Question 1

A nurse is assisting a client in room 1 with lunch. The charge nurse calls the nurse and states the client in room 3 is reporting pain and requests pain medication. What is the nurse’s best and first action?

Accepted Answer

Answer reason: Nursing priority is timely pain management while maintaining safety and continuity of care for the client currently eating. The RN should not abruptly stop feeding a client because doing so can create aspiration risk and neglect an ongoing basic need, but pain management should not be delayed unnecessarily either. The best approach is to delegate the non-RN task of assisting with a meal to an available qualified nurse while the RN promptly assesses the pain, verifies the order, and administers analgesia. Options that delay treatment or shift medication administration to someone else without ensuring proper role responsibility reduce efficiency and may compromise care.

Question 2

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant?

Accepted Answer

Answer reason: Delegation to a nursing assistant is appropriate for routine, noninvasive, predictable tasks that do not require clinical assessment, teaching, or nursing judgment. Upright positioning helps optimize lung expansion and ventilation in COPD and is a standard supportive measure that can be performed safely with basic assistance. In contrast, teaching (effective coughing or incentive spirometry) requires evaluation of understanding and technique and must be performed by the nurse. Auscultation is an assessment skill that requires RN-level clinical judgment and cannot be delegated to unlicensed assistive personnel.

Question 3

The charge nurse on a busy medical-surgical unit is assigning tasks to the team, which includes one RN, one LPN/LVN, and two UAPs. Four clients require immediate attention: 1. Client A: Post-operative day 1 following a bowel resection, reporting sudden abdominal pain rated 9/10 and rigid abdomen. 2. Client B: Stable CHF patient requiring morning weights and assistance with toileting. 3. Client C: Client with COPD needing a scheduled nebulizer treatment and evaluation of lung sounds afterward. 4. Client D: Client with dementia who keeps attempting to get out of bed and needs continuous safety monitoring. Which task is MOST appropriate to delegate to the LPN/LVN?

Accepted Answer

Answer reason: A scheduled nebulizer is a predictable intervention with expected outcomes that fits within LPN/LVN scope on a med-surg unit. The postoperative client with sudden severe pain and rigid abdomen suggests an acute complication (e.g., peritonitis/anastomotic leak) requiring rapid RN assessment and escalation, so it should not be delegated. Client B’s weights/toileting and Client D’s sitter-type observation are appropriate for UAPs rather than using the LPN/LVN.

Question 4

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?

Accepted Answer

Answer reason: Delegation is based on client stability and task complexity: an LPN/LVN may perform routine, predictable procedures and equipment preparation that do not require RN-only assessment or clinical judgment. Preparing oxygen and suction at the bedside is a standard safety setup for a patient at risk of seizure-related airway compromise and can be completed using established protocols. In contrast, the admission assessment is an initial comprehensive assessment that requires RN judgment and cannot be delegated. Placing an object in the mouth (e.g., a tongue blade) is unsafe and not recommended for seizure care, so it should not be assigned as a preparatory intervention.

Question 5

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient’s care will be best to delegate to an LPN/LVN whom you are supervising?

Accepted Answer

Answer reason: LPN/LVNs can provide routine, standardized teaching and reinforce previously established education under RN supervision, which fits oral-hygiene instruction. In contrast, developing a discharge plan requires RN-level assessment, coordination, and interdisciplinary planning. Detailed seizure assessment/documentation (onset, characteristics, postictal findings) is an RN responsibility because it involves ongoing assessment and clinical judgment that guides provider notification and therapy. Medication administration may be within LPN scope in some settings, but with a new-onset seizure disorder it requires RN oversight for evaluation of response, safety, and potential toxicity monitoring, making it a less appropriate delegation choice than basic teaching.

Question 6

The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely delegate to a UAP?

Accepted Answer

Answer reason: A bed bath is a standard hygiene intervention that can be delegated, with the RN retaining responsibility to assess pain, skin integrity, neuro status, and safety needs related to the injuries. Monitoring I&O for a comatose child with salicylate poisoning requires close interpretation and trending for toxicity and fluid status, which is not appropriate for UAP. Checking an IV site/patency in a child with Kawasaki disease involves assessment for infiltration/phlebitis and evaluation of therapy, which requires licensed nursing assessment.

