**The NGN Case Study Compass: Clinical
Judgment in Complex Care**
**CASE STUDY 1 – ACUTE RESPIRATORY FAILURE**
A 68-year-old patient with a history of COPD and heart failure is admitted to the medical unit with
worsening dyspnea, orthopnea, and a productive cough with pink, frothy sputum. Vital signs: BP 160/95,
HR 118, RR 32, SpO2 85% on 2 L/min nasal cannula. Lung auscultation reveals crackles bilaterally to the
mid-fields and faint wheezes. The patient is anxious and diaphoretic.
1. Which action should the nurse take first?
A) Administer furosemide 40 mg IV push
B) Apply a non-rebreather mask at 15 L/min
C) Place the patient in high Fowler's position
D) Notify the rapid response team
💫RATIONALE✔️✔️: High Fowler's position optimizes diaphragmatic excursion and reduces preload,
improving oxygenation. This is an immediate, independent nursing action while preparing for other
interventions.
💫ANSWER✔️✔️: C) Place the patient in high Fowler's position
---
2. The nurse places the patient on BiPAP (IPAP 14, EPAP 6, FiO2 0.6). Which finding indicates the BiPAP is
effective?
A) Respiratory rate decreases from 32 to 22
B) Blood pressure decreases from 160/95 to 140/90
C) Patient reports feeling more anxious
D) SpO2 decreases from 85% to 80%
,💫RATIONALE✔️✔️: A decreasing respiratory rate with improved work of breathing indicates effective
BiPAP. Oxygenation should also improve (SpO2 increase). Anxiety should decrease.
💫ANSWER✔️✔️: A) Respiratory rate decreases from 32 to 22
---
3. One hour after initiating BiPAP, the patient's SpO2 is 92%, but the patient is now lethargic and has a
respiratory rate of 8. What is the priority action?
A) Increase the FiO2 to 1.0
B) Decrease the IPAP to 10
C) Prepare for intubation
D) Draw an arterial blood gas
💫RATIONALE✔️✔️: Lethargy and bradypnea on BiPAP indicate worsening respiratory failure and possible
hypercapnia. Immediate intubation is needed. Do not delay for ABG.
💫ANSWER✔️✔️: C) Prepare for intubation
---
4. The patient is intubated and placed on mechanical ventilation. Settings: SIMV, rate 14, TV 450 mL,
FiO2 0.8, PEEP 8. The high-pressure alarm sounds. Which action should the nurse take first?
A) Suction the endotracheal tube
B) Decrease the FiO2 to 0.6
C) Check for a kink in the ventilator tubing
D) Sedate the patient to reduce coughing
💫RATIONALE✔️✔️: High-pressure alarms often indicate secretions, biting, or kinked tubing. Quickly
check the circuit for kinks or water. If none, auscultate and suction.
💫ANSWER✔️✔️: C) Check for a kink in the ventilator tubing
---
5. The patient's arterial blood gas (ABG) results are: pH 7.32, PaCO2 58, PaO2 72, HCO3 30. Which
ventilator change is most appropriate?
A) Increase respiratory rate to 18
, B) Decrease tidal volume to 400 mL
C) Increase FiO2 to 1.0
D) Decrease PEEP to 5
💫RATIONALE✔️✔️: pH <7.35, PaCO2 >45 indicates hypercapnic respiratory failure. Increasing respiratory
rate will lower PaCO2 and correct acidosis. FiO2 is adequate (PaO2 72).
💫ANSWER✔️✔️: A) Increase respiratory rate to 18
---
**CASE STUDY 2 – POST-OPERATIVE COMPLICATION**
A 72-year-old patient is 2 days post-operative after a right total knee replacement. The patient has been
using a patient-controlled analgesia (PCA) pump with hydromorphone. The patient reports sudden
shortness of breath and chest pain. Vital signs: BP 100/60, HR 110, RR 28, SpO2 86% on room air.
6. What is the priority action?
A) Administer oxygen at 4 L/min via nasal cannula
B) Notify the provider of suspected pulmonary embolism
C) Elevate the head of the bed
D) Assess the surgical site for bleeding
💫RATIONALE✔️✔️: Sudden dyspnea, hypoxia, and chest pain post-operatively suggest pulmonary
embolism. Apply oxygen first, then notify provider. Elevating HOB is also helpful but oxygen is priority.
💫ANSWER✔️✔️: A) Administer oxygen at 4 L/min via nasal cannula
---
7. The nurse applies oxygen and notifies the provider. Which diagnostic test is most appropriate to
confirm a pulmonary embolism?
