NCLEX-RN Unfolding Case Studies
Nurses' Notes / Vital Signs
Mr. James Holloway is a 68-year-old male with a history of hypertension, type 2 diabetes, and chronic heart failure with reduced ejection fraction (EF 30%) who presents to the emergency department reporting worsening shortness of breath over the past 3 days. He states he has gained 8 pounds in the last week and has been unable to lie flat without becoming breathless. On assessment, vital signs are: blood pressure 158/96 mmHg, heart rate 112 beats per minute and irregular, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air, and temperature 37.1 degrees Celsius. Physical examination reveals bilateral crackles in the lower two-thirds of both lung fields, 3-plus pitting edema to the knees bilaterally, distended neck veins, and an S3 gallop on auscultation. The patient appears anxious and is using accessory muscles to breathe.
Nurses' Notes / Vital Signs
Ms. Priya Nair is a 24-year-old female with a 10-year history of type 1 diabetes mellitus who is brought to the emergency department by her roommate after being found confused and difficult to arouse. Her roommate reports that Ms. Nair has had nausea, vomiting, and abdominal pain for the past 2 days and has been running a low-grade fever, suggesting a possible viral illness. She has not been eating and her roommate is unsure if she took her insulin. On assessment, vital signs are: blood pressure 96/60 mmHg, heart rate 126 beats per minute, respiratory rate 28 breaths per minute with deep, labored breaths, temperature 38.2 degrees Celsius, and oxygen saturation 97% on room air. Her blood glucose is 542 mg/dL by point-of-care testing. The nurse notes a fruity odor on her breath, dry mucous membranes, poor skin turgor, and sunken eyes. Laboratory results are pending.
Nurses' Notes / Vital Signs
Maria G., a 28-year-old G2P1 at 36 weeks gestation, presents to labor and delivery reporting a severe headache, visual disturbances, and right upper quadrant pain that began two hours ago. Her blood pressure on arrival is 162/110 mmHg, confirmed on repeat measurement 10 minutes later at 164/108 mmHg. Her urine dipstick shows 3-plus protein, her deep tendon reflexes are 3-plus with two beats of clonus at the ankles, and her oxygen saturation is 97% on room air. Laboratory results reveal a platelet count of 98,000 per microliter, AST of 85 units per liter, and serum creatinine of 1.2 mg per dL.
Nurses' Notes / Vital Signs
Derek S., a 45-year-old male with a history of alcohol use disorder and hypertension, is admitted for community-acquired pneumonia. On hospital day 2, the nurse notes that Derek has become increasingly restless and diaphoretic, with a fine tremor of both hands. His vital signs are: temperature 38.2 degrees Celsius, heart rate 118 beats per minute, blood pressure 156/94 mmHg, and respiratory rate 22 breaths per minute. He reports that his last alcoholic drink was approximately 36 hours ago. He is oriented to person and place but not time, and is picking at the bed linens. His CIWA-Ar score is 18.
Nurses' Notes / Vital Signs
A 2-year-old male weighing 13 kg is brought to the emergency department by his parents after a witnessed generalized tonic-clonic seizure lasting approximately 90 seconds that stopped before arrival. The parents report the child had a runny nose and decreased appetite for 24 hours. Vital signs on arrival: temperature 39.8 degrees Celsius (103.6 degrees Fahrenheit) rectal, heart rate 138 beats per minute, respiratory rate 28 breaths per minute, oxygen saturation 97% on room air, blood pressure 98/62 mmHg. On assessment, the child is now alert and crying, skin is warm and flushed, mucous membranes are moist, and the anterior fontanelle is closed. Neurological exam is non-focal with no signs of meningismus.
Nurses' Notes / Vital Signs
A 28-year-old gravida 2 para 1 woman at 32 weeks and 2 days gestation presents to labor and delivery reporting low back pain and pelvic pressure for the past 3 hours. She states she is having contractions that feel like menstrual cramps occurring every 6 to 8 minutes. Vital signs: temperature 36.9 degrees Celsius, heart rate 88 beats per minute, respiratory rate 18 breaths per minute, blood pressure 118/72 mmHg, oxygen saturation 99% on room air. Tocometric monitoring confirms uterine contractions every 6 minutes lasting 45 to 60 seconds. Cervical exam reveals the cervix is 2 cm dilated, 60% effaced, and the fetus is at -2 station in vertex presentation. Fetal heart rate tracing shows a baseline of 148 beats per minute with moderate variability and no decelerations.
Nurses' Notes / Vital Signs
Maria, a 34-year-old woman, is brought to the emergency department by her sister after the sister found a suicide note and an empty bottle of Maria's prescribed sertraline. Maria is alert and oriented but tearful, stating she has felt hopeless for months and 'wanted everything to stop.' Vital signs: BP 112/70 mmHg, HR 98 bpm, RR 16 breaths/min, temperature 98.4 F, SpO2 98% on room air. She admits to ingesting an unknown number of sertraline tablets approximately 2 hours ago. Physical assessment reveals mild diaphoresis, hyperreflexia, and clonus of the lower extremities, raising concern for serotonin toxicity.
Nurses' Notes / Vital Signs
Daniel, a 52-year-old male, is 4 hours post-operative following a laparoscopic cholecystectomy for acute cholecystitis. He has a history of hypertension managed with lisinopril and takes aspirin 81 mg daily, which was not held preoperatively. The PACU nurse notes his abdominal dressing has a 4 cm area of bright red blood-soaked saturation, increasing from 2 cm noted 30 minutes ago. Vital signs: BP 88/54 mmHg (decreased from 124/76 mmHg intraoperatively), HR 122 bpm, RR 22 breaths/min, temperature 98.2 F, SpO2 94% on 2 L/min nasal cannula. Daniel is pale, diaphoretic, and reports feeling 'dizzy and weak,' with urine output of 15 mL over the past hour.