Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021)
Prepare for success with Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021), a comprehensive guide to your certification test.
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2019v1.0
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understanding of textbook content so you can be more
prepared for class, perform better on exams, and succeed
in your course.
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Prioritization,
Delegation,
and Assignment
Practice Exercises
for the NCLEX- RN® Examination
Delegation,
and Assignment
Practice Exercises
for the NCLEX- RN® Examination
Loading page 4...
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PPPPPP a tt i eee nn t -Linda A. LaCharity, PhD, RN
Formerly, Accelerated Program Director
Assistant Professor
College of Nursing
University of Cincinnati
Cincinnati, Ohio
Shirley M. Hosler, MSN, RN
Formerly, Nursing Instructor
School of Nursing
National American University
Albuquerque, New Mexico
Candice K. Kumagai, MSN, RN
Formerly, Clinical Instructor
School of Nursing
University of Texas at Austin
Austin, Texas
With an introduction by
Ruth Hansten, MBA, PhD, RN, FACHE
Principal Consultant and CEO
Hansten Healthcare
Santa Rosa, California
5th EDITION
Prioritization,
Delegation,
and Assignment
Practice Exercises
for the NCLEX-RN® Examination
Formerly, Accelerated Program Director
Assistant Professor
College of Nursing
University of Cincinnati
Cincinnati, Ohio
Shirley M. Hosler, MSN, RN
Formerly, Nursing Instructor
School of Nursing
National American University
Albuquerque, New Mexico
Candice K. Kumagai, MSN, RN
Formerly, Clinical Instructor
School of Nursing
University of Texas at Austin
Austin, Texas
With an introduction by
Ruth Hansten, MBA, PhD, RN, FACHE
Principal Consultant and CEO
Hansten Healthcare
Santa Rosa, California
5th EDITION
Prioritization,
Delegation,
and Assignment
Practice Exercises
for the NCLEX-RN® Examination
Loading page 6...
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICE EXERCISES
FOR THE NCLEX-RN® EXAMINATION, FIFTH EDITION ISBN: 978- 0-323-68316-6
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2019, 2014, 2011, and 2006.
Library of Congress Control Number: 2021936204
Executive Content Strategist: Lee Henderson
Senior Content Development Manager: Lisa Newton
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Julie Eddy
Senior Project Manager: Abigail Bradberry
Design Direction: Margaret Reid
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
3251 Riverport Lane
St. Louis, Missouri 63043
PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICE EXERCISES
FOR THE NCLEX-RN® EXAMINATION, FIFTH EDITION ISBN: 978- 0-323-68316-6
Copyright © 2022 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of rapid
advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors
or contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Previous editions copyrighted 2019, 2014, 2011, and 2006.
Library of Congress Control Number: 2021936204
Executive Content Strategist: Lee Henderson
Senior Content Development Manager: Lisa Newton
Senior Content Development Specialist: Tina Kaemmerer
Publishing Services Manager: Julie Eddy
Senior Project Manager: Abigail Bradberry
Design Direction: Margaret Reid
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Loading page 7...
v
Contributors and Reviewers
CONTRIBUTORS
Martha Barry, MS, RN, APN, CNM
Certified Nurse Midwife
OB Faculty Practice
Advocate Medical Group
Chicago, Illinois;
Adjunct Clinical Instructor
College of Nursing
University of Illinois at Chicago
Chicago, Illinois
Mary Tedesco-Schneck, PhD, RN, CPNP
Assistant Professor
School of Nursing
University of Maine
Orono, Maine
REVIEWERS
Amber Ballard, MSN, RN
Registered Nurse
Emergency Department
Sparrow Health System
Lansing, Michigan
Angela McConachie, DNP, MSN-FNP, RN
Director, BSN Program Accelerated Option
Associate Professor
Goldfarb School of Nursing at Barnes Jewish College
St. Louis, Missouri
Contributors and Reviewers
CONTRIBUTORS
Martha Barry, MS, RN, APN, CNM
Certified Nurse Midwife
OB Faculty Practice
Advocate Medical Group
Chicago, Illinois;
Adjunct Clinical Instructor
College of Nursing
University of Illinois at Chicago
Chicago, Illinois
Mary Tedesco-Schneck, PhD, RN, CPNP
Assistant Professor
School of Nursing
University of Maine
Orono, Maine
REVIEWERS
Amber Ballard, MSN, RN
Registered Nurse
Emergency Department
Sparrow Health System
Lansing, Michigan
Angela McConachie, DNP, MSN-FNP, RN
Director, BSN Program Accelerated Option
Associate Professor
Goldfarb School of Nursing at Barnes Jewish College
St. Louis, Missouri
Loading page 8...
vi
Preface
Prioritization, Delegation, and Assignment: Practice Exercises
for the NCLEX-RN® Examination has evolved since its
first edition from a medical-surgical nursing–focused
test preparation workbook to a resource that spans gen-
eral nursing knowledge while emphasizing management
of care to assist students in preparing for the NCLEX®
Examination. Our fifth edition includes many examples
of new question types that will be included in the forthcom-
ing Next-Generation NCLEX® Examination (NGN). A
second and equally important purpose of the book contin-
ues to be assisting students, novice nurses, and seasoned
nurses in applying concepts of prioritization, delegation,
and assignment to nursing practice in today’s patient care
settings.
