NCLEX PRIORITIZATION AND N N
DELEGATION N
The nurse received a change-of-shift report on four assigned clients. In what order should the
N N N N N N N N N N N N N N
nurse attend to the clients? Prioritize the nurse's actions by placing each client in the correct
N N N N N N N N N N N N N N N N
order.
N N
1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has
N N N N N N N N N N N N N N N N
a serum potassium level of 5.5 mEq/L
N N N N N N N
2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of
N N N N N N N N N N N N N N
102.8F, BP 98/66 mmHg, and P 114 bpm
N N N N N N N N
3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who
N N N N N N N N N N N N N N N N N
has been crying since recent visitors left
N N N N N N N
4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a
N N N N N N N N N N N N N N N N N N N
medication for pain rated at a 6 on the 0 - 10 scale. - CORRECT ANSWER-2, 4, 1, 3
N N N N N N N N N N N N N N N NN N N N
2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of
N N N N N N N N N N N N N N
102.8F, BP 98/66 mmHg, and P 114 bpm should be attended to first. The elevated temperature,
N N N N N N N N N N N N N N N N
low BP, and tachycardia are signs that indicate septic shock or sepsis may be developing.
N N N N N N N N N N N N N N N N
4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a
N N N N N N N N N N N N N N N N N N N
medication for pain rated at a 6 on a 0-10 scale should be attended to next. Post-op pain control
N N N N N N N N N N N N N N N N N N N
is needed to keep on top of the pain and enable the client to be involved in post-op activities,
N N N N N N N N N N N N N N N N N N N
such as coughing and deep breathing, to prevent complications of bed rest
N N N N N N N N N N N N N
1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has
N N N N N N N N N N N N N N N N
a serum potassium level of 5.5 mEq/L should be attended to third. The serum potassium level is
N N N N N N N N N N N N N N N N N
borderline high (normal 3.5-5.5)
N N N N
,3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who
N N N N N N N N N N N N N N N N N
has been crying since recent visitors left can be attended to last among the clients. The client
N N N N N N N N N N N N N N N N N
needs emotional support, which is important to recovery, but clients with physiological needs
N N N N N N N N N N N N N
are priority.
N N
The RN is leading a team of an NA and an LPN in the care of a group of clients. Which tasks
N N N N N N N N N N N N N N N N N N N N N
should the nurse assign to the NA and LPN?
N N N N N N N N N
1. NA to perform two simple dressing changes; LPN to assess and care for two non-complex
N N N N N N N N N N N N N N N
clients
N
2. NA to empty and record urinary catheter bag drainage; LPN to administer oral and IM
N N N N N N N N N N N N N N N
medications
N N
3. NA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased
N N N N N N N N N N N N N N N N
client's family
N N N
4. NA to take and document vital signs on all clients; LPN to complete the discharge paperwork
N N N N N N N N N N N N N N N N
to be reviewed with two clients - CORRECT ANSWER-2. The scope of practice for the NA
N N N N N N N N NN N N N N N N N
includes measuring and recording I&O and for the LPN includes administering oral and IM
N N N N N N N N N N N N N N
medications
N
The nurse is supervising the experienced NA who is new to the unit. Which question is best to
N N N N N N N N N N N N N N N N N
evaluate the NA's knowledge and skill in obtaining the client's fingerstick blood glucose, which is
N N N N N N N N N N N N N N N
a permissible NA-performed skill within the facility?
N N N N N N N N
1. "How many times did you perform a fingerstick blood glucose measurement on the unit in
N N N N N N N N N N N N N N N
which you previously worked?"
N N N N
2. "How would you obtain a blood specimen and perform the procedure for measuring the
N N N N N N N N N N N N N N
client's blood glucose?"
N N N
3. When was the last time you were observed by a RN performing a blood glucose measurement
N N N N N N N N N N N N N N N N
on the client?"
