NCLEX Question of the Day – Friday, May 15, 2026

Today’s question targets priority setting in med-surg nursing, especially knowing when a patient’s symptoms point to a dangerous complication rather than expected recovery. This matters on real shifts because nurses often see the first warning signs. Catching a change early can prevent respiratory failure, shock, or a rapid transfer to intensive care.

Clinical Scenario

A 68-year-old client is on a surgical unit 24 hours after an open right hemicolectomy for colon cancer. The client has a history of chronic obstructive pulmonary disease, hypertension, and type 2 diabetes. He has a nasogastric tube to low intermittent suction, an IV infusion, and a patient-controlled analgesia pump with morphine.

During the start-of-shift assessment, the nurse notes the following:

• Temperature 38.1 C (100.6 F)
• Heart rate 118/min
• Blood pressure 92/58 mm Hg
• Respiratory rate 26/min
• Oxygen saturation 91% on 2 L nasal cannula
• Urine output for the last 4 hours: 60 mL total
• Abdomen mildly distended
• Surgical dressing has a small amount of old serosanguineous drainage

The client tells the nurse, “I feel more short of breath than earlier,” and appears restless. On auscultation, breath sounds are diminished at the bases bilaterally.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Encourage use of the incentive spirometer and assist the client to cough and deep breathe
2. B. Increase the oxygen flow rate and notify the surgeon of the client’s change in status
3. C. Reassess the pain level and instruct the client to use the PCA pump
4. D. Document the findings as expected on the first postoperative day and continue routine monitoring

Correct Answer

B. Increase the oxygen flow rate and notify the surgeon of the client’s change in status

Detailed Rationale

This client is showing signs of possible early postoperative deterioration, not simple discomfort or routine atelectasis alone. The nurse needs to recognize a pattern, not just one abnormal value.

Here is the concerning picture:

• Hypotension: 92/58 mm Hg
• Tachycardia: 118/min
• Tachypnea: 26/min
• Low oxygen saturation: 91% even on 2 L oxygen
• Low urine output: 60 mL in 4 hours = 15 mL/hour
• Restlessness: often an early sign of hypoxia

Together, these findings suggest inadequate oxygenation and poor tissue perfusion. The cause could include postoperative bleeding, third spacing, sepsis, worsening atelectasis, or a developing pulmonary complication. The exact cause still needs evaluation, but the priority is clear: support oxygenation now and escalate the change in condition.

Increasing oxygen is an immediate nursing action within the airway and breathing priority. It helps improve oxygen delivery while the nurse activates the provider response. Notifying the surgeon promptly is necessary because the client may need urgent orders such as a rapid fluid bolus, stat labs, arterial blood gases, chest imaging, or evaluation for internal bleeding or an anastomotic complication.

The nurse should also continue focused assessment while help is being arranged. That includes:

• Rechecking full vital signs
• Assessing level of consciousness and work of breathing
• Inspecting the incision and drains for bleeding
• Checking abdomen for increasing distention, firmness, or pain
• Reviewing intake and output trends
• Confirming NG output and IV patency
• Preparing for possible new orders

The low urine output is especially important. In adults, expected urine output is generally at least 30 mL/hour. This client is producing only half that amount. That suggests decreased renal perfusion, often tied to hypovolemia or shock. In a postoperative client with tachycardia and hypotension, that is not something to watch casually.

The mild fever does not change the priority. A low-grade postoperative fever can occur, but fever plus hypoxia, tachycardia, restlessness, and low urine output means the nurse must think beyond “normal postop.” NCLEX questions often test whether you can spot a dangerous cluster of signs.

Why the Other Options Are Wrong

A. Encourage use of the incentive spirometer and assist the client to cough and deep breathe

This is a useful intervention for preventing and treating postoperative atelectasis. The problem is that it is not enough as the first action here. The client has signs of systemic instability, including hypotension and poor urine output. Incentive spirometry can be part of care, but the nurse must first address the worsening oxygenation and report the overall deterioration.

C. Reassess the pain level and instruct the client to use the PCA pump

Pain should be assessed, but giving more opioid is risky when the client is already short of breath and hypoxic. Morphine can worsen respiratory depression. Also, pain does not explain the full pattern of low blood pressure, tachycardia, restlessness, and oliguria as well as circulatory or respiratory compromise does.

D. Document the findings as expected on the first postoperative day and continue routine monitoring

This is incorrect because these findings are not routine. A small fever or mild bibasilar atelectasis can be common after surgery, but persistent hypoxia, hypotension, tachycardia, and urine output of 15 mL/hour are red flags. Delayed action could allow rapid decline.

Key Takeaways

• Do not judge one sign in isolation. Look for patterns that suggest hypoxia or poor perfusion.
• Restlessness can be an early sign of low oxygen, even before severe distress appears.
• Urine output below 30 mL/hour in an adult postoperative client needs attention.
• When airway or breathing is worsening, support oxygenation first, then escalate.
• Postoperative fever does not automatically mean the problem is minor.

What you’d do on shift:

• Increase oxygen per protocol or nursing judgment within scope
• Repeat vital signs and focused respiratory assessment
• Check urine output, IV access, incision, drains, and abdominal findings
• Notify the surgeon or rapid response team if indicated
• Stay with the client if condition appears unstable

Quick Practice Extension

1. A postoperative client has an oxygen saturation of 88%, is drowsy, and has a respiratory rate of 8/min after receiving IV opioid medication. What assessment should the nurse make immediately before calling the provider?

2. A client 12 hours after abdominal surgery has a heart rate of 124/min, cool clammy skin, and increasing abdominal firmness. Which complication should the nurse suspect first?

For NCLEX, the safest answer is often the one that treats the immediate threat while also recognizing that the patient needs rapid evaluation. In this case, shortness of breath alone matters. Shortness of breath plus hypotension, tachycardia, restlessness, and low urine output means the nurse should act fast.

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