TO FACULTY AND OTHER USERS
Patient care acuity continues to be higher than ever with
the essential added care of COVID-19 patients, while
staffing shortages remain very real. Nurses must use all
available patient care personnel and resources compe-
tently and efficiently and be familiar with variations in
state laws governing the practice of nursing, as well as
differences in scopes of practice and facility-specific job
descriptions. Nurses must also be aware of the different
skill and experience levels of the health care profession-
als with whom they work on a daily basis. Which nursing
actions can be assigned to an experienced versus a new
graduate RN or LPN/LVN? What forms of patient care
can the nurse delegate to assistive personnel (AP)? Who
should help the postoperative patient who has had a total
hip replacement get out of bed and ambulate to the bath-
room? Can the nurse ask APs such as nursing assistants
to check a patient’s oxygen saturation using pulse oxim-
etry or check a diabetic patient’s glucose level? What
reporting parameters should the nurse give to an LPN/
LVN who is monitoring a patient after cardiac catheter-
ization or to the AP checking patients’ vital signs? What
patient care interventions and actions should not be dele-
gated by the nurse? The answers to these and many other
questions should be much clearer after completion of the
exercises in this book.
Exercises in this book range from simple to complex
and use various patient care scenarios. The purpose of
the chapters and case studies is to encourage the student
or new graduate nurse to conceptualize using the skills
of prioritization, delegation, and assignment, as well as
supervision in many different settings. Our goal is to make
these concepts tangible to our readers.
The questions are written in NCLEX® Examination
formats, including new NGN styles to help faculty as
they teach student nurses how to prepare for licensure
examination. The chapters and case studies focus on real
and hypothetical patient care situations to challenge
nurses and nursing students to develop the skills nec-
essary to apply these concepts in practice. The exercises
are also useful to nurse educators as they discuss, teach,
and test their students and nurses for understanding and
application of these concepts in nursing programs, exam-
ination preparations, and facility orientations. Correct
answers, along with in-depth rationales, are provided
at the end of each chapter and case study to facilitate
the learning process, along with the focus/foci for each
item. The faculty exercise keys include QSEN (Quality
and Safety Education for Nurses) categories, concepts,
and cognitive levels for each question, as well as IPEC
(Interprofessional Education Collaborative) competen-
cies where appropriate.
TO STUDENTS
Prioritization, delegation, and assignment are essential
concepts and skills for nursing practice. Our students
and graduate nurses have repeatedly told us of their dif-
ficulties with the application of these principles when
taking program exit and licensure examinations. Nurse
managers have told us many times that novice nurses
and even some experienced nurses lack the expertise to
effectively and safely practice these skills in real-world
settings.
Although several excellent resources deal with these
issues, there is still a need for a book that incorporates
management of these care concepts into real-world
practice scenarios. Our goal in writing the fifth edition
of Prioritization, Delegation, and Assignment: Practice
Exercises for the NCLEX-RN® Examination is to provide
a resource that challenges nursing students, as well as
novice and experienced nurses, to develop the knowledge
and understanding necessary to effectively apply these
important nursing skills: examination preparation and
real-world practice. From the original focus on medical-
surgical nursing, subsequent editions have expanded to
Preface
Prioritization, Delegation, and Assignment: Practice Exercises
for the NCLEX-RN® Examination has evolved since its
first edition from a medical-surgical nursing–focused
test preparation workbook to a resource that spans gen-
eral nursing knowledge while emphasizing management
of care to assist students in preparing for the NCLEX®
Examination. Our fifth edition includes many examples
of new question types that will be included in the forthcom-
ing Next-Generation NCLEX® Examination (NGN). A
second and equally important purpose of the book contin-
ues to be assisting students, novice nurses, and seasoned
nurses in applying concepts of prioritization, delegation,
and assignment to nursing practice in today’s patient care
settings.
TO FACULTY AND OTHER USERS
Patient care acuity continues to be higher than ever with
the essential added care of COVID-19 patients, while
staffing shortages remain very real. Nurses must use all
available patient care personnel and resources compe-
tently and efficiently and be familiar with variations in
state laws governing the practice of nursing, as well as
differences in scopes of practice and facility-specific job
descriptions. Nurses must also be aware of the different
skill and experience levels of the health care profession-
als with whom they work on a daily basis. Which nursing
actions can be assigned to an experienced versus a new
graduate RN or LPN/LVN? What forms of patient care
can the nurse delegate to assistive personnel (AP)? Who
should help the postoperative patient who has had a total
hip replacement get out of bed and ambulate to the bath-
room? Can the nurse ask APs such as nursing assistants
to check a patient’s oxygen saturation using pulse oxim-
etry or check a diabetic patient’s glucose level? What
reporting parameters should the nurse give to an LPN/
LVN who is monitoring a patient after cardiac catheter-
ization or to the AP checking patients’ vital signs? What
patient care interventions and actions should not be dele-
gated by the nurse? The answers to these and many other
questions should be much clearer after completion of the
exercises in this book.
Exercises in this book range from simple to complex
and use various patient care scenarios. The purpose of
the chapters and case studies is to encourage the student
or new graduate nurse to conceptualize using the skills
of prioritization, delegation, and assignment, as well as
supervision in many different settings. Our goal is to make
these concepts tangible to our readers.
