NCSBN - National Council of State Boards of Nursing Prioritization and Delegation Questions and Answers — Questions and Answers
Question 1: A nurse on a medical-surgical unit receives the change-of-shift report. Which of the following clients should the nurse assess first?
- A client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 91% on 2 liters of oxygen via nasal cannula.
- A client admitted 2 hours ago with a suspected small bowel obstruction who is now reporting sudden, sharp abdominal pain and has a rigid abdomen. (Correct answer)
- A client postoperative day 2 following a total knee replacement who is requesting pain medication for pain rated 6 on a 0-10 scale.
- A client with type 2 diabetes mellitus who has a fasting blood glucose level of 180 mg/dL and is awaiting a breakfast tray.
Correct answer: A client admitted 2 hours ago with a suspected small bowel obstruction who is now reporting sudden, sharp abdominal pain and has a rigid abdomen.
The nurse should prioritize the client with a suspected small bowel obstruction who is now reporting sudden, sharp pain and has a rigid abdomen. These are hallmark signs of a potential bowel perforation, a life-threatening emergency that requires immediate assessment and intervention. This client's condition is unstable and has changed acutely. The other clients, while requiring care, are more stable: the COPD client's oxygen saturation is at an acceptable baseline, the postoperative client's pain is expected, and the diabetic client's blood glucose is elevated but not critically so.
Question 2: The registered nurse (RN) is creating the daily assignment for a team that includes a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which task is most appropriate to delegate to the UAP?
- Administering a scheduled subcutaneous insulin injection for a client with stable blood glucose levels.
- Performing a sterile dressing change on a client's central line.
- Developing the plan of care for a newly admitted client.
- Assisting a stable client who is 2 days postoperative with personal hygiene and ambulation. (Correct answer)
Correct answer: Assisting a stable client who is 2 days postoperative with personal hygiene and ambulation.
The most appropriate task to delegate to the UAP is assisting a stable, postoperative client with activities of daily living (ADLs) such as personal hygiene and ambulation. This task is routine, has a predictable outcome, and does not require nursing judgment. Administering medications (insulin) is within the scope of an LPN or RN. Performing a sterile dressing change requires advanced skill and sterile technique, which is not within the UAP's scope of practice. Developing a plan of care is a core function of the RN and involves assessment and nursing judgment, which cannot be delegated.
Question 3: A charge nurse is making assignments on a telemetry unit. Which client is the most appropriate to assign to a licensed practical nurse (LPN)?
- A client with chronic heart failure who is stable and requires administration of routine oral diuretics and monitoring of daily weights. (Correct answer)
- A client newly admitted with chest pain who requires an initial cardiac assessment and administration of intravenous nitroglycerin.
- A client who requires discharge teaching about a new anticoagulation medication regimen.
- A client who experienced a sudden change in level of consciousness and requires frequent neurological assessments.
Correct answer: A client with chronic heart failure who is stable and requires administration of routine oral diuretics and monitoring of daily weights.
The most appropriate assignment for an LPN is the client with chronic heart failure who is stable and has predictable care needs. LPNs can administer oral medications, monitor intake and output, and collect data such as daily weights for stable clients with predictable outcomes. The newly admitted client with chest pain, the client requiring complex discharge teaching, and the client with a change in neurological status are all unstable or require comprehensive assessments, planning, and evaluation, which fall within the RN's scope of practice.
Question 4: A nurse is caring for a client who suddenly develops dyspnea, tachypnea, and uses accessory muscles to breathe. What is the nurse's priority action?
- Notify the respiratory therapist.
- Obtain a full set of vital signs.
- Raise the head of the bed to a high-Fowler's position. (Correct answer)
- Administer oxygen via a non-rebreather mask.
Correct answer: Raise the head of the bed to a high-Fowler's position.
The priority action is to raise the head of the bed. This is a quick and non-invasive intervention that can immediately facilitate lung expansion and ease the work of breathing by lowering the diaphragm. This action directly addresses the client's airway and breathing (ABCs) and should be done first. While administering oxygen, obtaining vital signs, and notifying respiratory therapy are all important subsequent actions, repositioning the client is the most immediate intervention to improve their respiratory status.
Question 5: A registered nurse (RN) is supervising a newly hired unlicensed assistive personnel (UAP). Which action by the UAP requires immediate intervention by the RN?
- The UAP reports a client's blood pressure of 110/70 mmHg to the nurse.
- The UAP is observed applying a moisturizing lotion to the feet of a client with peripheral vascular disease. (Correct answer)
- The UAP documents a client's oral intake and urinary output on the flowsheet.
- The UAP ambulates a stable postoperative client in the hallway.
Correct answer: The UAP is observed applying a moisturizing lotion to the feet of a client with peripheral vascular disease.
The RN must intervene immediately if the UAP is applying lotion to the feet of a client with peripheral vascular disease. Clients with PVD or diabetes often have decreased sensation and are at high risk for skin breakdown and infection. Foot care for these clients is complex and should be performed by the RN or LPN, as it requires careful assessment of the skin. Applying lotion between the toes can lead to maceration and fungal infections. This action poses a potential safety risk to the client. The other actions are within the appropriate scope of a UAP's duties.
Question 6: The nurse is planning care for four clients. Which client's needs should the nurse prioritize as the most immediate?
- A client with a new diagnosis of diabetes who requires initial education on insulin administration.
- An elderly client with dementia who is agitated and repeatedly trying to get out of bed without assistance. (Correct answer)
- A client who is 24 hours post-appendectomy and reports their incisional pain is 5/10.
- A client with pneumonia whose family has questions about the plan of care.
Correct answer: An elderly client with dementia who is agitated and repeatedly trying to get out of bed without assistance.
The nurse should prioritize the elderly client with dementia who is agitated and trying to get out of bed. This client presents the most immediate and significant safety risk (a fall). According to Maslow's Hierarchy of Needs, safety is a fundamental need that must be addressed immediately after physiological needs. The client requiring education, the client with expected postoperative pain, and the family with questions are all important, but the risk of imminent physical harm to the agitated client makes their needs the highest priority.
NCSBN - National Council of State Boards of Nursing Prioritization and Delegation Questions and Answers
A nurse on a medical-surgical unit receives the change-of-shift report.
Which of the following clients should the nurse assess first?