Rapid Response & Clinical Deterioration
A nurse notes that a postoperative patient has new confusion, tachycardia, hypotension, and hypoxemia. Which action should the nurse take first?
A. Activate the rapid response team
B. Notify the provider
C. Reassess vital signs in 30 minutes
A. Activate the rapid response team
A nurse finds a patient unresponsive and pulseless. What is the nurse’s priority action?
A. Call the provider
B. Begin chest compressions
C. Apply oxygen
B. Begin chest compressions
Shock is best defined as:
A. Inadequate blood pressure
B. Acute impaired tissue perfusion
C. Failure of one organ system
B. Acute impaired tissue perfusion
After ROSC, which nursing intervention has the highest priority?
A. Obtain a 12-lead ECG
B. Notify family
C. Ensure airway and oxygenation
C. Ensure airway and oxygenation
During a cardiac arrest, which team member is responsible for directing the code and making treatment decisions?
A. Primary bedside nurse
B. Code leader
C. Nursing supervisor
B. Code leader
Which assessment finding most clearly indicates the need for immediate RRT activation?
A. Heart rate of 108/min after ambulation
B. Sudden unresponsiveness with snoring respirations
C. Oxygen saturation of 93% in a patient with COPD
B. Sudden unresponsiveness with snoring respirations
Which action most directly improves survival during cardiac arrest?
A. Early high-quality CPR
B. Early medication administration
C. Immediate intubation
A. Early high-quality CPR
Which finding is most consistent with the compensatory stage of shock?
A. Hypotension
B. Anuria
C. Tachycardia and narrowed pulse pressure
C. Tachycardia and narrowed pulse pressure
During ACLS, continuous waveform capnography is primarily used to:
A. Confirm airway placement and CPR effectiveness
B. Measure oxygen saturation
C. Monitor blood pressure
A. Confirm airway placement and CPR effectiveness
Which nursing action best demonstrates closed-loop communication during a code blue?
A. Preparing medications without verbal confirmation
B. Administering medications as quickly as possible
C. Repeating back medication orders before administration
C. Repeating back medication orders before administration
The primary purpose of a rapid response team is to:
A. Manage patients already in cardiac arrest
B. Prevent clinical deterioration and arrest
C. Replace provider notification
B. Prevent clinical deterioration and arrest
Which characteristic defines high-quality chest compressions?
A. Rate of 60–80/min
B. Depth of at least 2 inches with full recoil
C. Interruptions every 30 seconds
B. Depth of at least 2 inches with full recoil
A rising serum lactate level primarily indicates:
A. Metabolic alkalosis
B. Tissue hypoxia and anaerobic metabolism
C. Renal compensation
B. Tissue hypoxia and anaerobic metabolism
A sudden rise in end-tidal CO₂ during CPR most likely indicates:
A. Worsening hypoxia
B. Equipment malfunction
C. Return of spontaneous circulation
C. Return of spontaneous circulation
A nurse arrives first to a patient who has collapsed and is unresponsive. Which action is the nurse’s priority responsibility as the first responder?
A. Begin CPR and direct someone to activate the code
B. Obtain a full set of vital signs
C. Call the provider before initiating interventions
A. Begin CPR and direct someone to activate the code
Which early indicator is most commonly present before in-hospital cardiac arrest?
A. Hypotension
B. Severe hypoxemia
C. Altered mental status
C. Altered mental status
Before delivering a defibrillation shock, the nurse must:
A. Establish IV access
B. Administer epinephrine
C. Ensure all staff are clear
C. Ensure all staff are clear
Which stage of shock is characterized by irreversible cellular damage and MODS?
A. Initiation
B. Progressive
C. Refractory
C. Refractory
Which medication is administered first during pulseless cardiac arrest?
A. Amiodarone
B. Epinephrine
C. Atropine
B. Epinephrine
Which action is the primary responsibility of the nursing supervisor during a code?
A. Performing chest compressions
B. Managing the defibrillator
C. Controlling the environment and coordinating resources
C. Controlling the environment and coordinating resources
Failure to rescue most often results from:
A. Delayed recognition of deterioration
B. Inadequate staffing
C. Equipment malfunction
A. Delayed recognition of deterioration
Which rhythm requires immediate defibrillation?
A. Asystole
B. Pulseless ventricular fibrillation
C. Pulseless electrical activity
B. Pulseless ventricular fibrillation
Which assessment finding suggests progression from shock toward MODS?
A. Improved urine output
B. Rising creatinine and bilirubin
C. Normal mental status
B. Rising creatinine and bilirubin
Which nursing action best supports safe medication administration during a code?
A. Preparing multiple medications in advance
B. Using closed-loop verbal communication
C. Minimizing verbal interaction
B. Using closed-loop verbal communication
A patient has a valid Do Not Resuscitate (DNR) order in the chart. Which nursing action is most appropriate when the patient becomes pulseless?
A. Initiate CPR until the provider arrives
B. Withhold resuscitation and notify the provider
C. Activate the code blue and wait for clarification
B. Withhold resuscitation and notify the provider