The questions are written in NCLEX® Examination
formats, including new NGN styles to help faculty as
they teach student nurses how to prepare for licensure
examination. The chapters and case studies focus on real
and hypothetical patient care situations to challenge
nurses and nursing students to develop the skills nec-
essary to apply these concepts in practice. The exercises
are also useful to nurse educators as they discuss, teach,
and test their students and nurses for understanding and
application of these concepts in nursing programs, exam-
ination preparations, and facility orientations. Correct
answers, along with in-depth rationales, are provided
at the end of each chapter and case study to facilitate
the learning process, along with the focus/foci for each
item. The faculty exercise keys include QSEN (Quality
and Safety Education for Nurses) categories, concepts,
and cognitive levels for each question, as well as IPEC
(Interprofessional Education Collaborative) competen-
cies where appropriate.
TO STUDENTS
Prioritization, delegation, and assignment are essential
concepts and skills for nursing practice. Our students
and graduate nurses have repeatedly told us of their dif-
ficulties with the application of these principles when
taking program exit and licensure examinations. Nurse
managers have told us many times that novice nurses
and even some experienced nurses lack the expertise to
effectively and safely practice these skills in real-world
settings.
Although several excellent resources deal with these
issues, there is still a need for a book that incorporates
management of these care concepts into real-world
practice scenarios. Our goal in writing the fifth edition
of Prioritization, Delegation, and Assignment: Practice
Exercises for the NCLEX-RN® Examination is to provide
a resource that challenges nursing students, as well as
novice and experienced nurses, to develop the knowledge
and understanding necessary to effectively apply these
important nursing skills: examination preparation and
real-world practice. From the original focus on medical-
surgical nursing, subsequent editions have expanded to
Loading page 9...
PREFACEvii
include pediatrics, labor and delivery, psychiatric nursing,
and long-term care as well as the role of the nurse in a vari-
ety of nonacute care settings. Additionally, we have made
changes that reflect the current focus on evidence-based
best practices, fundamentals of safe practice, and expan-
sion of diabetes care. For the fifth edition, we responded
to requests for more questions, especially about medica-
tions. New questions, including drug-related questions,
have been added to each chapter. We also added questions
specific to the needs of the lesbian, gay, bisexual, transgen-
der, queer, intersexual, and asexual (LGBTQIA) commu-
nity. New questions were added and revised throughout
the book to broaden comprehension of key concepts and
knowledge areas and to update current knowledge lev-
els. Our fifth edition expands on all of these topics and
incorporates examples of Next-Generation NCLEX®
Examination (NGN) question formats to prepare stu-
dents for the upcoming NCLEX® changes.
Each new copy of the book comes with a fully interac-
tive version of the book content, with scoring, on Evolve at
http://evolve.elsevier.com/LaCharity/prioritization. This
interactive version of the book helps to simulate the expe-
rience of taking the NCLEX® Examination. Students can
use this interactive option to create multiple different test
versions for practice and self-assessment.
ACKNOWLEDGMENTS
We would like to thank the many people whose support
and assistance made the creation of the fifth edition of
this book possible. Thanks to our families, colleagues, and
friends for listening, reading, encouraging, and making
sure we had the time to research, write, and review this
book. We truly appreciate the expertise of our two con-
tributing authors, Martha Barry (reproductive health) and
Mary Tedesco-Schneck (pediatrics), who each contributed
an excellent chapter and case study related to their areas
of expertise. Very special thanks to Ruth Hansten, whose
expertise in the area of clinical prioritization, delegation,
and assignment skills continues to keep us on track. Many
thanks to the faculty reviewers, whose expertise helped us
keep the scenarios accurate and realistic. Finally, we wish
to acknowledge our faculty, students, graduates, and read-
ers who have taken the time to keep in touch and let us
know about their needs for additional assistance in devel-
oping the skills to practice the arts of prioritization, del-
egation, and assignment.
Linda A. LaCharity
Candice K. Kumagai
Shirley M. Hosler
include pediatrics, labor and delivery, psychiatric nursing,
and long-term care as well as the role of the nurse in a vari-
ety of nonacute care settings. Additionally, we have made
changes that reflect the current focus on evidence-based
best practices, fundamentals of safe practice, and expan-
sion of diabetes care. For the fifth edition, we responded
to requests for more questions, especially about medica-
tions. New questions, including drug-related questions,
have been added to each chapter. We also added questions
specific to the needs of the lesbian, gay, bisexual, transgen-
der, queer, intersexual, and asexual (LGBTQIA) commu-
nity. New questions were added and revised throughout
the book to broaden comprehension of key concepts and
knowledge areas and to update current knowledge lev-
els. Our fifth edition expands on all of these topics and
incorporates examples of Next-Generation NCLEX®
Examination (NGN) question formats to prepare stu-
dents for the upcoming NCLEX® changes.
Each new copy of the book comes with a fully interac-
tive version of the book content, with scoring, on Evolve at
http://evolve.elsevier.com/LaCharity/prioritization. This
interactive version of the book helps to simulate the expe-
rience of taking the NCLEX® Examination. Students can
use this interactive option to create multiple different test
versions for practice and self-assessment.
