NCLEX-RN Management of Care Summary

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.

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.

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.

Shakiness, sweating, and pale skin in a client with type 1 diabetes are classic signs of hypoglycemia (low blood sugar). Low blood sugar can quickly lead to confusion, seizures, and loss of consciousness, so it needs treatment right away. This client is the most unstable.

Use this rule: first see the client whose problem can get worse fast and threaten life.

Wrong choices

• "A client with COPD whose oxygen saturation is 90%": Many clients with COPD normally run lower saturation levels; 90% on low-flow oxygen is often within their target and is stable.
• "A client 1 day after surgery who rates pain 6 out of 10": Pain needs attention, but this is expected after surgery and is not life-threatening.
• "A client who is waiting for discharge teaching": This client is stable and can wait.

An LPN/LVN works under the direction of an RN and is best assigned to clients who are stable and whose care is predictable, such as giving routine oral medications and reinforcing teaching.

The client with stable chronic heart failure who needs scheduled oral medications fits this well.

The RN keeps clients who need an initial assessment, who are unstable or at high risk of a sudden change, or who need initial teaching.

Wrong choices

• "A client just admitted ... with chest pain": A new admission with chest pain needs an initial assessment and may become unstable. This stays with the RN.
• "A client who is about to start the first unit of a blood transfusion": The start of a transfusion carries the highest risk of a serious reaction and needs close RN assessment.
• "A client with newly diagnosed diabetes who needs teaching": First-time teaching belongs to the RN. The LPN/LVN can reinforce teaching later.

Checking whether a pain medicine has worked is evaluation. Evaluation needs nursing judgment and cannot be delegated to a UAP. The UAP may report what the client says, but deciding whether the medication worked, and what to do next, belongs to a licensed nurse.

The other tasks are within the usual role of the person they were given to.

Wrong choices

• "Helping a stable client walk": Routine help with walking for a stable client is a common UAP task.
• "Asking the LPN/LVN to give scheduled oral medications": Giving routine oral medications to a stable client is within LPN/LVN scope.
• "Measure and record intake and output": Measuring and recording is data collection. The RN reviews the results.

Furosemide (a loop diuretic) causes the body to lose potassium. This client's potassium is well below the reference range, and the client has an irregular pulse. Low potassium can cause dangerous heart rhythm problems, so this client is the most unstable and needs to be seen first.

Look for a lab result that is abnormal plus a sign that the body is already affected.

Wrong choices

• "A client with a fractured tibia who rates pain 7 out of 10": Pain needs treatment soon, but is expected and not life-threatening. (Severe pain that does not respond to medicine could suggest compartment syndrome, but nothing else here points to that.)
• "A mildly hoarse voice 1 day after thyroid surgery": Mild hoarseness is common after this surgery. Noisy, high-pitched breathing (stridor) or trouble breathing would be an emergency.
• "Blood glucose of 180 mg/dL before lunch": This is above goal and needs follow-up, but is not an immediate danger.

After a cardiac catheterization through the femoral artery (a large artery in the groin), the biggest early risk is bleeding from the puncture site. A feeling of warmth and wetness at the site suggests blood is leaking. Bleeding from an artery can become severe quickly, so this client must be assessed first.

The nurse checks the site, applies firm pressure above the site if it is bleeding, and gets help.

Wrong choices

• "COPD with oxygen saturation of 89%": For many clients with COPD, a saturation in the high 80s to low 90s is the target range, so this client is likely stable.
• "Blood glucose of 210 mg/dL before lunch": This needs follow-up but is not an immediate threat.
• "Water level rises and falls with breathing": This is called tidaling and is an expected finding that shows the chest tube is working.

A durable power of attorney for health care names a person (the agent or proxy) to make health care decisions for the client. The agent steps in only when the client is unable to make decisions, for example when the client is unconscious or lacks decision-making capacity.

While the client can still decide, the client's own choices come first.

Wrong choices

• "Whenever she disagrees with the client's choices": A client who can decide keeps the right to make their own choices.
• "Only after the client has died": Health care decisions are needed while the client is alive. The agent's role is for when the client is alive but cannot decide.
• "Whenever the health care provider asks her to": The provider cannot hand decisions to the agent while the client is able to decide.

A competent adult has the right to refuse treatment. The nurse's first step is to find out why. The client may have side effects, a misunderstanding, or a concern the nurse can address.

After that, the nurse explains what may happen if the medication is not taken, documents the refusal and the reason, and notifies the provider.

Wrong choices

• "Mix the medication into the client's food": Giving medication secretly to a competent client violates their rights and can be a form of battery.
• "Tell the client that the provider insists": Pressuring the client does not respect their right to refuse.
• "Write that the client refused and leave the room": Documenting is needed, but not before finding out the reason and addressing it.