SNLE ABCDE Strategy

A patient with a history of seizures starts jerking in bed. What is your first action?

• Insert oral airway

• Restrain the arms

• Turn patient on the side

• Call the doctor

A post-op patient suddenly becomes confused. What is the nurse’s first response?

• Administer pain meds

• Call physician

• Check oxygen saturation

• Give fluids

A child with epiglottitis is drooling and sitting in a tripod position. What should you do first?

• Inspect throat

• Start antibiotics

• Insert nasal cannula

• Provide oxygen and prepare for airway management

A child with asthma is wheezing and using accessory muscles. What should you do first?

• Monitor temperature

• Administer bronchodilator

• Provide fluids

• Encourage coughing

A nurse is caring for a client with bipolar disorder who is receiving lithium carbonate. Before the next dose, the client complains of nausea and vomiting. The nurse finds the lithium level to be 1.5 mEq/L. What is the priority action?

• Call the physician

• Withhold the next dose

• Administer IV fluids

• Repeat blood test

A 49-year-old woman presents to the ED with severe chest pain. ECG confirms myocardial infarction. Doctor orders 800 mg aspirin. Why?

• Breaks down thrombus

• Decreases platelet aggregation

• Inhibits prothrombin

• Maintains clotting via Vitamin K

A patient is on digoxin. Current level is 2.6 ng/mL. What is the most important action?

• Notify physician

• Check previous vitals

• Record value

• Administer dose

A child is brought in after ingesting unknown pills. He's drowsy and bradycardic. What’s the first action?

• Give syrup of ipecac

• Induce vomiting

• Assess airway and give oxygen

• Wait for toxicology

A burn patient develops hoarseness and singed nasal hairs. What is your priority?

• Start IV fluids

• Insert foley catheter

• Secure airway

• Clean the wound

Post-op patient suddenly complains of chest pain and SOB. Vitals: HR 120, RR 30, BP 90/60. What’s the likely issue?

• Infection

• Atelectasis

• Pulmonary embolism

• Hypoglycemia