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.

A 76-year-old with nonvalvular atrial fibrillation presents with palpitations. Vitals: BP 132/76, HR 124 and irregular, RR 18, SpO2 98% room air. The plan includes preventing thromboembolism and controlling ventricular rate. Drag each medication into its correct therapeutic category.

An older adult with advanced cirrhosis is receiving scheduled lactulose for hepatic encephalopathy. Which finding best indicates the medication is effective?

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 58-year-old client admitted for community-acquired pneumonia is on continuous telemetry. Rhythm: regular sinus at 68/min. PR interval measures 0.22 second and is constant; QRS 0.08 second. The client is awake, BP 126/74, denies dizziness or chest pain. Which nursing action is most appropriate?

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?

A 29-year-old with known Crohn disease reports sudden worsening abdominal pain after 2 days of diarrhea. Vitals: T 39.1°C (102.4°F), HR 118, BP 96/58, RR 24. Exam shows abdominal guarding with diffuse tenderness, worst in the right lower quadrant; bowel sounds are hypoactive, and the patient has rebound pain when the examiner releases pressure. Which finding pattern is most concerning and requires immediate intervention?

A 58-year-old with newly diagnosed acute myeloid leukemia started induction chemotherapy 7 days ago. The client reports fatigue and mild mouth soreness. Vitals: T 37.2°C (99.0°F), HR 104, BP 110/68, RR 18, SpO₂ 98% on room air. Current meds: ondansetron as needed, allopurinol. Which laboratory testing should the nurse prioritize to detect the most serious complication at this phase of therapy?  

A patient with a history of ulcerative colitis presents with worsening abdominal pain and fatigue. Which assessment finding is most characteristic of an acute ulcerative colitis flare?

An adult with prolonged QT history suddenly becomes unresponsive. The monitor shows a rapid polymorphic wide-complex tachycardia with “twisting” QRS axes. No pulse is palpable. Which action should the nurse take first?