In this special rapid-fire episode of Think Like a Nurse, created by Brooke Wallace—20-year ICU nurse, organ transplant coordinator, clinical instructor, and published author—we’re testing your NCLEX critical thinking in real time. You’ll tackle 10 classic nursing scenarios covering respiratory distress, cardiac safety, newborn assessment, postoperative complications, maternal-fetal monitoring, pharmacology, mental health, and pediatric oncology. But this isn’t just about memorizing answers—it’s about understanding the why. Learn the rationale behind every choice, the safety principles that guide your decisions, and the quick mental frameworks that help you prioritize in seconds. From “Hold Digoxin if HR < 60” to “Left lateral first for late decels,” this episode is packed with clear explanations, clinical pearls, and test-ready reasoning that sharpen your nursing judgment. Stay tuned till the end for a full recap of key takeaways—vital signs, medication rationale, and the ABCs of prioritization—so you can think, act, and truly Think Like a Nurse. Make sure to check out ThinkLikeaNurse.org for more educational resources for nurses!
What You’ll Learn:
High Fowler’s vs. supine: Why positioning saves oxygenation in COPD
The “below 60 rule” for Digoxin (and why bradycardia = danger)
Normal newborn vitals that trick NCLEX students
The hallmark sign of peritonitis after surgery
Early compensation in hypovolemic shock: why tachycardia appears first
Insulin teaching mistake that signals knowledge gaps
Therapeutic communication for auditory hallucinations: safety first
The LIONS mnemonic for late decelerations
ACE inhibitor safety: monitoring for hypotension and angioedema
Neutropenic precautions that save lives in pediatrics
Nursing Pearls:
Always ask “What’s my priority? Airway, Breathing, or Circulation?”
Position changes are often the fastest lifesaving move.
Never dismiss patient symptoms—assess, document, and escalate.
Know normal values cold; they guide every safe decision.
Safety trumps everything.
Make sure to check out ThinkLikeaNurse.org for more educational resources for nurses!
Welcome back everyone. You're listening to Think Like a Nurse. This is the place designed to really sharpen your clinical skills, whether you're, you know, hitting the books for exams or stepping onto the floor for the very first time. And Think Like a Nurse, the whole platform. It was created by the amazing Brooke Wallace. We're talking to someone with two decades of incredible experience, a 20-year ICU nurse, organ transplant coordinator, clinical instructor, and a published author. Just phenomenal background. Our mission, it's pretty straightforward, actually. We take these really complex nursing topics, break them down, make them easier to grasp, and basically give you a shortcut to feeling confident in what you do. Today, uh we're not just covering basics. We are diving into some highstakes clinical judgment scenarios, the kind you will encounter.
That's exactly right. We've pulled together some really critical decision points. You know, things like patient positioning, knowing when to act on vitals, recognizing shock. These are the situations where we absolutely need to make the right call fast. For you listening, these are the questions where, well, hesitation just isn't an option, right? We're really zeroing in on that first step. What's the action that stops things from going downhill? And hey, if you want even more tools after this, definitely check out think like a nurse.org. Lots of good stuff there. Okay, enough preamble. Let's jump right in. We're starting foundational breathing, making sure our patients can actually breathe. So, classic scenario, you've got a client with COPD. They're really short of breath acutely. What position do we need to get them into? Like immediately, what's the priority?
Uh, Definitely high fowlers. That's the absolute priority. So that means sitting them up pretty much straight up, right? Like 60 to 90 degrees high fers. Okay. And physiologically, why is that the gold standard? Especially for someone with COPD. Well, it's largely about gravity actually. When you sit someone upright like that, gravity pulls the abdominal organs down, and that gives the diaphragm more room to move, more space to expand downwards. Ah, okay. For a COPD patient who's already struggling with air trapping, maximizing that diaphragmatic excursion, that movement It's just crucial for getting air in and out.
right? So, putting them flat like supine or prone. Oh, non-starters. You'd be compressing the chest, restricting the very movement they desperately need. You'd be working against them essentially. Got it. Crystal clear. Okay, let's pivot from breathing difficulty to uh brand new life, newborn vital signs. This one seems to trip people up all the time on exams. So, you assess a newborn, heart rate 140, respiratory rate 50, temp is 36.8 C, which is 98.2 Fahrenheit. What's the very first thing you do.
Yeah, this is where new nurses often uh kind of panic a bit because you know 50 breaths a minute in an adult that's a huge warning sign. But here for this newborn, the correct first action is simply document the findings. They're normal. Just document. Why is that such a common mistake? Then it comes down to applying adult norms where they don't fit. You just have to learn those newborn ranges cold. So heart rate 120 to 160 is normal. Respiratory rate 30 to 60 is normal. Temp 36.5 to 37. 5 Celsius is normal.
So this baby's right in the middle. Textbook. Yeah, exactly. Textbook normal. And the lesson here for you, the listener, is huge. Sometimes the most critical clinical judgment is knowing when not to intervene. You don't want to be paging doctors or, you know, unnecessarily warming a perfectly stable baby. Confidence and normaly is key, too. That's a really great point. Confidence and normaly. Okay, moving on to medication safety. Let's talk Doxin. Definitely a high alert drug, a cardiac glycoside. very narrow safety window. When do you absolutely without question hold the dose in an adult?
