The example case study: initial materials
Scenario
The nurse cares for a 58-year-old male who was brought into the emergency department (ED) by his son.
Tab 1: Nurses’ notes
- The client reports “heaviness” and pain in his chest that “comes and goes” over the past three days. The client states, “When I was shoveling snow this morning, I felt continuous chest discomfort.”
- The client is diaphoretic and reports fatigue and nausea. The client rates his pain as an 8 on 1–10 scale.
- Physical examination reveals absent jugular vein distention and the presence of S1 and S2 heart sounds, and continuous telemetry shows an irregular rate.
- He is oriented to person, place, and time. His pupils are equal, round, and reactive to light, and his skin is pale with a capillary refill of > 3 seconds.
- The client is unable to complete speaking full sentences due to shortness of breath.
- Bowel sounds are heard in all four quadrants.
- Peripheral pulses are 2+ bilaterally, and 1+ edema is noted in the bilateral lower extremities.
- He has a history of diabetes, hypertension, and hyperlipidemia.
- The client reports that he quit smoking at 54 years of age but drinks 2 to 3 glasses of alcohol occasionally.
- The client’s body mass index (BMI) is 36.6 and pulse oximetry reading is 89% on room air.
- Height: 5’4” (162 cm); weight: 212 lb (96 kg)
Tab 2: Vital signs
| Vital signs | Results |
| Temperature | 98.6 °F (37.0 °C) |
| Heart rate | 120 beats/min |
| Respiratory rate | 24 breaths/min |
| Blood pressure | 155/98 mm Hg |
| Pulse oximeter reading | 89% on room air |
Tab 3: Home Medication
- Losartan 50 mg PO QD in am
- Atorvastatin 40 mg PO QD HS
- Metformin 500 mg PO BID
First step: create a picture of the initial information
Start with reading through the scenario and the initial tabs of information provided. Translate them into your own words and judge if the findings are normal or not, identifying the abnormal/unstable clues.
- Abnormal findings:
- Heaviness and pain in the chest “comes and goes”, but since exertion this morning (snow shoveling) the discomfort is constant. Current pain is 8/10 (severe).
- Client is diaphoretic/sweaty, fatigued, nauseous, and abnormally short of breath.
- Heart rate is irregular and too high at 120.
- Respiratory rate and blood pressure are too high.
- Capillary refill is too slow.
- Pulse oximetry of 89% is too low.
- + 1 edema is not normal, but could have a number of causes.
- History: Diabetes, hypertension, and hyperlipidemia are risk factors for heart disease, as well as the elevated BMI and having smoked until 4 years ago.
- The following are normal/unproblematic: orientation, pupils, bowel sounds, peripheral pulse, no current heart murmur, absent jugular vein distention, no current fluid volume overload, temperature WNL, moderate alcohol consumption.
- Medications:
- Losartan by mouth every day in the morning
- Atorvastin by mouth every day at bedtime
- Metformin by mouth twice daily (with breakfast and dinner)
Tip: Client statements are always important!
Tip: The NCLEX allows clicking through the tabs at any time, but we recommend going through them once, but slowly and methodically. You can always check back later, but rushing can scatter your thoughts.
Step 2: Work through the questions one by one
Question 1
This is the initial task displayed on the right side of the screen. You will be solving this using the initial information you got which is described above.
Select the 4 findings that require immediate follow-up.
- Chest pain
- Vital signs
- Pulse characteristics
- Edema
- Body mass index
- Capillary refill
- Alcohol intake
- Telemetry
Tip: Note the number: they’re asking for exactly 4, not a “select all that apply.”
This is a prioritization question and reworded could be: Which 4 things out of this list need to be handled first?
- Chest pain: indication for at least ischemia, maybe infarction, so needs immediate attention
- Vital signs: low pulse ox and high respiratory rate need follow-up,
- Pulse characteristics: normal, so no priority
- Edema: mild case, so does not need immediate urgent follow-up
- Body mass index: not an urgent concern
- Capillary refill: may indicate perfusion problem, so should be looked at
- Alcohol intake: is moderate, not a priority
- Telemetry: could also impact perfusion and should be looked at now
Tip: For some students, it is safer to arrive at an answer on scratch paper rather than clicking a lot to check and uncheck boxes. Writing on paper may help you trust your reasoning more. Try it out and settle on your strategy!
Question 2
After you submit an answer to the first question, the right-hand side of the screen will change to the next one. The tabs on the left side have changed, so the initial information is still being used.
