The nurse on a medical–surgical unit is caring for a client who complains of chest pain. Assessment findings include a blood pressure of 72/40, pulse rate of 40, and respiratory rate of 32. Which action by the nurse is the priority in this situation?
1. Calling a code
2. Calling the rapid response team
3. Calling the client's primary health care provider
4. Calling the emergency department (ED) and requesting they send a health care provider
2
Rationale 1: The client is still breathing, so the nurse would not call a code.
Rationale 2: Because the client is in distress, the rapid response team should be assembled.
Rationale 3: Only after calling for the rapid response team would the primary care provider be notified.
Rationale 4: The emergency department health care provider is generally busy with clients, and cannot respond to clients admitted to the hospital in most facilities.
Global Rationale: The client is still breathing, so the nurse would not call a code, but because the client is in distress, the rapid response team should be assembled. Only after calling for the rapid response team would the primary care provider be notified. The emergency department health care provider is generally busy with clients, and cannot respond to clients admitted to the hospital in most facilities.
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