Ace the Certified Medical-Surgical RN Exam 2025 – Power Up Your Nursing Game!

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Which vital sign changes would require immediate nursing intervention?

Stable heart rate with normal temperature

A significant drop in blood pressure with a rapid heart rate

A significant drop in blood pressure combined with a rapid heart rate indicates a potential state of shock or a critical deterioration in the patient's hemodynamic status. This combination is concerning because it suggests that the body is not maintaining adequate perfusion, which could lead to organ dysfunction or failure if not addressed promptly.

In this scenario, the swift nursing intervention is crucial as it may involve administering fluids, medications, or other supportive measures to stabilize the patient. While other options may reflect changes in vital signs, they do not carry the same level of immediate risk that requires urgent intervention. For instance, a stable heart rate with a normal temperature suggests that the patient is typically stable, minor fluctuations in blood oxygen levels are often manageable without immediate intervention, and an increased heart rate during physical activity can be a normal physiological response. The combination of a significant drop in blood pressure with a rapid heart rate requires a focused and immediate nursing response to ensure patient safety and prevent further complications.

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Minor fluctuations in blood oxygen levels

Increased heart rate during physical activity

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