Based on the client’s assessment, which additional information is helpful to interpret the client’s risk for potential issues?
| Assessment | Pulmonary embolism | Coronary artery disease | Hypovolemic shock |
| Chest pain | ☐ | ☐ | ☐ |
| Shortness of breath | ☐ | ☐ | ☐ |
| High blood pressure | ☐ | ☐ | ☐ |
| O2 saturation 89% | ☐ | ☐ | ☐ |
| Diminished pulse in lower extremities | ☐ | ☐ | ☐ |
| 1+ peripheral edema | ☐ | ☐ | ☐ |
Tip: Before you get to checking boxes, recap the pathophysiologies of all 3 conditions in your head and summarize their symptoms (maybe even shortly write them down).
Tip: In a table like this, you could go diagnosis by diagnosis, or go through the symptoms across all columns. We recommend you do it both ways as a double-check to be confident in your answers!
Question 3
The third question has a fill-in-the-blanks statement with dropdowns giving you the options to choose from.
The client is at the highest risk for developing _______________ as evidenced by ____________ and _____________.
A lot of signs point to the client being at risk for myocardial infarction over the other options: chest pain, shortness of breath, irregular heartbeat, severe pain, hypertension. With no or insufficient signs of infection (normal temperature), stroke (no confusion or numbness), DVT (does have edema but no leg pain or reddened skin), or seizures, myocardial infarction is the correct answer here.
Solution:
The second and third slots ask for the reasoning for the condition you chose as the one the client is most likely experiencing. Both dropdowns have the same options, so it comes down to choosing 2 out of 5.
Chest pain is a classic symptom of myocardial infarction, so definitely a correct choice.
For the others:
- Edema is mild and could have other causes.
- Shortness of breath is definitely a well-known sign of MI.
- Decreased capillary refill could indicate perfusion but is not a clearer sign of MI than of pain or shortness of breath.
- Hypotension does not apply here: the client is hypertensive!
So, the best answers for myocardial infarction would be chest pain and shortness of breath.
Tip: Note how the second and third slot depend on your answer in the first one. Always keep an overview of the statement in its entirety while going through the dropdowns to not miss connections between the options.
Tip: Review the statement as a whole after picking all your answer choices to make sure it really makes sense.
Question 4
New info appears on the left side: The nurse reviews the medical records and plans care for the client. The tabs, however, stay the same.
For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
| Potential interventions | Indicated | Contraindicated |
| Place the client in a supine position. | ☐ | ☐ |
| Obtain an electrocardiogram. | ☐ | ☐ |
| Provide supplemental O2. | ☐ | ☐ |
| Administer nitrates. | ☐ | ☐ |
| Instruct to increase fluid intake. | ☐ | ☐ |
Tip: For each intervention, there are only 2 options here: to do or not to do it. So, there is no prioritization to think about, it is “simply” yes or no. It works the same as a select-all-that-apply question would.
- Placing the client in a supine position could aggravate their breathlessness → no.
- Electrocardiogram follows up on irregular heartbeat and chest pain → yes.
- Saturation below 90% would indicate giving oxygen → yes.
- Nitrates will dilate the vessels and decrease the workload of the heart → yes, give for the chest pain.
- Increased fluid intake would not be a good idea assuming the client is having a heart attack, has perfusion and oxygenation problems, and might probably be NPO in case of some test or heart cath. → no.
Question 5
The scenario text changes to:
The nurse reviews the orders from the health care provider.
Additional tab appears:
Laboratory tests ordered
- Complete blood count
- Electrolytes
- Blood urea nitrogen
- Creatinine
- Blood glucose
- Creatine kinase-MB STAT and q 8 h x 3
- Cardiac troponin STAT and q 6 hours x 24 h
Click to highlight the 4 orders that the nurse needs to perform immediately.
- 0.9% sodium chloride (1 L) to keep vein open
- O2 2 L/min via nasal cannula
- Continuous pulse oximetry
- Electrocardiogram
- Vital signs q 30 min
- Nitroglycerin 0.4 mg sublingual q 5 min x 3 or until chest pain is relieved
- Aspirin 325 mg PO now
- Morphine sulfate 5 mg intravenous (IV) q 2 h PRN for severe pain
- Clopidogrel 600 mg PO now
- Atorvastatin 40 mg PO QD now
- Metoprolol tartrate 5 mg IVP over 2 min, repeat q 5 min x 2 (hold if systolic blood pressure < 90 mm Hg)
Again, you need to choose 4 out of the full list that have the highest priority. All of these will be done, the question only asks which ones to do first. Including the new information provided (the laboratory tests that were done), there are 2 that are more specific: CKMB test for heart damage and the cardiac troponin STAT.
