NCLEX Question of the Day – Wednesday, April 29, 2026

Today’s question targets priority action and delegation in a fast-moving inpatient situation. This matters in real nursing because the safest nurse is not the one who knows the most facts, but the one who can spot what needs attention first and act before a patient declines.

Clinical Scenario

You are the charge nurse on a medical-surgical unit. A 68-year-old client was admitted 6 hours ago with community-acquired pneumonia and dehydration. The client has a history of type 2 diabetes, hypertension, and chronic kidney disease stage 3. Current orders include IV ceftriaxone, 0.9% sodium chloride at 75 mL/hr, blood glucose checks before meals and at bedtime, and oxygen at 2 L/min by nasal cannula as needed to keep oxygen saturation at or above 92%.

At 1400, the licensed practical nurse (LPN) tells you the client “does not look right.” On assessment, the client is restless and says, “I feel like I can’t catch my breath.” Findings are: temperature 38.7 C, heart rate 118/min, respiratory rate 30/min, blood pressure 88/54 mm Hg, oxygen saturation 89% on 2 L/min nasal cannula, skin cool, and urine output 20 mL over the last 2 hours. Crackles are present in the right lower lung field.

The Question

What is the nurse’s priority action?

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 client may need a different antibiotic
3. C. Activate the rapid response team and begin immediate sepsis-focused assessment and interventions
4. D. Ask the LPN to obtain a full set of vital signs again after the client rests in bed

Correct Answer

C. Activate the rapid response team and begin immediate sepsis-focused assessment and interventions

Detailed Rationale

This client is showing signs of possible sepsis with hemodynamic instability. The key clues are not just the fever and pneumonia. The most important findings are hypotension, tachycardia, tachypnea, low oxygen saturation, restlessness, cool skin, and low urine output. Together, these suggest poor tissue perfusion and possible progression toward septic shock.

The nurse should think in order of airway, breathing, and circulation. The client is struggling to breathe and is hypoxic, but circulation is also failing. A rapid response is appropriate because the client is unstable and may need aggressive treatment right away.

What the nurse should assess right now:

• Current airway and work of breathing
• Oxygen saturation trend and lung sounds
• Mental status changes such as restlessness or confusion
• Blood pressure, heart rate, capillary refill, skin temperature
• Urine output as a sign of kidney perfusion

What the nurse should do next:

• Call the rapid response team
• Apply or increase oxygen using facility protocol while awaiting advanced support
• Ensure IV access is working and anticipate fluid resuscitation orders
• Prepare for labs such as lactate, blood cultures, CBC, CMP, and repeat glucose if indicated
• Review timing of antibiotic administration and any recent changes in condition

What the nurse should monitor:

• Response to oxygen and any worsening respiratory distress
• Blood pressure and signs of shock
• Urine output and kidney function
• Level of consciousness
• Potential need for transfer to a higher level of care

The reason this is the best answer is simple: this client is already unstable. Waiting for routine reassessment or a nonurgent provider callback could delay lifesaving treatment. Early recognition and rapid intervention improve outcomes in sepsis because tissue hypoperfusion can quickly damage the brain, kidneys, heart, and other organs.

Why the Other Options Are Wrong

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

Increasing oxygen may be part of care, but it is not enough by itself. The client is hypotensive and showing signs of systemic deterioration. Reassessing in 30 minutes is too slow for a client who may be entering septic shock. This option treats only one part of the problem.

B. Notify the provider that the client may need a different antibiotic

The antibiotic plan may need review later, but this is not the immediate priority. The current danger is unstable perfusion and oxygenation. The nurse must first escalate the acute change in condition. Also, there is no evidence yet that the antibiotic is wrong. The client may simply be worsening despite early treatment.

D. Ask the LPN to obtain a full set of vital signs again after the client rests in bed

This delays action. The client already has a full set of concerning vital signs plus clinical signs of poor perfusion. “Resting” will not fix sepsis. Delegation is also the wrong focus here. The RN must take direct action for an unstable client.

Key Takeaways

• In suspected sepsis, look beyond fever. Low blood pressure, fast breathing, mental status change, and low urine output are major warning signs.
• Restlessness can be an early sign of hypoxia or poor perfusion, not just anxiety.
• Priority means treating instability first, not solving the whole diagnosis at once.
• Rapid response is appropriate when a client shows acute deterioration with possible shock.
• Oxygen alone is supportive care, not the full answer when circulation is failing.

• On-shift mini-checklist:
• Compare current vital signs to baseline
• Assess airway, breathing, circulation, and mental status
• Check urine output and IV access
• Escalate early if hypotension and hypoxia are present together
• Prepare for sepsis labs, fluids, and closer monitoring

Quick Practice Extension

1. A client with a urinary tract infection becomes confused and has a blood pressure of 92/50 mm Hg. Which assessment finding would most strongly support concern for sepsis progression?

2. After sepsis treatment begins, which trend would suggest the client is improving: urine output, respiratory rate, mental status, or skin temperature?

Category today: Med-Surg

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