NCLEX Question of the Day – Tuesday, June 23, 2026

Today’s question targets priority setting in a changing patient condition, a skill that matters on every shift. The NCLEX tests whether you can spot the detail that changes everything. In real nursing, that same skill helps you act early, prevent harm, and know when routine care is no longer enough.

Clinical Scenario

A 68-year-old man is admitted to a medical-surgical unit with community-acquired pneumonia. He has a history of type 2 diabetes, chronic kidney disease stage 3, and hypertension. He has been receiving IV antibiotics and 2 L/min oxygen by nasal cannula since admission yesterday.

At 0700, the night nurse reports that the patient was alert, eating small amounts, and using the urinal without difficulty. At 0930, the day nurse enters the room and finds the patient restless and slightly confused. He says, “I can’t catch my breath.” His skin is warm, and he is breathing faster than earlier in the shift. Vital signs are: temperature 38.9 C, heart rate 118/min, respiratory rate 30/min, blood pressure 88/54 mm Hg, oxygen saturation 91% on 2 L/min nasal cannula. Urine output over the last 4 hours is 20 mL total.

The Question

Which action should the nurse take first?

Answer Choices

1. A. Increase oxygen to 4 L/min by nasal cannula and reassess in 30 minutes
2. B. Notify the provider that the patient may need a stronger antibiotic
3. C. Activate the rapid response team and begin a focused sepsis assessment
4. D. Administer the prescribed PRN acetaminophen for fever

Correct Answer

C. Activate the rapid response team and begin a focused sepsis assessment

Detailed Rationale

This patient has several red flags for sepsis with possible progression to septic shock. The key clues are not just the fever and pneumonia. The bigger issue is the change in organ perfusion and mental status.

Here is what stands out:

• New confusion and restlessness: possible decreased cerebral perfusion
• Blood pressure 88/54 mm Hg: hypotension
• Heart rate 118/min and respiratory rate 30/min: signs of systemic stress
• Low urine output: possible kidney hypoperfusion
• Known infection source: pneumonia

Together, these findings suggest that the patient is not simply “still sick with pneumonia.” He may be deteriorating into sepsis-related organ dysfunction. That makes this a priority problem.

The first action is to get immediate help through the rapid response team while starting a focused assessment. On the NCLEX, when a patient shows acute instability, delayed escalation is unsafe. The rapid response team brings extra clinical support fast, which matters because sepsis can worsen quickly.

While help is being activated, the nurse should assess airway, breathing, and circulation. That includes checking work of breathing, lung sounds, level of consciousness, skin perfusion, capillary refill, and current IV access. The nurse should verify oxygen delivery is functioning, place the patient in a position that supports breathing, and prepare for interventions such as increased oxygen, blood cultures, lactate level, CBC, metabolic panel, fluid resuscitation, and broader monitoring.

The nurse should also monitor trends, not single numbers. A blood pressure of 88/54 mm Hg is concerning on its own, but paired with confusion and poor urine output, it points to decreased organ perfusion. That is why this is not a “watch and wait” situation.

In practice, early sepsis care often includes oxygen support, IV fluids, labs, cultures, and timely antibiotics. The nurse’s role is to recognize the pattern early, escalate fast, and keep reassessing response to treatment. If the patient’s oxygen saturation drops further, breathing worsens, or mental status declines, the urgency increases even more.

Why the Other Options Are Wrong

A. Increase oxygen to 4 L/min by nasal cannula and reassess in 30 minutes

Oxygen may be needed, but this option is incomplete and delays escalation. The main problem is not mild hypoxemia alone. The patient has hypotension, altered mental status, tachycardia, tachypnea, and low urine output. Reassessing in 30 minutes without calling for urgent help could allow shock to worsen.

B. Notify the provider that the patient may need a stronger antibiotic

The patient may indeed need a change in treatment, but this is not the first action. Calling the provider without activating urgent support slows response to an unstable condition. Also, the immediate issue is hemodynamic instability, not just antibiotic selection.

D. Administer the prescribed PRN acetaminophen for fever

Fever treatment may improve comfort, but it does nothing to address the priority threat: impaired perfusion and possible septic shock. On the NCLEX, comfort measures come after life-threatening problems are recognized and urgent action is taken.

Key Takeaways

• New confusion in an infected patient is a serious change, not a minor symptom.
• Hypotension plus low urine output suggests poor organ perfusion.
• In suspected sepsis, trend recognition matters more than any one isolated vital sign.
• If the patient is unstable, escalate first. Do not manage a high-risk decline alone.

What you’d do on shift:

• Recognize the infection plus organ dysfunction pattern early
• Call rapid response for acute deterioration
• Assess airway, breathing, circulation, mental status, and urine output
• Confirm IV access and prepare for fluids, labs, cultures, and increased monitoring
• Reassess often and document the patient’s response clearly

Quick Practice Extension

1. If this patient’s blood pressure improves after IV fluids but urine output remains very low, what finding would concern you most next?

2. Which assessment change would suggest the patient’s respiratory status is worsening despite oxygen therapy?

Category used today: Med-Surg

Download