ACKNOWLEDGMENTS
We would like to thank the many people whose support
and assistance made the creation of the fifth edition of
this book possible. Thanks to our families, colleagues, and
friends for listening, reading, encouraging, and making
sure we had the time to research, write, and review this
book. We truly appreciate the expertise of our two con-
tributing authors, Martha Barry (reproductive health) and
Mary Tedesco-Schneck (pediatrics), who each contributed
an excellent chapter and case study related to their areas
of expertise. Very special thanks to Ruth Hansten, whose
expertise in the area of clinical prioritization, delegation,
and assignment skills continues to keep us on track. Many
thanks to the faculty reviewers, whose expertise helped us
keep the scenarios accurate and realistic. Finally, we wish
to acknowledge our faculty, students, graduates, and read-
ers who have taken the time to keep in touch and let us
know about their needs for additional assistance in devel-
oping the skills to practice the arts of prioritization, del-
egation, and assignment.
Linda A. LaCharity
Candice K. Kumagai
Shirley M. Hosler
Loading page 10...
viii
Contents
PART 1 INTRODUCTION, 1
Guidelines for Prioritization, Delegation, and
Assignment Decisions, 1
PART 2 PRIORITIZATION, DELEGATION, AND
ASSIGNMENT IN COMMON HEALTH
SCENARIOS, 11
Chapter 1 Pain, 11
Chapter 2 Cancer, 25
Chapter 3 Immunologic Problems, 38
Chapter 4 Fluid, Electrolyte, and Acid-Base Balance
Problems, 47
Chapter 5 Safety and Infection Control, 54
Chapter 6 Respiratory Problems, 63
Chapter 7 Cardiovascular Problems, 73
Chapter 8 Hematologic Problems, 84
Chapter 9 Neurologic Problems, 92
Chapter 10 Visual and Auditory Problems, 102
Chapter 11 Musculoskeletal Problems, 112
Chapter 12 Gastrointestinal and Nutritional
Problems, 120
Chapter 13 Diabetes Mellitus, 133
Chapter 14 Other Endocrine Problems, 141
Chapter 15 Integumentary Problems, 149
Chapter 16 Renal and Urinary Problems, 157
Chapter 17 Reproductive Problems, 166
Chapter 18 Problems in Pregnancy and Childbearing, 176
Chapter 19 Pediatric Problems, 189
Chapter 20 Pharmacology, 201
Chapter 21 Emergencies and Disasters, 211
Chapter 22 Psychiatric/Mental Health Problems, 225
Chapter 23 NCLEX Next Generation, 237
PART 3 PRIORITIZATION, DELEGATION, AND
ASSIGNMENT IN COMPLEX HEALTH
SCENARIOS, 251
Case Study 1 Chest Pressure, Indigestion, and Nausea, 251
Case Study 2 Dyspnea and Shortness of Breath, 257
Case Study 3 Multiple Clients on a Medical-Surgical
Unit, 264
Case Study 4 Shortness of Breath, Edema, and
Decreased Urine Output, 271
Case Study 5 Diabetic Ketoacidosis, 276
Case Study 6 Home Health, 283
Case Study 7 Spinal Cord Injury, 289
Case Study 8 Multiple Patients With Adrenal Gland
Disorders, 294
Case Study 9 Multiple Clients With Gastrointestinal
Problems, 299
Case Study 10 Multiple Patients With Pain, 310
Case Study 11 Multiple Clients With Cancer, 320
Case Study 12 Gastrointestinal Bleeding, 330
Case Study 13 Head and Leg Trauma and Shock, 338
Case Study 14 Septic Shock, 345
Case Study 15 Heart Failure, 351
Case Study 16 Multiple Patients With Peripheral
Vascular Disease, 356
Case Study 17 Respiratory Difficulty After Surgery, 363
Case Study 18 Long-Term Care, 370
Case Study 19 Pediatric Clients in Clinic and Acute
Care Settings, 377
Case Study 20 Multiple Patients With Mental Health
Disorders, 386
Case Study 21 Childbearing, 397
Illustration Credits, 407
Contents
PART 1 INTRODUCTION, 1
Guidelines for Prioritization, Delegation, and
Assignment Decisions, 1
PART 2 PRIORITIZATION, DELEGATION, AND
ASSIGNMENT IN COMMON HEALTH
SCENARIOS, 11
Chapter 1 Pain, 11
Chapter 2 Cancer, 25
Chapter 3 Immunologic Problems, 38
Chapter 4 Fluid, Electrolyte, and Acid-Base Balance
Problems, 47
Chapter 5 Safety and Infection Control, 54
Chapter 6 Respiratory Problems, 63
Chapter 7 Cardiovascular Problems, 73
Chapter 8 Hematologic Problems, 84
Chapter 9 Neurologic Problems, 92
Chapter 10 Visual and Auditory Problems, 102
Chapter 11 Musculoskeletal Problems, 112
Chapter 12 Gastrointestinal and Nutritional
Problems, 120
Chapter 13 Diabetes Mellitus, 133
Chapter 14 Other Endocrine Problems, 141
Chapter 15 Integumentary Problems, 149
Chapter 16 Renal and Urinary Problems, 157
Chapter 17 Reproductive Problems, 166
Chapter 18 Problems in Pregnancy and Childbearing, 176
Chapter 19 Pediatric Problems, 189
Chapter 20 Pharmacology, 201
Chapter 21 Emergencies and Disasters, 211
Chapter 22 Psychiatric/Mental Health Problems, 225
Chapter 23 NCLEX Next Generation, 237
PART 3 PRIORITIZATION, DELEGATION, AND
ASSIGNMENT IN COMPLEX HEALTH
SCENARIOS, 251
Case Study 1 Chest Pressure, Indigestion, and Nausea, 251
Case Study 2 Dyspnea and Shortness of Breath, 257
Case Study 3 Multiple Clients on a Medical-Surgical
Unit, 264
Case Study 4 Shortness of Breath, Edema, and
