Acute pulmonary edema / respiratory distress — severe dyspnea, frothy sputum, hypoxia, or an inability to lie flat — emergency evaluation/transfer.

Chest pain / suspected ACS — activate EMS/transfer per policy; nitroglycerin per order while awaiting transport.

Symptomatic hypotension or a dangerous arrhythmia — hold the offending agent per parameters and escalate.

Rapid, large weight gain with worsening congestion unresponsive to the ordered diuretic — escalate promptly.