Final answer:
The nurse should address the infection and potential septic shock by administering oxygen, ensuring IV access, and initiating sepsis protocols. Monitoring vital signs, maintaining the airway, and supporting care to stabilize the patient are crucial.
Step-by-step explanation:
In the given clinical scenario, after calling the rapid response team due to signs of potential sepsis in a lung cancer patient with an inflamed central line insertion site, the nurse should take immediate steps to stabilize the patient's condition. The patient is displaying signs of infection and potential septic shock, indicated by symptoms such as hypotension, tachycardia, fever, hypoxemia, and dyspnea. The nurse should prioritize interventions such as administering oxygen to address hypoxemia, ensuring IV access for fluid resuscitation and medication administration, and preparing to collect blood cultures before initiating broad-spectrum antibiotics as ordered.
All of these interventions align with sepsis protocols and addressing the infection from the venous access device. Close monitoring of vital signs, maintaining the patient's airway, and supportive care to stabilize the patient are essential following the activation of the rapid response team. Ensuring the proper function of monitoring equipment like the pulse oximeter and preparing for further interventions as the medical team arrives are also imperative.