Decreased Urine Output, 271
Case Study 5 Diabetic Ketoacidosis, 276
Case Study 6 Home Health, 283
Case Study 7 Spinal Cord Injury, 289
Case Study 8 Multiple Patients With Adrenal Gland
Disorders, 294
Case Study 9 Multiple Clients With Gastrointestinal
Problems, 299
Case Study 10 Multiple Patients With Pain, 310
Case Study 11 Multiple Clients With Cancer, 320
Case Study 12 Gastrointestinal Bleeding, 330
Case Study 13 Head and Leg Trauma and Shock, 338
Case Study 14 Septic Shock, 345
Case Study 15 Heart Failure, 351
Case Study 16 Multiple Patients With Peripheral
Vascular Disease, 356
Case Study 17 Respiratory Difficulty After Surgery, 363
Case Study 18 Long-Term Care, 370
Case Study 19 Pediatric Clients in Clinic and Acute
Care Settings, 377
Case Study 20 Multiple Patients With Mental Health
Disorders, 386
Case Study 21 Childbearing, 397
Illustration Credits, 407
Loading page 11...
1Copyright © 2022, Elsevier Inc. All rights reserved.
IntroductionPART 1
OUTCOMES FOCUS
Expert nurses have discovered that the most success-
ful method of approaching their practice is to maintain a
laser-like focus on the outcomes that the patients and their
families want to achieve. To attempt to prioritize, delegate,
or assign care without understanding the patient’s preferred
results is like trying to put together a jigsaw puzzle with-
out the top of the puzzle box that shows the puzzle picture.
Not only does the puzzle player pick up random pieces that
don’t fit well together, wasting time and increasing frustra-
tion, but also the process of puzzle assembly is fraught with
inefficiencies and wrong choices. In the same way, a nurse
who scurries haphazardly without a plan, unsure of what
could be the most important, life-saving task to be done
first or which person should do which tasks for this group of
patients, is not fulfilling his or her potential to be a channel
for healing.
Let’s visit a change-of-shift report in which a group
of nurses receives information about two patients whose
blood pressure is plummeting at the same rate. How would
one determine which nurse would be best to assign to care
for these patients, which patient needs to be seen first,
and which tasks could be delegated to assistive person-
nel (APs), if none of the nurses is aware of each patient’s
preferred outcomes? Patient A is a young mother who
has been receiving chemotherapy for breast cancer; she
has been admitted this shift because of dehydration from
uncontrolled emesis. She is expecting to regain her nor-
mally robust good health and watch her children gradu-
ate from college. Everyone on the health care team would
concur with her long-term goals. Patient Z is an elderly
gentleman, 92 years of age, whose wife recently died from
complications of repeated cerebrovascular events and
dementia. Yesterday while in the emergency department
(ED), he was given the diagnosis of acute myocardial
infarction and preexisting severe heart failure. He would
like to die and join his wife, has requested a “do not resus-
citate” order, and is awaiting transfer to a hospice. These
two patients share critical clinical data but require widely
different prioritization, delegation, and assignment. A
savvy charge RN would make the obvious decisions: to
assign the most skilled RN to the young mother and to
ask APs to function in a supportive role to the primary
care RN.
The elderly gentleman needs palliative care and would
be best cared for by an RN and care team with excellent
people skills. Even a novice nursing assistant could be del-
egated tasks to help keep Mr. Z and his family comfortable
and emotionally supported. The big picture on the puzzle
box for these two patients ranges from long-term “robust
good health” requiring immediate emergency assessment
and treatment to “a supported and comfortable death”
requiring timely palliative care, including supportive
emotional and physical care. Without envisioning these
patients’ pictures and knowing their preferred outcomes,
the RNs cannot prioritize, delegate, or assign appropriately.
There are many times in nursing practice, however, when
correct choices are not so apparent. Patients in all care set-
tings today are often complex, and many have preexisting
comorbidities that may stump the expert practitioners and
clinical specialists planning their care. Care delivery sys-
tems must flex on a moment’s notice as an AP arrives in
place of a scheduled LPN/LVN and agency, float, or travel-
ing nurses fill vacancies, while new patients, waiting to be
admitted, accumulate in the ED or wait to be transferred to
another setting. APs arrive with varying educational prepa-
ration and dissimilar levels of motivation and skill. Critical
thinking and complex clinical judgment are required from
the minute the shift begins until the nurse clocks out.