N N N N
4. "When was the last time you obtained a blood glucose measurement that was out of the
N N N N N N N N N N N N N N N N
normal ranges, and what did you do about this?" - CORRECT ANSWER-2. The NA describing the
N N N N N N N N N N N NN N N N N
procedure is one method of evaluating the NA's knowledge and skills. Using an open-ended
N N N N N N N N N N N N N N
question elicits conversation and details.
N N N N N
,The NA's job responsibilities include totaling the I&O records for clients at the end of an 8-hour
N N N N N N N N N N N N N N N N
shift. Near the end of the shift, the LPN reports to the RN that the new NA on the unit has not
N N N N N N N N N N N N N N N N N N N N N N
completed the task. What is the RN's best action?
N N N N N N N N N
1. Ask the LPN to complete this task because the information is needed to give report.
N N N N N N N N N N N N N N N
2. Remind the NA that the task needs to be completed as quickly as possible
N N N N N N N N N N N N N N
3. Notify the charge nurse that the NA needs more orientation on job responsibilities
N N N N N N N N N N N N N N
4. Go to the NA to discuss the collection of I&O data and how to total I&O records - CORRECT
N N N N N N N N N N N N N N N N N N N N
ANSWER-4. Delegation of assigned tasks includes determining the delegate's knowledge and
N N N N N N N N N N N
ability to perform the task correctly. Discussing the task with the NA may clarify what the NA
N N N N N N N N N N N N N N N N N
knows and where additional teaching is needed regarding the task.
N N N N N N N N N N
The RN is informed by the NA that the client, hospitalized last evening with chest pain, plans to
N N N N N N N N N N N N N N N N N
leave right now because the pain is gone and "nobody has done anything anyway". Which is the
N N N N N N N N N N N N N N N N N
nurse's best action?
N N N N
1. Thank the NA for the information and then call the client's doctor regarding the situation
N N N N N N N N N N N N N N N N
2. Tell the NA that the client has the right to leave and send the NA to help the client pack
N N N N N N N N N N N N N N N N N N N N N
3. Talk with the client to discuss the client's concerns and explain the plan of care
N N N N N N N N N N N N N N N
4. Tell the NA to inform the client that it is unsafe to leave; the RN will see the client shortly -
N N N N N N N N N N N N N N N N N N N N N
CORRECT ANSWER-3. Seeing the client provides an opportunity for further assessment and
N NN N N N N N N N N N N
client teaching. The nurse's responsibility is to inform clients of the status of their care.
N N N N N N N N N N N N N N N
The nurse determines that the NA did not complete assigned tasks. Which statement is best?
N N N N N N N N N N N N N N
1. "All four of the clients' rooms assigned to you today are messy with a lot of trash in them. You
N N N N N N N N N N N N N N N N N N N N
really need to finish your assignment before you leave".
N N N N N N N N N N
2. "I am concerned that you didn't complete your work assignments today. What responsibilities
N N N N N N N N N N N N N
interfered with completing the tasks I assigned?"
N N N N N N N N
3. "I checked with the four clients you were assigned to ambulate, and you didn't ambulate
N N N N N N N N N N N N N N N
anyone. This cannot happen again".
N N N N N N
, 4. "Family members are upset today because you didn't get all the clients bathed yet. Why didn't
N N N N N N N N N N N N N N N N
you let me know you needed help?" - CORRECT ANSWER-2. This statement is best. Giving the
N N N N N N N N N NN N N N N N N
NA an opportunity to provide a rationale fosters team communication.
N N N N N N N N N N
The new nurse is discussing the organization of client care with the mentor. Which statement
N N N N N N N N N N N N N N
made by the new nurse requires immediate follow-up by the mentor?
N N N N N N N N N N N N
1. "I delegated all the stable vital signs to an unlicensed assistive personnel (UAP) and most of
N N N N N N N N N N N N N N N N
the treatments to the LPN
N N N N N
2. "I had the LPN bring the urinary catheterization supplies into the room so everything would
N N N N N N N N N N N N N N N
be available when I got there"
N N N N N N N
3. "I was taking vitals on one client and having a second client dangle while I had a third client sit
N N N N N N N N N N N N N N N N N N N N
on the bedside commode"
N N N N N
4. "I believe my organizational skills are improving and I am able to complete all the client cares
N N N N N N N N N N N N N N N N N
myself" - CORRECT ANSWER-3. This statement may appear that the new nurse is organized.
