NCLEX Question of the Day

NCLEX Question of the Day – Saturday, March 07, 2026

Today’s question targets early recognition of clinical deterioration and rapid, prioritized action. This matters because minutes count when a patient becomes hypoxic. The nurse’s first move can prevent respiratory failure and save a life.

Clinical Scenario

A 66-year-old man is on the surgical unit 24 hours after intramedullary nailing of a left femoral shaft fracture. History: hypertension and hyperlipidemia. He is on a PCA morphine pump for pain. The nurse notes sudden restlessness and confusion. Vital signs: BP 132/78, HR 118, RR 28, Temp 38.2 C, SpO2 88% on 2 L/min nasal cannula. Fine petechiae are visible on the upper chest and axillae. Lung sounds are mildly coarse at the bases.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Apply a nonrebreather mask at 15 L/min, position the client upright, and then notify the provider.
2. B. Prepare to administer IV heparin per pulmonary embolism protocol.
3. C. Obtain consent for CT pulmonary angiography.
4. D. Administer acetaminophen and encourage incentive spirometry.

Correct Answer

A. Apply a nonrebreather mask at 15 L/min, position the client upright, and then notify the provider.

Detailed Rationale

Start with airway, breathing, circulation (ABCs). The patient is acutely hypoxic (SpO2 88% on oxygen), tachypneic, and showing neurologic changes. Oxygen delivery must be increased immediately to prevent further hypoxemia and organ injury. A nonrebreather mask at 15 L/min provides a high FiO2 quickly. Upright positioning improves ventilation-perfusion matching by expanding dependent lung regions.

The triad of hypoxemia, neurologic changes, and petechiae 24–72 hours after long-bone surgery strongly suggests fat embolism syndrome (FES). In FES, fat droplets enter the circulation and lodge in pulmonary capillaries, causing ventilation-perfusion mismatch and inflammation. The management is supportive: maximize oxygenation, minimize movement of the affected limb, and notify the provider for urgent evaluation. Delaying oxygen to pursue diagnostics risks rapid decompensation.

After stabilizing breathing, the nurse should escalate care. Call the provider or rapid response if deterioration continues. Anticipate orders for ABG, chest x-ray, labs (CBC, platelets), and possible ICU transfer. Maintain IV access. Continuously monitor pulse oximetry, work of breathing, mental status, and urine output. Be ready to assist with advanced airway if the patient tires or mental status declines.

Why the Other Options Are Wrong

• B. Prepare to administer IV heparin per pulmonary embolism protocol. Heparin treats thrombotic clots. FES is not a thrombus; it is embolization of fat and an inflammatory response. Anticoagulation does not fix the underlying problem and can increase bleeding risk after recent surgery. The first priority is oxygenation, not anticoagulation.
• C. Obtain consent for CT pulmonary angiography. Diagnostic imaging may be ordered after stabilization, but this is not the initial action. Transporting a hypoxic, unstable patient without first improving oxygenation is unsafe. Stabilize breathing first, then proceed with diagnostics as directed.
• D. Administer acetaminophen and encourage incentive spirometry. Treating fever and promoting lung expansion are supportive, but they do not address the immediate threat of severe hypoxemia. Incentive spirometry relies on patient effort and will not provide the rapid FiO2 increase the patient needs now.

Key Takeaways

• Use ABCs to set priorities. Severe hypoxemia demands immediate high-flow oxygen.
• Suspect fat embolism syndrome 24–72 hours after long-bone fracture or orthopedic surgery when hypoxemia, neurologic changes, and petechiae are present.
• Management of FES is supportive: high FiO2, minimize limb movement, close monitoring, and early escalation.
• Heparin helps with thrombotic pulmonary embolism, not fat embolism.
• Stabilize first, then diagnose. Imaging waits until the patient is safer to transport.

• On-shift mini-checklist:
• Raise head of bed; switch to nonrebreather at 15 L/min; ensure good mask seal.
• Reassess SpO2, RR, work of breathing within minutes; stay with the patient.
• Notify provider/rapid response if no quick improvement or if mental status worsens.
• Maintain IV access; anticipate ABG, chest x-ray, and ICU evaluation.
• Limit manipulation of the affected limb; monitor vitals and urine output closely.

Quick Practice Extension

• You draw an ABG after applying the nonrebreather. Which ABG pattern would confirm worsening respiratory failure, and what change in care would you anticipate?
• The provider orders several tests. Which order would you prioritize next and why: chest x-ray, complete blood count with platelets, or CT pulmonary angiography?