A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following: Respiratory rate: 10 breaths/min Pulse: 136 beats/min Blood pressure: 92/78 mm Hg Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C) Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best?

A. Call the Rapid Response Team is correct because the client is exhibiting life-threatening signs of deterioration. A respiratory rate of 10 breaths per minute indicates bradypnea, which can lead to hypoxia and respiratory failure if not addressed immediately. The tachycardia (pulse 136) reflects the body’s attempt to compensate for hypotension and maintain perfusion. A blood pressure of 92/78 mm Hg is borderline low and may worsen, leading to inadequate organ perfusion. The altered level of consciousness, responding only to voice, suggests decreased cerebral perfusion, a critical warning sign. These findings collectively indicate the client is in early to moderate shock and requires immediate bedside evaluation and intervention to prevent progression to irreversible shock. The Rapid Response Team brings skilled personnel and resources to stabilize the client quickly, including interventions such as airway support, intravenous fluids, and medication administration. B. Transfer the client to the Intensive Care Unit is incorrect because while ICU care may ultimately be necessary, immediate stabilization is the priority. Rapid Response activation allows critical interventions to occur at the bedside before transfer, reducing the risk of further deterioration during transport. C. Continue monitoring every 30 minutes is incorrect because the client’s current vital signs indicate acute instability. Waiting 30 minutes could result in respiratory failure, shock progression, or cardiac arrest. Continuous monitoring alone is insufficient. D. Notify the unit charge nurse immediately is incorrect because while the charge nurse should be informed, this action does not ensure prompt bedside intervention by personnel trained to manage acute life-threatening changes. The Rapid Response Team is the recommended mechanism for urgent evaluation and treatment.