N N N NN N N N N N N N N N N
However, leaving the client dangling and another on a bedside commode while taking vital signs
N N N N N N N N N N N N N N N
on another client is unsafe and indicates that the new nurse is not properly delegating tasks.
N N N N N N N N N N N N N N N N
This statement would require immediate follow-up by the mentor because these actions
N N N N N N N N N N N N
increase the client's risk for falls.
N N N N N N
The RN is working with the UAP and the LPN in providing care to a group of clients. Which tasks
N N N N N N N N N N N N N N N N N N N
should the nurse plan to delegate? Select all that apply.
N N N N N N N N N N N
1. LPN to administer oral and IM medications
N N N N N N N N
2. UAP to perform chest tube dressing changes
N N N N N N N N
3. LPN to assess and care for two non-complex clients
N N N N N N N N N N
4. UAP to empty and record urinary catheter bag drainage
N N N N N N N N N N
5. UAP to take and document vital signs on all clients
N N N N N N N N N N N
6. LPN to initiate the discharge paperwork for two clients - CORRECT ANSWER-1, 4, & 5
N N N N N N N N N N N NN N N N
1. It is within the LPN's scope of practice to administer oral and IM medications
N N N N N N N N N N N N N N N
4. It is acceptable practice for the UAP to empty and record urinary catheter bag drainage
N N N N N N N N N N N N N N N
5. It is acceptable practice for the UAP to check and document vital signs on all clients
N N N N N N N N N N N N N N N N
DELEGATION N
The nurse received a change-of-shift report on four assigned clients. In what order should the
N N N N N N N N N N N N N N
nurse attend to the clients? Prioritize the nurse's actions by placing each client in the correct
N N N N N N N N N N N N N N N N
order.
N N
1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has
N N N N N N N N N N N N N N N N
a serum potassium level of 5.5 mEq/L
N N N N N N N
2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of
N N N N N N N N N N N N N N
102.8F, BP 98/66 mmHg, and P 114 bpm
N N N N N N N N
3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who
N N N N N N N N N N N N N N N N N
has been crying since recent visitors left
N N N N N N N
4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a
N N N N N N N N N N N N N N N N N N N
medication for pain rated at a 6 on the 0 - 10 scale. - CORRECT ANSWER-2, 4, 1, 3
N N N N N N N N N N N N N N N NN N N N
2. The 33-year-old client with a deep partial-thickness leg burn who has a temperature of
N N N N N N N N N N N N N N
102.8F, BP 98/66 mmHg, and P 114 bpm should be attended to first. The elevated temperature,
N N N N N N N N N N N N N N N N
low BP, and tachycardia are signs that indicate septic shock or sepsis may be developing.
N N N N N N N N N N N N N N N N
4. The 58-year-old client who had a skin graft to a leg burn 6 hours ago and is requesting a
N N N N N N N N N N N N N N N N N N N
medication for pain rated at a 6 on a 0-10 scale should be attended to next. Post-op pain control
N N N N N N N N N N N N N N N N N N N
is needed to keep on top of the pain and enable the client to be involved in post-op activities,
N N N N N N N N N N N N N N N N N N N
such as coughing and deep breathing, to prevent complications of bed rest
N N N N N N N N N N N N N
1. The 57-year-old client who was admitted 24 hours ago after being struck by lightning and has
N N N N N N N N N N N N N N N N
a serum potassium level of 5.5 mEq/L should be attended to third. The serum potassium level is
N N N N N N N N N N N N N N N N N
borderline high (normal 3.5-5.5)
N N N N
,3. The 25-year-old client admitted 1 week ago with facial and chest burns from a house fire who
N N N N N N N N N N N N N N N N N
has been crying since recent visitors left can be attended to last among the clients. The client
N N N N N N N N N N N N N N N N N
needs emotional support, which is important to recovery, but clients with physiological needs
N N N N N N N N N N N N N
are priority.
