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Comprehensive Nursing
Exam
Prep Notes
Delegation
Definition & Importance
Assigning specific tasks to another healthcare team member
while retaining overall accountability for the outcome.
Delegation optimizes workflow, elevates patient safety, and
ensures legal compliance when done within scope.
5 Rights of Delegation
Right Task – activity must be appropriate for delegation (e.g.,
routine vital signs, stable morning weights).
Right Circumstance – patient condition must be stable;
unstable or newly-postop patients require RN or LPN intervention.
Right Person – delegatee is competent/authorized (e.g., UAP vs.
LPN vs. RN).
Right Direction & Communication – clear, specific, and time-
oriented instructions ("Obtain 0600 weights before breakfast,
document in EHR").
Right Supervision & Evaluation – delegator must verify completion and
quality; if not done or done incorrectly, responsibility returns to delegator.
Tasks Commonly Delegated to UAP
ADLs: baths, hygiene, ambulation, turning, elimination assistance.
Routine, stable vital signs & daily weights.
Non-prescription eye/ear drops, OTC skin moisturizers.
Gathering supplies, transferring belongings at discharge.
Reinforcing (not initiating) previously taught techniques.
Tasks NOT Delegated to UAP
Initial patient education, assessment, or evaluation.
IV medication administration, TPA infusion, care-plan
development.
Unstable or post-procedure assessments (post-cath lab, fresh
strokes, new chest tubes).
LPN Scope Highlights
May contribute to (but not originate) nursing care plans.
Performs focused (not comprehensive) assessments.
Cannot administer TPA or initiate blood transfusions.
Nursing Process Review
Assessment – collect objective/subjective & socioeconomic data.
Diagnosis – prioritize based on Maslow, ABCs, safety.
Planning – RN formulates original care plan with measurable, time-
limited goals.
, xxx
Implementation – interventions, many of which may be delegated when
stable.
Evaluation – compare patient status before vs. after interventions (e.g.,
SpO2 pre- and post-oxygen application).
Medication Administration & Safety
National Patient Safety Goals (Joint Commission)
Identify patients with two identifiers: name and date of birth.
Improve communication: read-back orders, SBAR.
Use medications safely: 6 rights, label syringes, high-alert double
checks.
Prevent infections: hand hygiene, central-line bundles.
Prevent surgical mistakes: "time-out," correct-site marking.
6 Rights of Medication Administration (acronym “DR. TIMe D”)
Drug
Route
Time
Individual (patient)
MDose
eDocumentation
High-Frequency Errors
Skipping 3-check process (Pyxis → preparation → bedside).
Relying on one ID band scan alone; must verbally confirm
identifiers.
Stroke (CVA) Content
Screening Acronym B.E. F.A.S.T.
Balance – sudden loss of coordination
Eyes – visual changes
Face droop
Arm weakness
Speech slurred
Time to call 911
Golden Window
≤ 3hours from last known well for IV tissue plasminogen
activator (tPA).
Immediate non-contrast CT to differentiate ischemic vs
hemorrhagic stroke.
Comprehensive Nursing
Exam
Prep Notes
Delegation
Definition & Importance
Assigning specific tasks to another healthcare team member
while retaining overall accountability for the outcome.
Delegation optimizes workflow, elevates patient safety, and
ensures legal compliance when done within scope.
5 Rights of Delegation
Right Task – activity must be appropriate for delegation (e.g.,
routine vital signs, stable morning weights).
Right Circumstance – patient condition must be stable;
unstable or newly-postop patients require RN or LPN intervention.
Right Person – delegatee is competent/authorized (e.g., UAP vs.
LPN vs. RN).
Right Direction & Communication – clear, specific, and time-
oriented instructions ("Obtain 0600 weights before breakfast,
document in EHR").
Right Supervision & Evaluation – delegator must verify completion and
quality; if not done or done incorrectly, responsibility returns to delegator.
Tasks Commonly Delegated to UAP
ADLs: baths, hygiene, ambulation, turning, elimination assistance.
Routine, stable vital signs & daily weights.
Non-prescription eye/ear drops, OTC skin moisturizers.
Gathering supplies, transferring belongings at discharge.
Reinforcing (not initiating) previously taught techniques.
Tasks NOT Delegated to UAP
Initial patient education, assessment, or evaluation.
IV medication administration, TPA infusion, care-plan
development.
Unstable or post-procedure assessments (post-cath lab, fresh
strokes, new chest tubes).
LPN Scope Highlights
May contribute to (but not originate) nursing care plans.
Performs focused (not comprehensive) assessments.
Cannot administer TPA or initiate blood transfusions.
Nursing Process Review
Assessment – collect objective/subjective & socioeconomic data.
Diagnosis – prioritize based on Maslow, ABCs, safety.
Planning – RN formulates original care plan with measurable, time-
limited goals.
, xxx
Implementation – interventions, many of which may be delegated when
stable.
Evaluation – compare patient status before vs. after interventions (e.g.,
SpO2 pre- and post-oxygen application).
Medication Administration & Safety
National Patient Safety Goals (Joint Commission)
Identify patients with two identifiers: name and date of birth.
Improve communication: read-back orders, SBAR.
Use medications safely: 6 rights, label syringes, high-alert double
checks.
Prevent infections: hand hygiene, central-line bundles.
Prevent surgical mistakes: "time-out," correct-site marking.
6 Rights of Medication Administration (acronym “DR. TIMe D”)
Drug
Route
Time
Individual (patient)
MDose
eDocumentation
High-Frequency Errors
Skipping 3-check process (Pyxis → preparation → bedside).
Relying on one ID band scan alone; must verbally confirm
identifiers.
Stroke (CVA) Content
Screening Acronym B.E. F.A.S.T.
Balance – sudden loss of coordination
Eyes – visual changes
Face droop
Arm weakness
Speech slurred
Time to call 911
Golden Window
≤ 3hours from last known well for IV tissue plasminogen
activator (tPA).
Immediate non-contrast CT to differentiate ischemic vs
hemorrhagic stroke.
