Difficulty: Medium
Average Score: 76%
Simulated
The nurse is caring for a client diagnosed with deep vein thrombosis who suddenly becomes short of breath, anxious, and restless. The vital signs are: heart rate 130 beats/minute, respirations 42/minute, blood pressure 90/50, and pulse oximetry is 90%. An intravenous infusion of normal saline is running at 75ml/hr. The nurse elevates the head of the bed and applies nasal oxygen at 2L/min. What action should the nurse take next?
Correct answer
B
Rationale
Calling the rapid response team is the most appropriate next step. The client's symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention.