NCLEX Question of the Day – Monday, March 02, 2026

Today’s question targets rapid prioritization and safe delegation. This skill keeps the sickest patient safe first while the team handles everything else. In real nursing, minutes matter. Knowing who you see first and what you can delegate prevents delays, errors, and harm. Category: Leadership

Clinical Scenario

You are the charge nurse on a busy medical-surgical unit at 0730. Four issues hit at once:

• Mr. Lewis, 67, postoperative day 1 after open cholecystectomy (history: hypertension). The unlicensed assistive personnel (UAP) reports BP 86/50, HR 122, cool clammy skin, and 120 mL dark red output in the last hour from the surgical drain.
• Ms. Chen, 32, type 1 diabetes, NPO for an endoscopy. Point-of-care glucose is 58 mg/dL. She is diaphoretic and shaky.
• Mr. Ortiz, 79, recovering from pneumonia. Discharge is scheduled in 30 minutes. He is starting warfarin and has not received full teaching yet.
• Ms. Brooks, 45, admitted for pyelonephritis, reporting 8/10 flank pain. IV morphine is ordered PRN and due now.

The Question

Which action should the charge nurse take first?

Answer Choices

1. A. Direct the UAP to give Ms. Chen 120 mL of orange juice for hypoglycemia.
2. B. Go immediately to assess Mr. Lewis and activate the rapid response team for suspected postoperative hemorrhage.
3. C. Assign the LPN to complete warfarin discharge teaching for Mr. Ortiz to avoid delay.
4. D. Tell the LPN to administer IV morphine to Ms. Brooks for severe pain.

Correct Answer

B. Go immediately to assess Mr. Lewis and activate the rapid response team for suspected postoperative hemorrhage.

Detailed Rationale

Use ABCs and acuity. Mr. Lewis shows signs of shock: hypotension, tachycardia, cool clammy skin, and increasing drain output. This points to active bleeding with failure of circulation. Without rapid intervention, perfusion to the brain and organs will fall, causing arrest. The charge nurse must see him now to confirm findings, start life-saving steps, and mobilize resources.

What to assess first: airway, breathing, circulation, mental status, and the surgical site/drain. Verify vital signs and trend drain output. Look for abdominal distention, increasing pain, or new pallor.

Immediate actions:

• Call rapid response. This brings extra hands, equipment, and a provider quickly.
• Apply oxygen to keep SpO2 ≥ 94% and support tissue oxygenation.
• Position supine with legs flat unless contraindicated to help perfusion.
• Ensure two large-bore IV lines; start isotonic fluids per protocol to support blood pressure.
• Draw stat labs: CBC, type and screen/crossmatch, coagulation studies, lactate.
• Notify the surgeon; prepare for possible return to OR and blood transfusion.
• Keep NPO; hold anticoagulants.

Meanwhile, hypoglycemia in Ms. Chen is also urgent. As charge nurse, once you move to Mr. Lewis, direct another RN to initiate the hypoglycemia protocol. Because she is NPO, the correct treatment is IV dextrose (for example, D50 IV push per policy), followed by a glucose recheck in 15 minutes and provider notification if needed. This is safe parallel processing: life-threatening shock first, then immediate delegation of other time-sensitive care.

Why the Other Options Are Wrong

• A. Giving juice to an NPO patient is unsafe and outside UAP scope for clinical decision-making. Ms. Chen needs IV dextrose administered by an RN, not oral carbohydrates that violate NPO and risk aspiration. Also, the most unstable patient (hemorrhagic shock) still takes priority.
• C. Initial warfarin teaching is an RN responsibility because it requires assessment, clinical judgment, and education about bleeding risks, diet, and monitoring. This is not the first priority and should not be delegated to the LPN. The LPN can reinforce teaching after the RN completes it.
• D. Many LPN scopes do not allow IV push narcotics. Even where permitted, pain control is not prioritized over a patient with signs of active hemorrhage and shock. The RN should later address Ms. Brooks’s pain or delegate appropriate non-IV tasks while stabilizing the critical patient.

Key Takeaways

• Prioritize by threat to life: unstable circulation (shock) outranks symptomatic but non-seizing hypoglycemia, pain, and discharge tasks.
• Delegate by scope and condition: RNs manage IV dextrose and initial high-risk teaching; UAPs perform tasks without clinical judgment; LPNs provide stable care and reinforce teaching.
• Run problems in parallel: go to the sickest patient while directing another RN to treat urgent issues like hypoglycemia.
• Post-op red flags: falling BP, rising HR, cool/clammy skin, and rapid drain output suggest hemorrhage. Act fast.

On-shift mini-checklist

• Scan for ABC threats; go to the most unstable patient.
• Activate rapid response early for suspected shock.
• Secure airway/oxygen, IV access, fluids, and labs.
• Delegate urgent but appropriate tasks to the right team member.
• Communicate clearly: who is doing what, by when, and report back.

Quick Practice Extension

• In a similar scenario, what specific orders and supplies would you request immediately when you suspect postoperative hemorrhage?
• How would you divide tasks among an RN, LPN, and UAP to manage a unit with one patient in shock and another with severe hypoglycemia?

G S Sachin

I am a Registered Pharmacist under the Pharmacy Act, 1948, and the founder of PharmacyFreak.com. I hold a Bachelor of Pharmacy degree from Rungta College of Pharmaceutical Science and Research. With a strong academic foundation and practical knowledge, I am committed to providing accurate, easy-to-understand content to support pharmacy students and professionals. My aim is to make complex pharmaceutical concepts accessible and useful for real-world application.

Mail- Sachin@pharmacyfreak.com