A) D-dimer
B) CT pulmonary angiogram (CTPA)
C) Venous duplex ultrasound of the legs
D) Chest x-ray
Judgment in Complex Care**
**CASE STUDY 1 – ACUTE RESPIRATORY FAILURE**
A 68-year-old patient with a history of COPD and heart failure is admitted to the medical unit with
worsening dyspnea, orthopnea, and a productive cough with pink, frothy sputum. Vital signs: BP 160/95,
HR 118, RR 32, SpO2 85% on 2 L/min nasal cannula. Lung auscultation reveals crackles bilaterally to the
mid-fields and faint wheezes. The patient is anxious and diaphoretic.
1. Which action should the nurse take first?
A) Administer furosemide 40 mg IV push
B) Apply a non-rebreather mask at 15 L/min
C) Place the patient in high Fowler's position
D) Notify the rapid response team
💫RATIONALE✔️✔️: High Fowler's position optimizes diaphragmatic excursion and reduces preload,
improving oxygenation. This is an immediate, independent nursing action while preparing for other
interventions.
💫ANSWER✔️✔️: C) Place the patient in high Fowler's position
---
2. The nurse places the patient on BiPAP (IPAP 14, EPAP 6, FiO2 0.6). Which finding indicates the BiPAP is
effective?
A) Respiratory rate decreases from 32 to 22
B) Blood pressure decreases from 160/95 to 140/90
C) Patient reports feeling more anxious
D) SpO2 decreases from 85% to 80%
,💫RATIONALE✔️✔️: A decreasing respiratory rate with improved work of breathing indicates effective
BiPAP. Oxygenation should also improve (SpO2 increase). Anxiety should decrease.
💫ANSWER✔️✔️: A) Respiratory rate decreases from 32 to 22
---
3. One hour after initiating BiPAP, the patient's SpO2 is 92%, but the patient is now lethargic and has a
respiratory rate of 8. What is the priority action?
A) Increase the FiO2 to 1.0
B) Decrease the IPAP to 10
C) Prepare for intubation
D) Draw an arterial blood gas
💫RATIONALE✔️✔️: Lethargy and bradypnea on BiPAP indicate worsening respiratory failure and possible
hypercapnia. Immediate intubation is needed. Do not delay for ABG.
💫ANSWER✔️✔️: C) Prepare for intubation
---
4. The patient is intubated and placed on mechanical ventilation. Settings: SIMV, rate 14, TV 450 mL,
FiO2 0.8, PEEP 8. The high-pressure alarm sounds. Which action should the nurse take first?
A) Suction the endotracheal tube
B) Decrease the FiO2 to 0.6
C) Check for a kink in the ventilator tubing
D) Sedate the patient to reduce coughing
💫RATIONALE✔️✔️: High-pressure alarms often indicate secretions, biting, or kinked tubing. Quickly
check the circuit for kinks or water. If none, auscultate and suction.
💫ANSWER✔️✔️: C) Check for a kink in the ventilator tubing
---
5. The patient's arterial blood gas (ABG) results are: pH 7.32, PaCO2 58, PaO2 72, HCO3 30. Which
ventilator change is most appropriate?
A) Increase respiratory rate to 18
, B) Decrease tidal volume to 400 mL
C) Increase FiO2 to 1.0
D) Decrease PEEP to 5
💫RATIONALE✔️✔️: pH <7.35, PaCO2 >45 indicates hypercapnic respiratory failure. Increasing respiratory
rate will lower PaCO2 and correct acidosis. FiO2 is adequate (PaO2 72).
💫ANSWER✔️✔️: A) Increase respiratory rate to 18
---
**CASE STUDY 2 – POST-OPERATIVE COMPLICATION**
A 72-year-old patient is 2 days post-operative after a right total knee replacement. The patient has been
using a patient-controlled analgesia (PCA) pump with hydromorphone. The patient reports sudden
shortness of breath and chest pain. Vital signs: BP 100/60, HR 110, RR 28, SpO2 86% on room air.
6. What is the priority action?
A) Administer oxygen at 4 L/min via nasal cannula
B) Notify the provider of suspected pulmonary embolism
C) Elevate the head of the bed
D) Assess the surgical site for bleeding
💫RATIONALE✔️✔️: Sudden dyspnea, hypoxia, and chest pain post-operatively suggest pulmonary
embolism. Apply oxygen first, then notify provider. Elevating HOB is also helpful but oxygen is priority.
💫ANSWER✔️✔️: A) Administer oxygen at 4 L/min via nasal cannula
---
7. The nurse applies oxygen and notifies the provider. Which diagnostic test is most appropriate to
confirm a pulmonary embolism?
A) D-dimer
B) CT pulmonary angiogram (CTPA)
C) Venous duplex ultrasound of the legs
D) Chest x-ray
