Prioritization & Delegation — Set 1

1

A nurse receives report on four clients. Which client should the nurse assess FIRST?

Correct: A

New facial droop and slurred speech are signs of a possible acute stroke — a time-critical emergency where "time is brain." This client must be seen first to activate the stroke pathway. The others are important but stable and can wait; use the ABC/acuity framework and always prioritize new neurologic changes.

A. Correct. New neuro deficits suggest acute stroke — the most time-sensitive.
B. Discharge teaching for a stable client is the lowest acuity here.
C. A routine dressing change on a stable client can wait.
D. Chronic pain is a priority to treat but is not an unstable, time-critical change.

2

Which task is MOST appropriate for the RN to delegate to unlicensed assistive personnel (UAP)?

Correct: A

Delegation rule: UAP may perform standardized, predictable tasks on stable clients — routine vital signs qualify. Assessment, teaching, and evaluation require nursing judgment and cannot be delegated. Remember the five rights of delegation and that the nurse retains accountability.

A. Correct. Routine vitals on a stable client are within the UAP scope.
B. Evaluating a response to therapy is a nursing judgment — not delegable.
C. Client teaching requires the nurse’s knowledge and evaluation — not delegable.
D. Assessment requires nursing judgment — not delegable.

3

A nurse is caring for four clients. Which finding requires the MOST immediate intervention?

Correct: A

Airway and breathing come first. An oxygen saturation of 84% is significant hypoxemia requiring immediate intervention (oxygen, positioning, assessment). The elevated BP, mild hypokalemia, and low-grade fever all warrant attention but are not immediately life-threatening — apply the ABC framework.

A. Correct. SpO₂ 84% is acute hypoxemia — a breathing emergency, treat first.
B. 148/90 is elevated but not an emergency in a known hypertensive client.
C. A low-grade postoperative fever is common and not immediately dangerous.
D. K⁺ 3.4 is mildly low and expected on a loop diuretic; address, but not first.

4

The charge nurse is assigning clients. Which client is MOST appropriate to assign to a newly licensed RN?

Correct: A

Assign the most stable, predictable client to the least experienced nurse. A stable pneumonia client on oral antibiotics fits. A transfusion reaction, a vasopressor titration, and a fresh postoperative client all require rapid assessment and complex judgment better suited to an experienced nurse.

A. Correct. Stable and predictable — appropriate for a new RN.
B. Titrating a vasopressor on an unstable client requires experience.
C. A possible transfusion reaction needs immediate expert judgment.
D. A fresh postoperative client needs frequent, skilled reassessment.

5

A nurse is planning care for a group of clients. Which situation is the priority using the ABC framework?

Correct: D

A respiratory rate of 8 with shallow breathing is inadequate ventilation — a breathing emergency at the top of the ABCs. Pain, elimination, and anxiety matter but rank below an acute airway/breathing threat. Always resolve life-threatening ABC problems before comfort or psychosocial needs.

A. A full bladder is a comfort/elimination need, lower priority.
B. Pain is a priority to treat but not immediately life-threatening.
C. Anxiety is a psychosocial need, addressed after physiologic threats.
D. Correct. RR of 8 with shallow effort is a breathing emergency.

6

A nurse is supervising a UAP caring for assigned clients. Which action by the UAP requires the nurse to intervene?

Correct: B

The nurse must intervene when a UAP acts outside their scope. Interpreting a clinical finding and reassuring a client about a new mole is assessment and teaching — nursing judgment the UAP is not permitted to provide. Obtaining routine vitals, providing hygiene, and reporting I&O are all within the UAP scope and require no intervention.

A. Reporting I&O totals is within UAP scope.
B. Correct. Interpreting a finding and reassuring the client exceeds UAP scope — intervene.
C. Routine vitals on a stable client are within UAP scope.
D. Hygiene and oral care are within UAP scope.

7

Four clients call out at the same time. Which report from a UAP should the nurse respond to FIRST?

Correct: A

New shortness of breath with chest tightness could signal a cardiac or pulmonary emergency (MI, PE) and must be assessed first — airway/breathing/circulation. A beeping pump needs attention soon but is not immediately life-threatening; the blanket and bathroom requests are the lowest acuity.

A. Correct. New dyspnea + chest tightness is a potential ABC emergency.
B. A bathroom request is important for safety but ranks below the ABC threat.
C. A blanket request is a comfort need, lowest priority.
D. An occlusion alarm needs attention but is not immediately life-threatening.

8

Which client can the RN safely assign to an LPN/LVN?

Correct: B

LPNs/LVNs can care for stable clients with predictable outcomes and can REINFORCE teaching the RN has already provided. The initial assessment, the initial plan of care, and (in most facilities) IV push chemotherapy require the RN’s scope. Scope varies by state and facility, but this is the standard NCLEX framework.

A. IV push chemotherapy typically requires an RN with certification.
B. Correct. Reinforcing prior teaching on a stable client is within LPN/LVN scope.
C. The initial admission assessment is an RN responsibility.
D. Creating the initial plan of care is an RN responsibility.

9

A nurse is prioritizing care after receiving handoff. Which client should the nurse plan to see LAST?

Correct: D

See the most stable client last. A 2-day-post-op client with a healing incision and stable vitals is predictable and low-acuity. The others are emergencies: severe hyperkalemia with ECG changes (cardiac risk), hypoxemia, and a rigid acute abdomen (possible perforation) all demand rapid attention.

A. K⁺ 6.8 with peaked T waves is a cardiac emergency — see early.
B. Sudden rigidity and severe pain suggest an acute abdomen — see early.
C. O₂ sat 88% is hypoxemia — a breathing priority.
D. Correct. Stable, healing, predictable — lowest priority to see.

10

Using Maslow’s hierarchy, which client need should the nurse address first?

Correct: D

Maslow places physiologic needs — especially airway — at the base of the hierarchy and therefore first. Gurgling respirations suggest secretions threatening the airway and demand immediate action (suction, positioning). Emotional support, teaching, and self-image concerns are important but higher on the hierarchy and addressed after physiologic safety.

A. Discharge teaching is important but not a first-level physiologic need.
B. Body-image work is a self-esteem need, higher on the hierarchy.
C. Emotional support is a love/belonging need, addressed after physiologic safety.
D. Correct. Airway is the base of Maslow’s hierarchy — always first.