In this book, the authors have filled an educational need
for students and practicing nurses who wish to hone their
skills in prioritizing, assigning, and delegating. The scenar-
ios and patient problems presented in this workbook are
practical, challenging, and complex learning tools. Quality
and Safety Education for Nurses (QSEN) competencies
are incorporated into this chapter and throughout the ques-
tions to highlight patient- and family-centered care, quality
and safety improvement, and teamwork and collaboration
concepts and skills (QSEN Institute, 2019). Patient stories
will stimulate thought and discussion and help polish the
higher-order intellectual skills necessary to practice as a
successful, safe, and effective nurse. The Interprofessional
Collaboration Competency Community and Population
Oriented Domains from the Interprofessional Education
Collaborative (IPEC) are applied to the questions
in this book as appropriate (Interprofessional Education
Collaborative, 2016, https://ipecollaborative.org).
Domains include Interprofessional Teamwork and Team-
Based Practices, Interprofessional Teamwork Practices,
Guidelines for Prioritization, Delegation,
and Assignment Decisions
Ruth Hansten, PhD, MBA, BSN, RN, FACHE
IntroductionPART 1
OUTCOMES FOCUS
Expert nurses have discovered that the most success-
ful method of approaching their practice is to maintain a
laser-like focus on the outcomes that the patients and their
families want to achieve. To attempt to prioritize, delegate,
or assign care without understanding the patient’s preferred
results is like trying to put together a jigsaw puzzle with-
out the top of the puzzle box that shows the puzzle picture.
Not only does the puzzle player pick up random pieces that
don’t fit well together, wasting time and increasing frustra-
tion, but also the process of puzzle assembly is fraught with
inefficiencies and wrong choices. In the same way, a nurse
who scurries haphazardly without a plan, unsure of what
could be the most important, life-saving task to be done
first or which person should do which tasks for this group of
patients, is not fulfilling his or her potential to be a channel
for healing.
Let’s visit a change-of-shift report in which a group
of nurses receives information about two patients whose
blood pressure is plummeting at the same rate. How would
one determine which nurse would be best to assign to care
for these patients, which patient needs to be seen first,
and which tasks could be delegated to assistive person-
nel (APs), if none of the nurses is aware of each patient’s
preferred outcomes? Patient A is a young mother who
has been receiving chemotherapy for breast cancer; she
has been admitted this shift because of dehydration from
uncontrolled emesis. She is expecting to regain her nor-
mally robust good health and watch her children gradu-
ate from college. Everyone on the health care team would
concur with her long-term goals. Patient Z is an elderly
gentleman, 92 years of age, whose wife recently died from
complications of repeated cerebrovascular events and
dementia. Yesterday while in the emergency department
(ED), he was given the diagnosis of acute myocardial
infarction and preexisting severe heart failure. He would
like to die and join his wife, has requested a “do not resus-
citate” order, and is awaiting transfer to a hospice. These
two patients share critical clinical data but require widely
different prioritization, delegation, and assignment. A
savvy charge RN would make the obvious decisions: to
assign the most skilled RN to the young mother and to
ask APs to function in a supportive role to the primary
care RN.
The elderly gentleman needs palliative care and would
be best cared for by an RN and care team with excellent
people skills. Even a novice nursing assistant could be del-
egated tasks to help keep Mr. Z and his family comfortable
and emotionally supported. The big picture on the puzzle
box for these two patients ranges from long-term “robust
good health” requiring immediate emergency assessment
and treatment to “a supported and comfortable death”
requiring timely palliative care, including supportive
emotional and physical care. Without envisioning these
patients’ pictures and knowing their preferred outcomes,
the RNs cannot prioritize, delegate, or assign appropriately.
There are many times in nursing practice, however, when
correct choices are not so apparent. Patients in all care set-
tings today are often complex, and many have preexisting
comorbidities that may stump the expert practitioners and
clinical specialists planning their care. Care delivery sys-
tems must flex on a moment’s notice as an AP arrives in
place of a scheduled LPN/LVN and agency, float, or travel-
ing nurses fill vacancies, while new patients, waiting to be
admitted, accumulate in the ED or wait to be transferred to
another setting. APs arrive with varying educational prepa-
ration and dissimilar levels of motivation and skill. Critical
thinking and complex clinical judgment are required from
the minute the shift begins until the nurse clocks out.
In this book, the authors have filled an educational need
for students and practicing nurses who wish to hone their
skills in prioritizing, assigning, and delegating. The scenar-
ios and patient problems presented in this workbook are
practical, challenging, and complex learning tools. Quality
and Safety Education for Nurses (QSEN) competencies
are incorporated into this chapter and throughout the ques-
tions to highlight patient- and family-centered care, quality
and safety improvement, and teamwork and collaboration
concepts and skills (QSEN Institute, 2019). Patient stories
will stimulate thought and discussion and help polish the
higher-order intellectual skills necessary to practice as a
successful, safe, and effective nurse. The Interprofessional
Collaboration Competency Community and Population
Oriented Domains from the Interprofessional Education
Collaborative (IPEC) are applied to the questions
in this book as appropriate (Interprofessional Education
Collaborative, 2016, https://ipecollaborative.org).
Domains include Interprofessional Teamwork and Team-
Based Practices, Interprofessional Teamwork Practices,
Guidelines for Prioritization, Delegation,
and Assignment Decisions
Ruth Hansten, PhD, MBA, BSN, RN, FACHE
Loading page 12...
Guidelines for Prioritization, Delegation, and Assignment Decisions2Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
Roles and Responsibilities for Collaborative Practice, and
Values/Ethics for Interprofessional Practice. As reflected in
the IPEC sub-competencies, especially crucial for patient
outcomes is the role of the RN, armed with knowledge of
scopes of practice, successfully communicating with team
members to delegate, assign, and supervise (IPEC, 2016).
