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A
Only changes visible on the ECG monitor
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B
Acute changes in mental status, respiratory rate outside 8-30 breaths/min, heart rate outside 40-130 bpm, systolic BP below 90 mmHg, oxygen saturation below 90%, or a nurse's 'gut feeling' that something is wrong — early activation saves lives
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C
Vital sign changes only if outside normal range for 4+ hours
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D
Only after the attending physician is notified and unavailable
Why this is the answer
RAPID RESPONSE TEAMS (RRTs) exist to bring critical care expertise to deteriorating patients on general wards BEFORE they progress to cardiac arrest. Research consistently shows that most in-hospital cardiac arrests are preceded by 6-8 hours of deteriorating vital signs and clinical condition that were either not recognized or not acted upon. RRT ACTIVATION CRITERIA (typical, varies by facility): RESPIRATORY: Rate below 8 or above 30 breaths/min; SpO2 below 90% on any oxygen; new or increasing oxygen requirement; CARDIOVASCULAR: Heart rate below 40 or above 130 bpm; systolic BP below 90 mmHg; new chest pain; NEUROLOGICAL: Acute change in mental status or level of consciousness; seizure; new focal neurological deficit; URINE OUTPUT: Less than 50 mL over 4 hours without explanation; GENERAL: Staff is worried about the patient even if they can't identify a specific parameter — this is officially recognized as a valid RRT trigger at most institutions ('failure to rescue' research shows nurses' subjective concern is diagnostically valid). DO NOT WAIT: Call the RRT before calling the primary team if the situation is urgent — RRT and primary team communication can happen simultaneously; delay to confirm with a team that may not be immediately available is dangerous. AFTER CALLING RRT: Stay with the patient; have chart and medication list ready; be prepared to give an SBAR report; document the call and all actions.
Source: NCLEX-RN Test Plan: Safe Care — Rapid Response Team Activation