You withhold a gauin if that apical pulse is below 60 beats per minute. Period. And crucially, you need to listen to that apical pulse for a full minute. Don't estimate. Get an accurate count before you even think about giving it. Okay, full minute. Apical pulse less than 60. And the scenario we looked at had a pulse of 56. So that's a definite hold, right? Absolutely non-negotiable. Dyoxin slows the heart rate down while making the contra ction stronger. So if the patient's already brady cardiac already below 60, giving that dose could push them into a dangerously low heart rate, you could cause profound bradic cardia, even arrest.
Wow. Yeah. So a pulse of say 72 or 88. It's generally fine or maybe indicate something else, but it doesn't automatically mean you hold the deoxin based on that alone. Below 60 is the hard stop. Got it. Crucial safety check. All right, let's switch gears again. Patient education, specifically insulin administration. You're teaching a newly diagnosed diabetic client. They say something that tells you, "Uhoh, they didn't get it." What's that critical error statement? The statement that just screams, "Stop and retach is when the client says they can reuse their needles." Yeah.
Even if, you know, they say, "Oh, I'll clean it with alcohol." Oh, yeah. We hear that one. Why is that so bad? Can you break down the danger? It's not just infection, is it? No, it's twofold, really. First, yes, the infection risk is huge. Alcohol cleaning isn't sterilization, not for needles going into tissue. But second, and people often forget this, every single time you use a needle, The tip gets duller microscopically maybe, but it gets dull. Interesting. And that dullness, it causes more tissue trauma when you inject, more pain, more bruising, and it significantly increases the risk of developing lipodistrophe.
Okay, wait. Lipodistrophe for listeners who might not know that term, well, what is that exactly and how does rotating Sykes help? Right. So, lipodistrophe is basically abnormal changes in the fat tissue under the skin. It could be like lumpy areas or little pits or dents You keep injecting and the problem is that change tissue doesn't absorb insulin predictably. So your blood sugar control goes haywire. Ah okay that makes sense. That's precisely why sight rotation is so vital. You give the tissue time to recover. So the client knowing about sight rotation refrigerating unopened insulin using subcutaneous roundic that's all great but saying they can reuse needles that cancels out the good understanding. You have to correct that immediately.
Definitely a priority teaching point. Okay let's move into the surgical world. Posttop complications we have a client they had an apppendecttomy now they have severe pain and you assess their abdomen it's rigid like boardlike and distended this is where we need sharp assessment what critical diagnosis should jump to mind that combination severe pain rigid distended abdomen posttop that's a surgical emergency you have to immediately suspect peritonitis peritonitis inflammation of the paratonium what makes that rigidity that boardike feeling such a critical sign like life or death critical Well, there's an old surgical saying pain is common. Rigidity is ominous. Something like that. That rigidity means the lining of the abdominal cavity. The paratonium is severely inflamed.
Usually from infection, maybe a leak or rupture after surgery, spilling contents where they shouldn't be. Okay, this isn't just posttop soreness. It signals a massive inflammatory process, possibly sepsis starting. It's crucial to distinguish this from say wound adhesence where the incision opens or adaltois which is a lung issue. Those are problem. Yes, but they don't cause that specific diffuse board-like abdominal rigidity. That's the hallmark of peritonitis. Urgent intervention needed.
Understood. That's a very clear distinction. Okay. Now, big shift. Mental health. Therapeutic communication. Client with schizophrenia experiencing auditory hallucinations, hearing voices. We need to respond in a way that's both therapeutic and safe. What's the most important question to ask first? The most therapeutic and definitely the most safety focused response is to ask them directly. What are the voices telling you to do? Why that question specifically? Because I think the instinct for many might be to try and reassure them like the voices aren't real.
That's a common instinct. Yeah. But we prioritize safety first. We need to assess for command hallucinations. These are voices instructing the patient to do something specific, often harmful to themselves or to someone else. That's the absolute highest safety risk. Ah, okay. Command hallucination. Exactly. While reality testing, gently pointing out they aren't real, is part of therapy later on. If you jump straight to dismissing their experience, you shut down communication. You invalidate what's very real to them. By asking what the voices are saying, especially about actions, you're triaging the immediate danger. Safety assessment always comes first in psych nursing.
Safety first makes perfect sense. Okay, let's head over to OB labor and delivery. High stakes interventions here, too. Fetal heart monitor is showing late decelerations. We know that signals utral placental insufficiency. the baby's not getting enough oxygen from the placenta. What is the absolute first thing the nurse needs to do? The very first immediate priority intervention is repositioning the client. Specifically, get them under their left lateral position. Left lateral. Okay, I want to really understand the why here. The sequence is important. Why repositioning before other things like giving oxygen?