- 0.9% sodium chloride (1 L) to keep vein open → Venous access during an MI is important, but this needs to be compared with the other options to see if there are more urgent measures.
- O2 2 L/min via nasal cannula → To address the low saturation, this makes sense to do urgently – remember, the client can’t even finish a sentence.
- Continuous pulse oximetry → Should be done for monitoring the oxygen treatment and saturation.
- Electrocardiogram → Important as an immediate measure for this client’s symptoms as already established.
- Vital signs q 30 min → If administering nitroglycerin, this would be done more often – this item would not trump the ones before.
- Nitroglycerin 0.4 mg sublingual q 5 min x 3 or until chest pain is relieved → Nitroglycerin should be immediately administered.
- Aspirin 325 mg PO now → would address a clot, but is not the priority for the immediate problem
- Morphine sulfate 5 mg intravenous (IV) q 2 h PRN for severe pain → addressing the chest pain; will be given if continued pain is not addressed after nitroglycerin
- Clopidogrel 600 mg PO now → to prevent clots in the future; not immediate
- Atorvastatin 40 mg PO QD now → already in the client’s plan; long-term, not immediate
- Metoprolol tartrate 5 mg IVP over 2 min, repeat q 5 min x 2 (hold if systolic blood pressure < 90 mm Hg) → beta-blocker; not an immediate priority
Question 6
For the sixth and last question, you get new information. The scenario text stays at “The nurse reviews the orders from the health care provider.”
But, you get 3 new tabs with information, labeled with time stamps:
1318
Orders received. O2 applied at 2 L by nasal cannula, IV access obtained to the left metacarpal vein. IV fluids started. No signs of IV-related complications. The client was placed in the high Fowler’s position and administered nitroglycerin 0.4 mg sublingual x 1 for pain of 6/10, aspirin 325 mg PO, clopidogrel 600 mg PO, and metoprolol tartrate 5 mg IVP for blood pressure of 156/90 mm Hg. The client states upper chest pain has decreased to 4/10 after nitroglycerin. Blood pressure is reassessed and has decreased to 148/86 mm Hg.
1325
Electrocardiography shows ST elevation, which alerts the providers that there is a total blockage of the involved coronary artery and that the heart muscle is currently “dying”. Blood is drawn for labs. Pain in the upper chest is rated as 4/10.
1340
The client is awake, oriented x 3 (person, place, and time), and sitting up in bed. He appears comfortable and his breathing is unlabored and not diaphoretic. The client states, “I feel a little better.” The client rates the intermittent pain in his upper chest as a 4 (on a 1–10 scale) and states, “it is much less than it was.” His skin is pink, dry, and warm to the touch. The capillary refill is 3 sec. The client can now speak complete sentences without shortness of breath. Absence of adventitious sounds in lungs bilaterally. The vital signs are as follows: temperature: 97.52 °F (36.4 °C); heart rate: 88/min; respiratory rate: 18/min, blood pressure: 129/95 mm Hg; pulse oximetry reading: 90% on 2 L/min O2 via nasal cannula.
The question on the right side shows:
The nurse has performed the interventions as ordered by the physician. Which assessment data shows improvement in the client’s symptoms? Select all that apply.
- Capillary refill
- Respiratory rate
- Pulse oximetry
- Pain rating
- Neurologic assessment
- Temperature 97.52 °F (36.4 °C)
Tip: Remember, don’t second guess your previous answer. All interventions would have been done anyway. Look at this question with fresh eyes.
So, what changed about the client’s status?
- Blood pressure is still a little high, but better and improving over time
- Pain has decreased, stays at 4/10, client feeling better
- ECG shows ST elevation – This is serious, showing that this is a myocardial infarction and there is a total blockage.
- Shortness of breath has improved; client is not as diaphoretic.
- Respiratory rate has decreased as well.
Tip: Note the question asks for symptoms that have improved. This does not mean the values necessarily need to be in normal range – it just means they need to reflect a significant improvement!
- Capillary refill → This was more than 3 seconds initially, now it is 3 seconds, which is an improvement. Correct
- Respiratory rate → Respiratory rate has improved. Correct.
- Pulse oximetry → 89% to 90% is a small improvement, but it is still an improvement. Correct.
- Pain rating → The client reports improvement from an 8 to a 4. Correct.
- Neurologic assessment → Client was alert and oriented the whole time. There is no improvement here, nor is there an improvement necessary. Incorrect, this is a distractor.
- Temperature 97.52 °F (36.4 °C) → Temperature has been in normal range the whole time, so no improvement. Incorrect.