Question 7

After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Obtaining a full set of vital signs after a seizure is a predictable measurement task and can be reported to the nurse for interpretation. Neurologic checks require assessment skill and clinical judgment to detect postictal changes and are not appropriate for UAP. Documentation of the seizure and any decision to use restraints involve nursing responsibility, legal considerations, and ongoing evaluation, so they should be done by the nurse.

Question 8

You are preparing to admit a client with a seizure disorder. Which actions can you delegate to an LPN/LVN?

Accepted Answer

Answer reason: Preparing the environment to reduce injury risk for a seizure-prone client is a standard, routine intervention that can be carried out independently within LPN/LVN scope. The admission assessment is a comprehensive initial assessment that requires RN-level assessment and clinical decision-making. Keeping a tongue blade at the bedside is unsafe and not recommended because objects should not be inserted into the client’s mouth during a seizure, making that option an inappropriate “preparation” step.

Question 9

A nurse delegates a task to the unlicensed assistive personnel (UAP). The UAP states, "I can't do that." Which is the best initial response for the nurse to make?

Accepted Answer

Answer reason: Clarifying the reason first lets the nurse rapidly determine whether the task needs re-education, reprioritization, additional resources, or reassignment to maintain safe care. Immediately doing the task or escalating to management skips the immediate safety assessment and coaching opportunity. Repeating the request or appealing to teamwork can pressure the UAP without addressing competency or scope issues, increasing risk for errors.

Question 10

The nurse is floated from the emergency department to the neurological floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury?

Accepted Answer

Answer reason: Obtaining and documenting scheduled vital signs fits within UAP scope and provides data the nurse can interpret for trends and complications. Respiratory assessment requires clinical judgment and must be performed by the nurse, especially with spinal cord injury risk for hypoventilation. Nutritional monitoring with calorie counts and all client teaching are nursing responsibilities because they involve assessment, evaluation, and individualized planning.

Question 11

The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements the nurse would provide a UAP with the best directions about the assignment?

Accepted Answer

Answer reason: "The client is at risk for infection. Take the vital signs and report back to me if the temperature is above 100.5° F (38.1° C)." Delegation to UAP should include clear, specific, measurable tasks plus explicit parameters for when to report findings to the nurse. This direction assigns an appropriate UAP task (obtaining vital signs) and provides a concrete threshold that triggers communication, supporting timely nursing reassessment for possible infection. In contrast, broad instructions for multiple clients or planning care around therapies are less specific and can inappropriately shift clinical judgment and prioritization away from the nurse. Feeding assistance may be appropriate, but it lacks needed details (e.g., positioning, aspiration precautions) that ensure safe performance for a client with neurologic deficits.

Question 12

A newly admitted patient who is stable requires a bed bath. Health care team consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself/RN. To whom is it appropriate to assign complete care for?

Accepted Answer

Answer reason: A bed bath is a predictable task with minimal risk when the patient is stable and does not require nursing judgment or initial teaching. The RN retains responsibility for the overall assessment, planning, and evaluation, but does not need to personally perform basic hygiene in this context. The LPN/LVN is better utilized for tasks requiring clinical skill within scope (e.g., focused data collection, medication administration where permitted), while a student requires direct instructional oversight and is not the most efficient assignment for routine care.

Question 13

The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP?

Accepted Answer

Answer reason: Water temperature safety during bathing is a standard basic-care task and is especially relevant in diabetes because peripheral neuropathy can reduce heat sensation and increase burn risk. In contrast, discussing community resources and teaching foot inspection require patient education and care planning, which are RN responsibilities. Evaluating insulin-drawing technique is an assessment of a skill related to medication administration and safety and must be done by the RN.

Question 14

An 8-year-old child has stomatitis secondary to chemotherapy. Which task would be best to delegate to the UAP?

