# At shift change, a charge nurse receives six postoperative reports. Classify the timing of the RN assessment for each client. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question At shift change, a charge nurse receives six postoperative reports. Classify the timing of the RN assessment for each client. | | Activate emergency response now | Assess promptly after immediate threats | Routine follow-up or teaching | | --- | --- | --- | --- | | 2 hours after thyroidectomy: new stridor, restlessness, and increasing work of breathing | | | | | 6 hours after knee arthroplasty: sudden dyspnea, pleuritic chest pain, and oxygen saturation 86% | | | | | 8 hours after abdominal surgery: urine output 15 mL/hr for 2 hours despite a patent catheter; blood pressure remains stable | | | | | Postoperative day 2 after hip surgery: new unilateral calf swelling and tenderness without dyspnea or chest pain | | | | | Postoperative day 1 after colectomy: pain decreased from 4 to 2 of 10 after treatment and vital signs are stable | | | | | Postoperative day 2 after laparoscopic cholecystectomy: stable client asks to review the discharge diet | | | | ## 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. ## In-depth explanation 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 ## Clinical scenario No emergency response has yet been activated. Use airway, breathing, circulation, acute change, and current stability rather than the postoperative day alone. ## Key concepts - **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. ## Related questions - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en) - [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=en) - [The nurse receives report on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=en) - [Four hours after open reduction and internal fixation of a fractured tibia, a client repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=en) - [The nurse receives reports on four clients. 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