NCLEX Question of the Day

NCLEX Question of the Day – Friday, March 27, 2026

Today’s question focuses on early recognition of patient deterioration and the nurse’s first priority action. This skill matters because many NCLEX questions test whether you can spot the most dangerous finding, connect it to the likely problem, and act before the patient worsens. In real nursing, that can mean the difference between a quick intervention and a rapid decline.

Clinical Scenario

A nurse on a medical-surgical unit is caring for a 68-year-old client who had a right total hip arthroplasty yesterday morning. The client has a history of obesity, hypertension, and osteoarthritis. He has been receiving opioid pain medication as needed and has spent most of the day in bed, saying movement is too painful.

At 1430, the nurse enters the room and finds the client suddenly restless and anxious. He says, “I can’t catch my breath.” His skin is cool, and his oxygen saturation has dropped from 96% on room air earlier in the day to 88% now. Respiratory rate is 28/min, heart rate is 118/min, and blood pressure is 146/84 mm Hg. On assessment, the nurse notes clear but diminished breath sounds bilaterally and mild swelling of the right calf compared with the left.

The Question

Which action should the nurse take first?

Answer Choices

1. Apply oxygen and raise the head of the bed.
2. Massage the swollen calf to improve circulation.
3. Assist the client to ambulate in the hallway.
4. Administer the prescribed opioid pain medication.

Correct Answer

A. Apply oxygen and raise the head of the bed.

Detailed Rationale

This client’s sudden shortness of breath, low oxygen saturation, tachycardia, restlessness, and unilateral calf swelling strongly suggest a possible pulmonary embolism. The nurse does not need to prove the diagnosis before taking the first safety step. The priority is supporting oxygenation.

Applying oxygen helps increase the amount of oxygen available to the client right away. Raising the head of the bed improves lung expansion and reduces the work of breathing. These are immediate, low-risk interventions that address the most urgent problem: impaired gas exchange.

After this first action, the nurse should stay with the client, perform a focused respiratory and cardiovascular assessment, and notify the provider or rapid response team based on the client’s condition and facility policy. Important assessment points include work of breathing, mental status, chest pain, skin color, oxygen response, and any signs of hemodynamic instability such as hypotension or worsening tachycardia.

The nurse should also place the client on continuous pulse oximetry if available, obtain vital signs again, and prepare for likely follow-up orders. These may include arterial blood gases, imaging, anticoagulation, or transfer to a higher level of care. The reason this matters is simple: a pulmonary embolism can worsen fast, and delays in oxygen support and escalation can put the client at serious risk.

Notice the key NCLEX pattern here. The question asks what the nurse should do first. That means priority frameworks apply. Airway and breathing come before comfort and mobility. Even though calf swelling is important, the immediate danger is the client’s impaired oxygenation and acute respiratory distress.

Why the Other Options Are Wrong

B. Massage the swollen calf to improve circulation.

This is unsafe. If the client has a deep vein thrombosis, massaging the calf could dislodge part of the clot and worsen embolization. A swollen calf with sudden dyspnea is a red flag, not a reason for massage. The nurse should avoid manipulating the affected leg and instead focus on respiratory support and urgent reporting.

C. Assist the client to ambulate in the hallway.

Ambulation is not appropriate when the client is acutely short of breath and unstable. Activity would increase oxygen demand and may make hypoxemia worse. In addition, if a thrombus is present, unnecessary movement may increase risk. The client needs immediate stabilization, not hallway walking.

D. Administer the prescribed opioid pain medication.

This does not address the priority problem. Opioids may also depress respiratory drive, which could make the situation worse in a client already struggling to breathe. Pain control matters after surgery, but not before treating acute hypoxemia and evaluating a potentially life-threatening complication.

Key Takeaways

• Sudden dyspnea after surgery should always raise concern for pulmonary embolism, especially when paired with tachycardia, low oxygen saturation, and unilateral calf swelling.
• The first nursing action is to support breathing: apply oxygen and position the client upright.
• Do not massage a swollen calf when DVT is possible.
• Use priority thinking: airway and breathing come before mobility, comfort, or routine tasks.
• Restlessness and anxiety can be early signs of hypoxia. Do not dismiss them.

• What you’d do on shift: stop and assess, apply oxygen, raise the head of the bed, stay with the client, recheck vital signs, limit activity, and escalate care quickly.

Quick Practice Extension

1. A postoperative client becomes suddenly short of breath and reports sharp chest pain with inspiration. Which additional assessment finding would most support concern for pulmonary embolism?

2. A client with a confirmed deep vein thrombosis asks why the nurse does not want them to rub the sore leg. How should the nurse explain this?

This was a Med-Surg priority question built around recognizing a postoperative thromboembolic emergency. On the NCLEX, these questions are less about memorizing one disease and more about seeing the pattern, identifying the immediate threat, and acting in the safest order.