NCLEX-RN · Safe and Effective Care Environment
NCLEX-RN: Management of Care Concepts
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Overview
This chapter covers how a registered nurse decides who to see first, which tasks can be handed to other team members, and how to protect each client's rights. These ideas are tested often, because a safe nurse must think about priorities and responsibility before acting.
When several clients need you, airway comes first, then breathing, then circulation. An unstable or newly changed client comes before a stable one, and an acute problem comes before a chronic one. When you delegate, you hand a stable, routine task with a predictable result to a licensed practical nurse or an assistive person, but you stay accountable. Assessment, teaching, care planning and judging results stay with the RN.
Clients have the right to make their own choices, including the right to refuse care. Before a procedure, the provider explains it and gets informed consent, and the nurse may witness the signature. Health information is shared only with people directly involved in care. An advance directive tells the team the client's wishes in advance, and a structured handoff such as SBAR keeps care continuous between shifts.
Key concepts
Priority setting (ABC)
A way to decide who needs care first. Airway problems come first, then breathing, then circulation. An unstable client, or one whose condition has suddenly changed, comes before a stable client with an expected problem. An acute, new problem comes before a chronic, expected one.
Memory tipAsk yourself: which client could die or be harmed first if I wait? Go to that client.
Delegation
Handing a task to another team member, such as a licensed practical nurse or an assistive person, while the RN stays responsible for the outcome. Only stable, routine tasks with predictable results should be delegated.
Memory tipThe RN keeps assessment, teaching, care planning and evaluation. Bathing, feeding and routine vital signs on stable clients can be delegated.
Five rights of delegation
Right task, right circumstance, right person, right directions and communication, and right supervision and evaluation. All five must be in place before a task is handed off.
Memory tipIf any one 'right' is missing, such as an unstable client or an untrained helper, do not delegate.
Informed consent
The client's agreement to a procedure after learning its purpose, risks, benefits and other options. The provider must explain it. The nurse may witness the signature and confirms the client understands and is not sedated or confused.
Memory tipIf the client still has questions, stop and call the provider. Do not explain the procedure risks yourself.
Confidentiality
Keeping client health information private. Share it only with people directly caring for the client or those the client has approved. Do not discuss clients in hallways, elevators or on social media.
Memory tipAsk: does this person need this information to care for the client? If not, do not share it.
Advance directive
A legal document that states a client's wishes for future care. A living will lists treatments the client wants or refuses. A health care power of attorney names a person to make decisions if the client cannot.
Memory tipLiving will = 'what' the client wants. Power of attorney = 'who' decides.
SBAR handoff
A structured way to report: Situation, Background, Assessment, Recommendation. It is used for shift reports and for calling a provider about a change in the client.
Memory tipHave the latest vital signs, recent labs and your concern ready before you call.
Often tested
- Choose the client with an airway, breathing or circulation problem, or a sudden change, as the first to see.
- Assessment, teaching, care planning and evaluation cannot be delegated to an assistive person.
- The provider obtains informed consent; the nurse witnesses it and calls the provider if the client has questions.
- A competent adult may refuse any treatment, even if the team disagrees.
- An incident report is a quality tool; do not mention it in the client's chart.
- Use SBAR when calling a provider about a change in condition.
Easy to confuse: What the RN keeps and what can be delegated
| Task type | RN | Assistive person |
|---|---|---|
| First assessment of a client | Yes | No |
| Client teaching | Yes | No |
| Routine vital signs on a stable client | Yes | Yes |
| Bathing, feeding, walking a stable client | Yes | Yes |
| Care of an unstable client | Yes | No |
3 sample questions
Verified practice questions from this unit.
Question 1. The RN is caring for a group of clients on a medical-surgical unit. Which task is most appropriate for the RN to delegate to an unlicensed assistive personnel (UAP)?
- ① Measuring vital signs on a stable client 2 days after hip surgery
- ② Completing the skin assessment for a newly admitted client
- ③ Teaching a client how to use an incentive spirometer
- ④ Giving a scheduled oral medication to a client with heart failure
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ① Measuring vital signs on a stable client 2 days after hip surgery
Key point: UAP: routine care for stable clients; RN keeps assess, teach, evaluate
A UAP (such as a nursing assistant) can do routine, predictable tasks for clients who are stable. Taking vital signs on a stable client 2 days after surgery fits this rule. The RN still reviews the numbers and acts on anything abnormal.
A simple way to remember what the RN keeps: assessment, teaching, evaluation, and nursing judgment cannot be delegated to a UAP.
Wrong choices
- "Teaching a client how to use an incentive spirometer": Teaching is an RN responsibility. A UAP can remind a client to use it, but cannot do the teaching.
- "Completing the skin assessment": Assessment, especially on admission, needs nursing judgment and stays with the RN.
- "Giving a scheduled oral medication": Giving medications is outside the UAP role.
Question 2. The surgeon has explained a planned surgery to a client. The client agrees and is ready to sign the consent form. What is the nurse's role in this process?
- ① Witness that the client signed the form voluntarily
- ② Decide whether the client truly needs the surgery
- ③ Have the client's adult child sign the form for the client
- ④ Explain the risks and benefits of the surgery to the client
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ① Witness that the client signed the form voluntarily
Key point: Provider explains consent; nurse witnesses the signature
Getting informed consent is the provider's job (the surgeon or the person doing the procedure). The provider explains the procedure, risks, benefits, and other options.
The nurse's role is to witness the signature. This means the nurse confirms that the person signing is the client, that the client signed of their own free will, and that the client appears able to make the decision. If the client has questions, the nurse contacts the provider.
Wrong choices
- "Explain the risks and benefits": This is the provider's duty, not the nurse's.
- "Decide whether the client truly needs the surgery": The nurse does not decide medical treatment.
- "Have the client's adult child sign": A competent adult signs their own consent. A family member signs only if the client cannot legally make the decision and that person is the legal decision-maker.
Question 3. Which action by a nurse is a breach of client confidentiality?
- ① Giving the dietitian information needed to plan the client's meals
- ② Logging out of the electronic health record before leaving the computer
- ③ Telling a client's coworker, who called the unit, the client's diagnosis
- ④ Sharing the client's condition with the oncoming nurse during hand-off
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ③ Telling a client's coworker, who called the unit, the client's diagnosis
Key point: Share health info only with those caring for the client
Under privacy rules such as HIPAA (the US federal health privacy law), health information is shared only with people who need it to care for the client, or with people the client has given permission to receive it.
A coworker who calls the unit is not part of the care team. Telling them the diagnosis without the client's permission is a breach of confidentiality.
Wrong choices
- "Sharing the client's condition with the oncoming nurse": Hand-off report is needed for safe, continuous care.
- "Logging out of the electronic health record": This protects privacy. It is the correct action.
- "Giving the dietitian information": The dietitian is part of the care team and needs this to plan meals.