DEFINITION OF TERMS
The intellectual functions of prioritization, delegation,
and assignment engage the nurse in projecting into the
future from the present state. Thinking about what impact
might occur if competing decisions are chosen, weigh-
ing options, and making split-second decisions, given the
available data, is not an easy process. Unless resources in
terms of staffing, budget, time, or supplies are unlimited,
nurses must relentlessly focus on choosing which issues or
concerns must take precedence.
Prioritization
Prioritization is defined as “ranking problems in order of
importance” or “deciding which needs or problems require
immediate action and which ones could tolerate a delay
in action until a later time because they are not urgent”
(Silvestri, 2018). Prioritization in a clinical setting is a pro-
cess that involves clearly envisioning patient outcomes but
also includes predicting possible problems if another task
is performed first. One also must weigh potential future
events if the task is not completed, the time it would take
to accomplish it, and the relationship of the tasks and
outcomes. New nurses often struggle with prioritization
because they have not yet worked with typical patient
progressions through care pathways and have not expe-
rienced the complications that may emerge in association
with a particular clinical condition. In short, knowing the
patient’s purpose for care, current clinical picture, and
picture of the outcome or result is necessary to be able
to plan priorities. The part played by each team member is
designated as the RN assigns or delegates. The “four Ps”—
purpose, picture, plan, and part—become a guidepost for
appropriately navigating these processes (Hansten, 2008a,
2011, 2014b; Hansten and Jackson, 2009). The four Ps will
be referred to throughout this introduction because these
concepts are the framework on which RNs base decisions
about supporting patients and families toward their pre-
ferred outcomes, whether RNs provide the care themselves
or work closely with assistive team members.
Prioritization includes evaluating and weighing each
competing task or process using the following criteria
(Hansten and Jackson, 2009, pp. 194–196):
• Is it life threatening or potentially life threatening
if the task is not done? Would another patient be
endangered if this task is done now or the task is left
for later?
• Is this task or process essential to patient or staff
safety?
• Is this task or process essential to the medical or
nursing plan of care?
In each case, an understanding of the overall patient
goals and the context and setting is essential.
1. In her book on critical thinking and clinical judg-
ment, Rosalinda Alfaro-Lefevre (2017) suggests
three levels of priority setting: The first level is air-
way, breathing, cardiac status and circulation, and vi-
tal signs and lab values that could be life threatening
(“ABCs plus V and L”).
2. The second level is immediately subsequent to the
first level and includes concerns such as mental sta-
tus changes, untreated medical issues, acute pain,
acute elimination problems, and imminent risks.
3. The third level comprises health problems other than
those at the first two levels, such as more long-term
issues in health education, rest, coping, and so on
(p. 171).
Maslow’s hierarchy of needs can be used to prioritize
from the most crucial survival needs to needs related to
safety and security, affiliation (love, relationships), self-
esteem, and self-actualization (Alfaro-Lefevre, 2017,
p. 170).
Delegation and Assignment
The official definitions of assignment have been altered
through ongoing dialogue among nursing leaders in various
states and nursing organizations, and terminology distinc-
tions such as observation versus assessment, critical thinking
versus clinical reasoning, and delegation versus assignment
continue to be discussed as nursing leaders attempt to
describe complex thinking processes that occur in various
levels of nursing practice. Assignment has been defined
as “the distribution of work that each staff member is
responsible for during a given work period” (American
Nurses Association [ANA], Duffy & McCoy, 2014, p. 22).
In 2016, the National Council of State Boards of Nursing
(NCSBN) published the results of two expert panels to
clarify that assignment includes “the routine care, activi-
ties, and procedures that are within the authorized scope
of practice of the RN or LPN/LVN or part of the routine
functions of the UAP (Unlicensed Assistive Personnel)”
(NCSBN, 2016b, pp. 6–7), and this definition was adopted
by the ANA in 2019 in a joint statement with the NCSBN
with the addition of the acronym AP (assistive personnel)
(ANA & NCSBN 2019 National Guidelines for Nursing
Delegation, p. 2). Delegation was defined traditionally as
“transferring to a competent individual the authority to
perform a selected nursing task in a selected situation”
(NCSBN, 1995), and similar definitions are used by some
nurse practice statutes or regulations. Both the ANA and
the NCSBN describe delegation as “allowing a delegate
Introduction
PART 1
Roles and Responsibilities for Collaborative Practice, and
Values/Ethics for Interprofessional Practice. As reflected in
the IPEC sub-competencies, especially crucial for patient
outcomes is the role of the RN, armed with knowledge of
scopes of practice, successfully communicating with team
members to delegate, assign, and supervise (IPEC, 2016).
DEFINITION OF TERMS
The intellectual functions of prioritization, delegation,
and assignment engage the nurse in projecting into the
future from the present state. Thinking about what impact
might occur if competing decisions are chosen, weigh-
ing options, and making split-second decisions, given the
available data, is not an easy process. Unless resources in
terms of staffing, budget, time, or supplies are unlimited,
nurses must relentlessly focus on choosing which issues or
concerns must take precedence.