Great question. So late decelerations mean placental profusion is compromised often during contractions. If the mother is lying flat on her back supine, the weight of the uterus can press down. on the inferior venneava. That's the big vein returning blood to her heart. Ray, venneava syndrome. Exactly. Vneava syndrome. It reduces the blood flow back to the mom's heart, which then reduces the blood flow out to the uterus and placenta dramatically. Turning her onto her left side physically shifts the uterus off that venneava. It's the quickest way to potentially improve blood flow to the placenta.
So, it's a mechanical fix first. Precisely. If you don't fix the underlying profusion problem by repositioning, just giving mom more oxygen or IV fluids might not help much because the better oxygenated blood still isn't reaching the baby effectively. Repositioning is the fastest most direct intervention for this problem. Then you might add O2 fluids etc. That logic makes the sequence really clear. Okay, sticking with life or death emergencies, hypoalmic shock, massive volume loss. The body tries to compensate. Which physiological finding is the most indicative sign of that compensation kicking in?
The key compensatory finding you'll see early on is tacic cardia a fast heart rate. T cardia. Okay, explain that mechanism. Why does the heart speed up when the tank is essentially running low on volume? So, the body senses the blood pressure is dropping because there's just not enough volume, not enough preload returning to the heart. Cardiac output, which is heart rate times stroke volume, is falling. Stroke volume, the amount pumped per beat, is low because there's less blood to pump.
Makes sense. So, to try and maintain some level of cardiac output and tissue profusion, the brain signals the heart, speed up pump faster. It's trying to make up for the low volume per beat by increasing the number of beats per minute. So, it's a desperate attempt to keep things going. Exactly. It's often the earliest, most reliable sign before blood pressure crashes completely. Remember, in shock, patients are usually cool, pale, clammy, not warm and flushed. Blood pressure will eventually be low, hypotension, respirations fast, dipnia. But that tacic cardia, that's the body screaming for help right at the start.
Got it. Tacocardia is the key early warning. All right, let's swing back to pharmarmacology and common ACE inhibitor for hypertension. You give this medication. What's the number one adverse effect you need to be monitoring for? The primary risk, the main thing you're watching for because it's an anti-hypertensive is hypotension, blood pressure dropping too low and how does enolaperil actually cause that drop? What's the mechanism? So, it's an ACE inhibitor, right? It blocks the angotensin converting enzyme. This enzyme normally converts and angotensin the first to adotensin the second. And angotensin the second is a really potent vasoc constrictor. It squeezes blood vessels.
Okay. By blocking that conversion, analapo prevents that vasoc constriction. At least vasoddilation. The blood vessels relax and widen which lowers the pressure. Exactly. That's the intended effect. But you have to watch carefully. It doesn't drop too much. Especially watch out for what's called first dose hypotension. A significant drop after the very first time they take it. So monitoring blood pressure before and after giving it is absolutely essential. We also watch for things like hypercalemia that nagging dry cough but acute hypotension is the biggest immediate safety concern
right monitor that BP closely okay final scenario pediatrics and a really critical safety issue immune compromise you have a child undergoing chemotherapy who develops neutropenia their neutrfll count is dangerously low what is the absolute priority instruction you give the parents for safety at home this is potentially life-saving advice the number one absolute priority is avoid crowded places. Avoid crowds. Why is that single instruction so much more critical than say focusing on diet or encouraging rest?
Because neutropenia means the child has virtually no defense against bacterial or fungal infections. Neutrfils are their main infection fighters. They're gone. So they're wide open to anything. Completely wide open. We're not just talking about catching a simple cold, which would be bad enough. For a neutropenic child, even a minor infection can rapidly escalate into life-threatening sepsis. It can happen in hours. So avoiding potential sources of pathogens like shopping malls, movie theaters, crowded classrooms, even busy waiting rooms is the most immediate impactful way to protect them. Infection prevention is paramount.
Okay, so things like high protein diet, exercise important generally, but secondary, definitely secondary in this acute phase. Good nutrition helps rebuild the body, sure, but avoiding that initial exposure to terms is the absolute top priority when their defenses are down like this. If they get a fever, that's an emergency requiring immediate medical evaluation, not just Tylenol. at home avoidance is key. You know, looking back across all these scenarios we've discussed, the COPD positioning, the newborn vitals, dioxin safety, the peritonitis signs, the command hallucinations, the late D cells, shock, medication effects, neutropenia. The common thread really is prioritization. Nursing isn't just about knowing facts. It's about seeing the whole picture and instantly identifying what matters most right now. What's the first action I need to take? Which risk is the absolute highest? That fundamentally is what clinical judgment is all about. Make in that critical first step correctly.
Ah, that's such a great summary. It really is about that prioritization. We covered a huge range today from those first moments of life with newborn vitals through medication safety like deoxin, recognizing surgical emergencies like peritonitis, handling OB crises, understanding shock. Keep practicing these scenarios in your mind. Keep asking what's the first thing I do? That's how you build that intuition, that confidence. That's how you truly learn to think like a nurse. We really hope this session focusing on these high stakes decisions gave you some solid, actionable things you can use right away. Thank you so much for tuning in to Think Like a Nurse. Keep learning, keep questioning, and please join us again next week for more crucial conversations. And definitely don't forget to visit think like nurse.org. Tons more resources there to help you on your journey. We'll catch you next time.