Accepted Answer

Answer reason: Assisting with meals and encouraging prescribed diet textures for comfort in stomatitis fits within basic care and comfort and does not require nursing judgment. The other options involve assessment or evaluation of symptoms/ability or require clinical judgment about mucosal severity and tolerance of interventions. An anesthetic mouthwash also carries medication-related safety considerations and evaluation of response, which should remain with licensed nursing staff.

Question 15

A nurse cares for a client with a prescription for irrigation of an indwelling urinary catheter. The nurse knows this task can be delegated to which personnel?

Accepted Answer

Answer reason: These factors make it appropriate for delegation to a licensed practical/vocational nurse (within facility policy), with the RN retaining accountability and providing direction as needed. Unlicensed assistive personnel may provide catheter/perineal care and measure output but should not perform sterile irrigation. A radiology technician and a urologist are not appropriate delegates for routine bedside nursing catheter irrigation tasks.

Question 16

A nurse is caring for four clients. Which of the following tasks can the nurse assign to an assistive personnel (AP)?

Accepted Answer

Answer reason: Delegation to AP/UAP is appropriate for tasks that are routine, have predictable outcomes, and do not require nursing assessment, sterile technique for invasive lines, or client education. During a cardiac arrest, initiating high-quality chest compressions is a standardized, protocol-driven skill that trained assistive personnel can perform while the nurse leads and coordinates the code response. By contrast, changing a sterile central line dressing requires sterile technique and line-related complication prevention, and teaching inhaler use is patient education that requires RN judgment. Checking gastrostomy residuals involves clinical interpretation and subsequent feeding decisions, which should remain with licensed staff per many facility policies.

Question 17

A client with a left sided ischemic stroke is admitted to the unit after a quick evaluation in the emergency department. The team consists of an RN, LPN and unlicensed assistive personnel (UAP). How should the RN delegate care?

Accepted Answer

Answer reason: Delegation follows the principle that the RN performs initial assessments and clinical judgments for an unstable/newly admitted client, while UAP are assigned noninvasive, non-assessment, supportive tasks. A new stroke admission has risk for rapid changes in airway protection, hemodynamics, and neurologic status, so the RN must obtain and interpret vital signs and overall condition. UAP may provide comfort measures and emotional support to family members because this does not require nursing assessment or decision-making. A common trap is assigning “assess vital signs” to UAP in a high-acuity admission; even if UAP can measure them, the initial assessment and interpretation should be done by the RN in this context.

Question 18

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action?

Accepted Answer

Answer reason: A request for postoperative analgesia is important but is not an immediate threat to airway, breathing, circulation, or safety, so it can be addressed promptly after the sterile task is completed. The UAP can be delegated a non-assessment communication task (acknowledge the request and reassure the client) to prevent delay and reduce anxiety. Delegating pain assessment or clinical evaluation (e.g., rating pain or interpreting vitals for medication decisions) is inappropriate because assessment and medication administration require licensed nursing judgment.

Question 19

A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Answer reason: Cleaning around the boot is a predictable task that can be performed with instruction and standard precautions while the nurse retains accountability for outcomes. In contrast, checking perfusion and evaluating sensation/movement are neurovascular assessments needed to detect impaired circulation or compression complications from the boot and must be done by a licensed nurse. Teaching the family signs of infection is patient/family education and also cannot be delegated to UAP.

Question 20

A client's potassium level is 6.7 mEq/L (6.7 mmol/L). Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising?

Accepted Answer

Answer reason: Severe hyperkalemia places the client at immediate risk for life-threatening dysrhythmias, so rapid screening for classic ECG changes is a priority and can be carried out by a supervised novice. Medication administration for hyperkalemia involves higher-risk clinical judgment and verification (e.g., appropriateness, contraindications, and monitoring), which should not be delegated to a first-year student. One option is clearly unsafe in this context because it would worsen the electrolyte abnormality. Delegating ECG pattern recognition for tall T waves allows prompt escalation if dangerous changes are noted while the RN retains responsibility for treatment decisions.

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