts of prior wishes and the resident is too distressed to discuss details.

What should catch your attention

Severe symptoms
Unclear limits
Conflicting accounts

Your immediate priority

Call urgent clinical help and the responsible decision-maker while providing authorized comfort measures; clarify treatment limits without delaying relief.

01Severe symptoms
02Call urgent clinical help and the responsible decision-maker while providing authorized comfort measures; clarify treatment limits without delaying relief.
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 urgent clinical help and the responsible decision-maker while providing authorized comfort measures; clarify treatment limits without delaying relief. [1]
Why it matters A comfort-focused plan still requires active assessment and relief of suffering.
2
Assess and listen
Check pain, breathlessness, agitation and the person’s wishes; review the documented goals and emergency care plan. [1]
Why it matters A comfort-focused plan still requires active assessment and relief of suffering.
3
Clarify uncertainty
Contact the responsible clinician or palliative team when symptoms change or the plan is unclear; use the authorized emergency pathway if needed. [1]
Why it matters A resuscitation limit is not a blanket instruction to withhold all treatment.
4
Deliver the agreed care
Provide positioning, mouth care, presence and prescribed symptom medicines with monitoring; support family using clear explanations. [1]
Why it matters Individualized comfort care can reduce distress without making assumptions about prognosis.

What to look for next

Review the response and update the documented emergency plan after stabilization. Review symptom relief and medicine effects. Revisit uncertain deterioration or an ineffective plan with the team.

Avoid this shortcut

Do not choose either unlimited treatment or no treatment from an ambiguous phrase. Do not equate a do-not-resuscitate order with do-not-treat or independently change the escalation plan.

A clear way to hand it over

“I am calling about this new concern: severe breathlessness with an unclear emergency plan. 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 Goals of care describe which treatments fit the person’s wishes and clinical situation.

Sources behind the actions 2 primary references

NICE · NG31: Care of dying adults
Individual goals, reversible causes, uncertainty and symptom care.
NICE · NG108: Decision-making and mental capacity
Supported decision-making and decision-specific assessment; legal rules must be adapted locally.

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

Long-Term Care

The walking aid is out of reach

What should catch your attention

What the RN should do—and why

Respond to the situation first

Make movement safe

Assess before restarting

Update the plan

What to look for next

Avoid this shortcut

A clear way to hand it over

Red skin beneath a continence pad

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

Two versions of a discharge medicine list

What should catch your attention

What the RN should do—and why

Respond to the situation first

Pause and verify

Clarify with the team

Close the loop

What to look for next

Avoid this shortcut

A clear way to hand it over

The resident nods but cannot explain the plan

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

Fluids remain untouched throughout the shift

What should catch your attention

What the RN should do—and why

Respond to the situation first

Measure the change

Match support to safety

Check response

What to look for next

Avoid this shortcut

A clear way to hand it over

A usual tablet is now impossible to swallow

What should catch your attention

What the RN should do—and why

Respond to the situation first

Confirm the regimen

Escalate route or supply problems

Monitor and hand over

What to look for next

Avoid this shortcut

A clear way to hand it over

Repeated coughing at lunch

What should catch your attention

What the RN should do—and why

Respond to the situation first

Protect the airway

Use the agreed pathway

Make the plan visible

What to look for next

Avoid this shortcut

A clear way to hand it over

Several residents develop diarrhea

What should catch your attention

What the RN should do—and why

Respond to the situation first

Apply the right precautions

Assess clinical severity

Protect shared care

What to look for next

Avoid this shortcut