NCLEX Question of the Day – Sunday, June 21, 2026

Today’s question focuses on early recognition of patient deterioration and the nurse’s first priority action. That skill matters on every shift. A patient can look “stable enough” until one key assessment finding points to a serious problem. NCLEX questions often test whether you can spot that change and act in the safest order.

Clinical Scenario

A 68-year-old client is on a medical-surgical unit 8 hours after an open right hemicolectomy for colon cancer. History includes hypertension, type 2 diabetes, and chronic kidney disease stage 3. The client has a nasogastric tube to low intermittent suction, an IV infusion of lactated Ringer’s, and a hydromorphone PCA. During the 1500 assessment, the nurse notes that the client is drowsy but arouses to voice, reports increasing abdominal pain, and has a respiratory rate of 10/min. The abdomen is firm and more distended than it was at noon. The surgical dressing has a small amount of dried drainage. Urine output for the last 2 hours is 20 mL total. Vital signs are temperature 37.1 C, heart rate 118/min, blood pressure 88/54 mm Hg, oxygen saturation 93% on 2 L/min by nasal cannula.

The Question

Which action should the nurse take first?

Answer Choices

1. Increase the client’s oxygen to 4 L/min by nasal cannula and reassess in 15 minutes.
2. Stop the PCA infusion and administer naloxone for suspected opioid-induced respiratory depression.
3. Notify the surgeon that the client may be developing postoperative hemorrhage or third-spacing and prepare for rapid intervention.
4. Reposition the client, encourage use of the incentive spirometer, and assist with splinting for pain control.

Correct Answer

C. Notify the surgeon that the client may be developing postoperative hemorrhage or third-spacing and prepare for rapid intervention.

Detailed Rationale

This client is showing signs of possible shock after abdominal surgery. The pattern matters more than any one number. The nurse should not focus only on the low respiratory rate or the pain. The bigger picture is hypotension, tachycardia, low urine output, increasing abdominal distention, and a firm abdomen. Together, these findings suggest inadequate circulating volume, possibly from internal bleeding or major fluid shifting into tissues after surgery.

The first nursing priority is to recognize the instability and get rapid help. A postoperative client can bleed internally without soaking the dressing. The blood may collect in the abdomen, which explains the distention and firmness. Third-spacing is also a concern after major abdominal surgery because fluid can move out of the vessels and into interstitial spaces, leaving the patient intravascularly depleted. In both cases, the result is poor perfusion.

What should the nurse assess right away? Recheck vital signs, mental status, skin temperature, capillary refill, abdominal appearance, and urine output trend. Confirm that the IV is patent and that fluids are running as ordered. Look at the surgical site, but remember that a “clean” dressing does not rule out serious internal loss. Review recent hemoglobin and hematocrit if available, but do not delay escalation while waiting for lab results.

What should the nurse do while notifying the surgeon or rapid response team based on facility policy? Stay with the client or have another nurse stay. Ensure IV access is working and anticipate the need for additional fluids, lab work, or blood products. Positioning may help support perfusion depending on the situation and facility practice, but the key step is urgent escalation because this client is not stable. The nurse should also continue close monitoring of blood pressure, heart rate, respiratory status, oxygen saturation, abdominal changes, and hourly urine output.

Why is this the first action? Because the data point to a life-threatening circulation problem. NCLEX priority questions often follow ABCs, but ABCs are not just about airway equipment or oxygen. Circulation is failing here. If the cause is hemorrhage or severe fluid loss into the abdomen, simply adjusting oxygen or treating pain will not fix the problem. The client needs immediate evaluation and likely rapid treatment.

Why the Other Options Are Wrong

A. Increase the client’s oxygen to 4 L/min by nasal cannula and reassess in 15 minutes.

Oxygen may be reasonable as a supportive measure, but it is not the first or most important action. The oxygen saturation is slightly low but not the main danger sign. Reassessing in 15 minutes delays treatment of shock. This client needs urgent provider notification and likely a rapid response-level evaluation now.

B. Stop the PCA infusion and administer naloxone for suspected opioid-induced respiratory depression.

The respiratory rate of 10/min and drowsiness do require attention, especially with a PCA. But opioid toxicity alone does not explain the firm, distended abdomen, hypotension, tachycardia, and low urine output. Giving naloxone too quickly may also cause severe pain and does not address the likely perfusion problem. The nurse should consider the opioid as part of the picture, but it is not the priority diagnosis based on all the data.

D. Reposition the client, encourage use of the incentive spirometer, and assist with splinting for pain control.

These are appropriate postoperative comfort and lung-expansion measures for a stable client. They do not address probable internal bleeding or severe fluid deficit. Incentive spirometry helps prevent atelectasis, but this client’s condition suggests hemodynamic instability, not a simple pulmonary issue.

Key Takeaways

• Look for patterns, not isolated findings. Hypotension + tachycardia + low urine output + abdominal distention after surgery is a red flag.
• A dry dressing does not rule out internal bleeding.
• Postoperative shock can come from hemorrhage or third-spacing. Both reduce tissue perfusion.
• When circulation is failing, supportive steps alone are not enough. Escalate care quickly.
• Opioids can cause sedation and slow breathing, but do not anchor on that if the full assessment points elsewhere.

• On-shift mini-checklist: Reassess vitals, mental status, abdomen, dressing, urine output, and IV patency.
• Trend the data: Compare the current assessment with earlier findings.
• Escalate fast: Notify the surgeon or activate rapid response per policy.
• Prepare: Anticipate fluids, labs, blood products, and closer monitoring.
• Stay alert: Keep watching for worsening hypotension, decreased responsiveness, and falling urine output.

Quick Practice Extension

1. If this client’s blood pressure improves after a fluid bolus but the abdomen becomes more rigid and the heart rate remains high, what complication should the nurse suspect next?

2. If the same client had pinpoint pupils, oxygen saturation of 86%, and a soft, non-distended abdomen, how would that change the priority action?

Category used today: Med-Surg.

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