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You are the charge nurse on a 32-bed surgical unit during evening rounds. Several bedside nurses on your unit call with new patient changes. For which situations should you direct the bedside nurse to activate the Rapid Response Team immediately, before routine provider notification? Select all that apply.

The nurse prepares a room for a client with decompensated cirrhosis and known large esophageal varices who is being transferred from the ED. Which item is the priority to have immediately available at the bedside?  

A patient in remission from leukemia calls the clinic for guidance on which symptoms should be reported right away. Select all that apply.

A 41-year-old patient with Crohn disease presents with crampy abdominal pain that has become constant over 6 hours. The abdomen is distended. Vitals: T 38.6°C (101.5°F), HR 112, BP 100/62, RR 22. The patient is nauseated, has had no flatus for 24 hours, and vomited green fluid. Bowel sounds were high-pitched earlier but are now absent; palpation elicits involuntary guarding. Which assessment cluster requires immediate intervention?

A 58-year-old with cirrhosis and hematemesis arrives pale and clammy. Two large-bore IVs are placed; octreotide is started; 1 L LR given and 1 unit PRBCs is infusing. Current data: BP 86/52 mm Hg, HR 118/min, RR 24/min, SpO₂ 96% on 2 L NC, urine output 10 mL in the last hour. Which bedside measurement signals the need for the most immediate intervention?

A 19-year-old varsity soccer goalkeeper completes a screening exam. ECG shows sinus rhythm 48/min; BP 118/62 mm Hg. The student runs 5–6 days/week and denies syncope, chest pain, or exercise intolerance. Cardiac exam is normal. What should the nurse do?

A 55-year-old patient in urgent care reports 2 days of progressive abdominal pain and anorexia. Vitals: T 38.0°C (100.4°F), HR 96, BP 132/76, RR 16. Labs: WBC 13,200/µL. The patient denies vomiting. Which assessment finding would the nurse expect with uncomplicated diverticulitis? Which assessment finding is most consistent with this diagnosis?

A preceptor observes a new RN treating a stable patient with regular narrow-complex tachycardia at 185/min who remains alert and normotensive after unsuccessful vagal maneuvers. Which action shows correct medication administration?

Thirty minutes after a large-volume paracentesis removing 6.0 L, a patient with cirrhosis reports lightheadedness when turning in bed. Orders: vitals every 15 minutes for 1 hour, strict I&O, occlusive dressing, bedrest 1 hour, albumin 25% IV now, and 500 mL normal saline IV bolus only if systolic BP < 90 mmHg. Vitals: BP 94/56, HR 112, RR 18, SpO₂ 98% on room air. The dressing is dry with minimal serous strike-through. What is the nurse’s priority actioN?

A 56-year-old with cirrhosis arrives with large-volume hematemesis and pallor. Two large-bore IVs are placed. Orders pending include: octreotide infusion, pantoprazole IV bolus, ceftriaxone IV, and propranolol PO when stable. Which medication should the nurse administer immediately to help control the bleeding?