Prioritization and Delegation
The two skills behind most "who do you see first" and "which task can you delegate" questions.
Who first: the ladder
Work down the list. The first rung that separates the choices gives you your answer.
- Immediate threat to lifeAirway, then breathing, then circulation. A blocked airway beats low blood pressure.
- Unstable before stableA change from baseline, a new symptom, or a result outside the expected range comes before a client who is doing as expected.
- Acute before chronicA new problem beats a long-standing one the client is used to.
- Actual before potentialA problem happening now beats a risk that might happen.
- SafetyFalls, suicide risk, violence, infection, and medication errors.
- Maslow's hierarchyPhysical needs, then safety, then love and belonging, esteem, and self-actualization.
Common traps
- Expected findings aren't priorities. Some drainage after surgery, or pain at an incision, is usually expected. A sudden change is not.
- Assess before you act, unless the question shows a clear emergency that needs action now.
- Don't leave to get help when the client needs you there. Call for help and stay.
- Least restrictive first. Try other measures before restraints.
The five rights of delegation
From the 2019 National Guidelines for Nursing Delegation, published jointly by NCSBN and the ANA.
| Right | What it means |
|---|---|
| Right task | The activity is in the delegatee's job description or your facility's written policies and procedures. |
| Right circumstance | The client is stable. If the client's condition changes, the delegatee tells you and you reassess. |
| Right person | The delegatee has the skills and knowledge to do it. |
| Right directions and communication | You give specific instructions for this client and task. The delegatee can ask questions and must agree to accept the task. |
| Right supervision and evaluation | You monitor, follow up when it's done, evaluate the client's outcome, and are ready to step in. |
Never delegated
The 2019 guidelines are clear: clinical reasoning, nursing judgment, and critical decision making can't be delegated. On the NCLEX, that means the RN keeps:
- Assessment, including the initial assessment and assessing a change
- Care planning
- Teaching new information
- Evaluating outcomes
- Care of unstable or unpredictable clients
Delegation versus assignment: under the 2019 guidelines, assignment is giving routine care that is already within someone's scope or job. Delegation is letting someone perform a specific nursing activity that is beyond their usual role. Either way, you stay accountable for the care.
Who can do what
Scope is set by each state's nurse practice act and by facility policy, so the details vary. These are the patterns the NCLEX tests.
| Team member | Usually appropriate | Usually not |
|---|---|---|
| Assistive personnel (AP, UAP, CNA) | Vital signs on stable clients; bathing, feeding, toileting, and ambulating; intake and output; collecting specimens; turning and positioning | Assessment, teaching, medications, judging whether a finding is normal, care of unstable clients |
| LPN/VN | Care of stable clients with predictable outcomes; many medications, as allowed by state law and policy; reinforcing teaching the RN started; data collection | Initial assessment, care planning, new teaching, unstable clients, and tasks your state reserves for RNs |
| RN | Assessment; planning; teaching; evaluation; new admissions and unstable clients; clients receiving blood or high-alert drugs | Delegating any of the RN-only items above |
Test-taking tips
- Give the most stable, predictable client to the least-trained team member.
- If a task needs a judgment about whether something is normal, it stays with the RN.
- Teaching that reinforces what the RN already taught can go to the LPN/VN. New teaching stays with the RN.
- When a client becomes unstable, the RN takes over.
Sources
- NCSBN and American Nurses Association. National Guidelines for Nursing Delegation (2019).
- NCSBN. NCLEX-RN Test Plan: Management of Care.
- Your state's nurse practice act and board of nursing rules on scope of practice.
For exam study only. In clinical practice, follow your facility's policies, the prescriber's orders, and current references. Free to print and share for personal and classroom study; not for resale. NCLEX® is a registered trademark of NCSBN, which does not endorse NCLEXSim.
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