N N
The RN is leading a team of an NA and an LPN in the care of a group of clients. Which tasks
N N N N N N N N N N N N N N N N N N N N N
should the nurse assign to the NA and LPN?
N N N N N N N N N
1. NA to perform two simple dressing changes; LPN to assess and care for two non-complex
N N N N N N N N N N N N N N N
clients
N
2. NA to empty and record urinary catheter bag drainage; LPN to administer oral and IM
N N N N N N N N N N N N N N N
medications
N N
3. NA to assist clients with hygiene; LPN to provide postmortem care and meet with a deceased
N N N N N N N N N N N N N N N N
client's family
N N N
4. NA to take and document vital signs on all clients; LPN to complete the discharge paperwork
N N N N N N N N N N N N N N N N
to be reviewed with two clients - CORRECT ANSWER-2. The scope of practice for the NA
N N N N N N N N NN N N N N N N N
includes measuring and recording I&O and for the LPN includes administering oral and IM
N N N N N N N N N N N N N N
medications
N
The nurse is supervising the experienced NA who is new to the unit. Which question is best to
N N N N N N N N N N N N N N N N N
evaluate the NA's knowledge and skill in obtaining the client's fingerstick blood glucose, which is
N N N N N N N N N N N N N N N
a permissible NA-performed skill within the facility?
N N N N N N N N
1. "How many times did you perform a fingerstick blood glucose measurement on the unit in
N N N N N N N N N N N N N N N
which you previously worked?"
N N N N
2. "How would you obtain a blood specimen and perform the procedure for measuring the
N N N N N N N N N N N N N N
client's blood glucose?"
N N N
3. When was the last time you were observed by a RN performing a blood glucose measurement
N N N N N N N N N N N N N N N N
on the client?"
N N N N
4. "When was the last time you obtained a blood glucose measurement that was out of the
N N N N N N N N N N N N N N N N
normal ranges, and what did you do about this?" - CORRECT ANSWER-2. The NA describing the
N N N N N N N N N N N NN N N N N
procedure is one method of evaluating the NA's knowledge and skills. Using an open-ended
N N N N N N N N N N N N N N
question elicits conversation and details.
N N N N N
,The NA's job responsibilities include totaling the I&O records for clients at the end of an 8-hour
N N N N N N N N N N N N N N N N
shift. Near the end of the shift, the LPN reports to the RN that the new NA on the unit has not
N N N N N N N N N N N N N N N N N N N N N N
completed the task. What is the RN's best action?
N N N N N N N N N
1. Ask the LPN to complete this task because the information is needed to give report.
N N N N N N N N N N N N N N N
2. Remind the NA that the task needs to be completed as quickly as possible
N N N N N N N N N N N N N N
3. Notify the charge nurse that the NA needs more orientation on job responsibilities
N N N N N N N N N N N N N N
4. Go to the NA to discuss the collection of I&O data and how to total I&O records - CORRECT
N N N N N N N N N N N N N N N N N N N N
ANSWER-4. Delegation of assigned tasks includes determining the delegate's knowledge and
N N N N N N N N N N N
ability to perform the task correctly. Discussing the task with the NA may clarify what the NA
N N N N N N N N N N N N N N N N N
knows and where additional teaching is needed regarding the task.
N N N N N N N N N N
The RN is informed by the NA that the client, hospitalized last evening with chest pain, plans to
N N N N N N N N N N N N N N N N N
leave right now because the pain is gone and "nobody has done anything anyway". Which is the
N N N N N N N N N N N N N N N N N
nurse's best action?
