Rationale for Choice A:
Documenting and continuing to monitor is a crucial aspect of nursing care; however, in this scenario, it would not be the first action to take. The significant drop in blood pressure warrants immediate intervention to prevent potential complications.
While monitoring is essential, it does not actively address the underlying cause of the hypotension. Relying solely on monitoring could delay necessary interventions and potentially compromise patient safety.
It's important to balance monitoring with timely interventions to ensure optimal patient outcomes. In this case, calling for assistance takes priority over documentation and continued monitoring.
Rationale for Choice B:
Repeating the blood pressure in 15 minutes could delay critical interventions if the hypotension is severe. Timely action is crucial to maintain adequate tissue perfusion and prevent organ damage.
Waiting to recheck the blood pressure could potentially worsen the patient's condition and lead to adverse outcomes. It's essential to act promptly when a significant change in vital signs occurs.
Rationale for Choice D:
While notifying the primary healthcare provider is an important step, it may not be the most immediate action in this situation. The Rapid Response Team is specifically trained to handle acute patient deterioration and can provide timely interventions.
The Rapid Response Team can initiate life-saving measures, such as administering fluids or medications, while the primary healthcare provider is being notified. This ensures that the patient receives prompt and appropriate care.
Rationale for Choice C:
Calling the Rapid Response Team is the most appropriate first action in this scenario because it ensures a rapid and coordinated response to the patient's hypotension.
The Rapid Response Team can quickly assess the patient, initiate interventions, and potentially prevent further complications. They can also facilitate communication and collaboration among healthcare providers.
Early activation of the Rapid Response Team has been shown to improve patient outcomes in various clinical settings, including postoperative care.

Rationale for Choice A:
Documentation is essential for communication and continuity of care, but it is not the most immediate priority in this situation.
The nurse should document the episode of vomiting, including the time, amount, and characteristics of the vomitus, as well as any associated symptoms or interventions.
However, auscultating lung sounds should be done first to assess for potential aspiration, which is a more urgent concern.
Rationale for Choice B:
Offering dry toast may be appropriate after the nurse has assessed for aspiration and determined that it is safe for the client to resume oral intake.
However, it is not the most important action at this time.
The nurse should first assess the client's respiratory status and address any potential complications.
Rationale for Choice C:
Rest is important for healing and recovery, but it is not the most immediate priority in this situation. The nurse should first assess the client's respiratory status and address any potential complications. Once the client is stable, the nurse can then encourage rest.
Rationale for Choice D:
Auscultating lung sounds is the most important action for the nurse to take after a client vomits.
This is because aspiration of vomitus is a serious complication that can lead to pneumonia, respiratory distress, and even death.
By auscultating lung sounds, the nurse can assess for signs of aspiration, such as crackles, wheezing, or diminished breath sounds.
If aspiration is suspected, the nurse can initiate appropriate interventions, such as suctioning, oxygen therapy, and positioning the client to facilitate drainage of secretions.