At shift change, a charge nurse receives six postoperative reports. Classify the timing of the RN assessment for each client.
Matrix
Choose your responses, then check the answer.
Explanation
New stridor and acute hypoxemia with pleuritic chest pain are immediate airway or breathing emergencies. Persistent oliguria and new unilateral calf swelling require prompt assessment after those immediate threats because they can signal impaired perfusion or venous thrombosis. Improving pain with stable vital signs and a discharge diet question remain legitimate needs but can be handled in routine follow-up after unstable clients are addressed.
Correct Answer Rows 1 and 2 require emergency response now, rows 3 and 4 are the next prompt assessments, and rows 5 and 6 are routine follow-up or teaching.
Why It Fits Three priority levels prevent a binary shortcut and require the nurse to separate active threats from concerning but currently stable changes and routine needs.
Clinical Picture Airway obstruction and severe hypoxemia can deteriorate within minutes. Oliguria and possible DVT need timely evaluation but do not outrank an active airway or oxygenation crisis.
Memory Link Rescue the threat, assess the warning, then complete the stable task.
NCLEX Rule Prioritize current instability and risk of rapid deterioration, not diagnosis prestige or postoperative calendar day.
Why the Alternatives Fail Treating every abnormal finding as the same priority delays rescue, while dismissing oliguria or unilateral swelling as routine can miss a developing complication.
Sources
12026 NCLEX-RN Test Plan
No emergency response has yet been activated. Use airway, breathing, circulation, acute change, and current stability rather than the postoperative day alone.
Priority setting — The nurse assesses current airway, breathing, circulation, acute change, instability, and risk of deterioration before addressing stable or routine needs.
Stridor — A high-pitched airway sound that can indicate upper-airway narrowing. New postoperative stridor requires immediate assessment and escalation.
Persistent oliguria — Sustained low urine output after catheter patency is confirmed can signal impaired perfusion, obstruction, or another postoperative complication and requires prompt assessment.