N N N N
1. Thank the NA for the information and then call the client's doctor regarding the situation
N N N N N N N N N N N N N N N N
2. Tell the NA that the client has the right to leave and send the NA to help the client pack
N N N N N N N N N N N N N N N N N N N N N
3. Talk with the client to discuss the client's concerns and explain the plan of care
N N N N N N N N N N N N N N N
4. Tell the NA to inform the client that it is unsafe to leave; the RN will see the client shortly -
N N N N N N N N N N N N N N N N N N N N N
CORRECT ANSWER-3. Seeing the client provides an opportunity for further assessment and
N NN N N N N N N N N N N
client teaching. The nurse's responsibility is to inform clients of the status of their care.
N N N N N N N N N N N N N N N
The nurse determines that the NA did not complete assigned tasks. Which statement is best?
N N N N N N N N N N N N N N
1. "All four of the clients' rooms assigned to you today are messy with a lot of trash in them. You
N N N N N N N N N N N N N N N N N N N N
really need to finish your assignment before you leave".
N N N N N N N N N N
2. "I am concerned that you didn't complete your work assignments today. What responsibilities
N N N N N N N N N N N N N
interfered with completing the tasks I assigned?"
N N N N N N N N
3. "I checked with the four clients you were assigned to ambulate, and you didn't ambulate
N N N N N N N N N N N N N N N
anyone. This cannot happen again".
N N N N N N
, 4. "Family members are upset today because you didn't get all the clients bathed yet. Why didn't
N N N N N N N N N N N N N N N N
you let me know you needed help?" - CORRECT ANSWER-2. This statement is best. Giving the
N N N N N N N N N NN N N N N N N
NA an opportunity to provide a rationale fosters team communication.
N N N N N N N N N N
The new nurse is discussing the organization of client care with the mentor. Which statement
N N N N N N N N N N N N N N
made by the new nurse requires immediate follow-up by the mentor?
N N N N N N N N N N N N
1. "I delegated all the stable vital signs to an unlicensed assistive personnel (UAP) and most of
N N N N N N N N N N N N N N N N
the treatments to the LPN
N N N N N
2. "I had the LPN bring the urinary catheterization supplies into the room so everything would
N N N N N N N N N N N N N N N
be available when I got there"
N N N N N N N
3. "I was taking vitals on one client and having a second client dangle while I had a third client sit
N N N N N N N N N N N N N N N N N N N N
on the bedside commode"
N N N N N
4. "I believe my organizational skills are improving and I am able to complete all the client cares
N N N N N N N N N N N N N N N N N
myself" - CORRECT ANSWER-3. This statement may appear that the new nurse is organized.
N N N NN N N N N N N N N N N
However, leaving the client dangling and another on a bedside commode while taking vital signs
N N N N N N N N N N N N N N N
on another client is unsafe and indicates that the new nurse is not properly delegating tasks.
N N N N N N N N N N N N N N N N
This statement would require immediate follow-up by the mentor because these actions
N N N N N N N N N N N N
increase the client's risk for falls.
N N N N N N
The RN is working with the UAP and the LPN in providing care to a group of clients. Which tasks
N N N N N N N N N N N N N N N N N N N
should the nurse plan to delegate? Select all that apply.
N N N N N N N N N N N
1. LPN to administer oral and IM medications
N N N N N N N N
2. UAP to perform chest tube dressing changes
N N N N N N N N
3. LPN to assess and care for two non-complex clients
N N N N N N N N N N
4. UAP to empty and record urinary catheter bag drainage
N N N N N N N N N N
5. UAP to take and document vital signs on all clients
N N N N N N N N N N N
6. LPN to initiate the discharge paperwork for two clients - CORRECT ANSWER-1, 4, & 5
N N N N N N N N N N N NN N N N
1. It is within the LPN's scope of practice to administer oral and IM medications
N N N N N N N N N N N N N N N
4. It is acceptable practice for the UAP to empty and record urinary catheter bag drainage
N N N N N N N N N N N N N N N
5. It is acceptable practice for the UAP to check and document vital signs on all clients
N N N N N N N N N N N N N N N N