Prioritization
Prioritization is defined as “ranking problems in order of
importance” or “deciding which needs or problems require
immediate action and which ones could tolerate a delay
in action until a later time because they are not urgent”
(Silvestri, 2018). Prioritization in a clinical setting is a pro-
cess that involves clearly envisioning patient outcomes but
also includes predicting possible problems if another task
is performed first. One also must weigh potential future
events if the task is not completed, the time it would take
to accomplish it, and the relationship of the tasks and
outcomes. New nurses often struggle with prioritization
because they have not yet worked with typical patient
progressions through care pathways and have not expe-
rienced the complications that may emerge in association
with a particular clinical condition. In short, knowing the
patient’s purpose for care, current clinical picture, and
picture of the outcome or result is necessary to be able
to plan priorities. The part played by each team member is
designated as the RN assigns or delegates. The “four Ps”—
purpose, picture, plan, and part—become a guidepost for
appropriately navigating these processes (Hansten, 2008a,
2011, 2014b; Hansten and Jackson, 2009). The four Ps will
be referred to throughout this introduction because these
concepts are the framework on which RNs base decisions
about supporting patients and families toward their pre-
ferred outcomes, whether RNs provide the care themselves
or work closely with assistive team members.
Prioritization includes evaluating and weighing each
competing task or process using the following criteria
(Hansten and Jackson, 2009, pp. 194–196):
• Is it life threatening or potentially life threatening
if the task is not done? Would another patient be
endangered if this task is done now or the task is left
for later?
• Is this task or process essential to patient or staff
safety?
• Is this task or process essential to the medical or
nursing plan of care?
In each case, an understanding of the overall patient
goals and the context and setting is essential.
1. In her book on critical thinking and clinical judg-
ment, Rosalinda Alfaro-Lefevre (2017) suggests
three levels of priority setting: The first level is air-
way, breathing, cardiac status and circulation, and vi-
tal signs and lab values that could be life threatening
(“ABCs plus V and L”).
2. The second level is immediately subsequent to the
first level and includes concerns such as mental sta-
tus changes, untreated medical issues, acute pain,
acute elimination problems, and imminent risks.
3. The third level comprises health problems other than
those at the first two levels, such as more long-term
issues in health education, rest, coping, and so on
(p. 171).
Maslow’s hierarchy of needs can be used to prioritize
from the most crucial survival needs to needs related to
safety and security, affiliation (love, relationships), self-
esteem, and self-actualization (Alfaro-Lefevre, 2017,
p. 170).
Delegation and Assignment
The official definitions of assignment have been altered
through ongoing dialogue among nursing leaders in various
states and nursing organizations, and terminology distinc-
tions such as observation versus assessment, critical thinking
versus clinical reasoning, and delegation versus assignment
continue to be discussed as nursing leaders attempt to
describe complex thinking processes that occur in various
levels of nursing practice. Assignment has been defined
as “the distribution of work that each staff member is
responsible for during a given work period” (American
Nurses Association [ANA], Duffy & McCoy, 2014, p. 22).
In 2016, the National Council of State Boards of Nursing
(NCSBN) published the results of two expert panels to
clarify that assignment includes “the routine care, activi-
ties, and procedures that are within the authorized scope
of practice of the RN or LPN/LVN or part of the routine
functions of the UAP (Unlicensed Assistive Personnel)”
(NCSBN, 2016b, pp. 6–7), and this definition was adopted
by the ANA in 2019 in a joint statement with the NCSBN
with the addition of the acronym AP (assistive personnel)
(ANA & NCSBN 2019 National Guidelines for Nursing
Delegation, p. 2). Delegation was defined traditionally as
“transferring to a competent individual the authority to
perform a selected nursing task in a selected situation”
(NCSBN, 1995), and similar definitions are used by some
nurse practice statutes or regulations. Both the ANA and
the NCSBN describe delegation as “allowing a delegate
Loading page 13...
Guidelines for Prioritization, Delegation, and Assignment Decisions 3Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
to perform a specific nursing activity, skill, or procedure
that is beyond the delegatee’s traditional role and is not
routinely performed” (ANA & NCSBN 2019, p. 2).
Nevertheless, the delegatee must be competent to perform
that delegated task as a result of extra training and skill
validation. The ANA specifies that delegation is a transfer
of responsibility or assignment of an activity while retain-
ing the accountability for the outcome and the overall care
(ANA, 2014; Duffy & McCoy, p. 22).
Some state boards have argued that assignment is
the process of directing a nursing assistant to perform a
task such as taking blood pressure, a task on which nurs-
ing assistants are tested in the certified nursing assistant
examination and that would commonly appear in a job
description. Others contend that all nursing care is part
of the RN scope of practice and therefore that such a task
would be delegated rather than assigned. Other nursing
leaders argue that only when a task is clearly within the
RN’s scope of practice, and not included in the role of an
AP, is the task delegated. Regardless of whether the alloca-
tion of tasks to be done is based on assignment or delega-
tion, in this book, assignment means the “work plan” and
connotes the nursing leadership role of human resources
deployment in a manner that most wisely promotes the
patient’s and family’s preferred outcome.
Although states vary in their definitions of the functions
and processes in professional nursing practice, including
that of delegation, the authors use the NCSBN and ANA’s
definition, including the caveat present in the sentence
following the definition: delegation is “transferring to a
competent individual the authority to perform a selected
nursing task in a selected situation. The nurse retains the
accountability for the delegation” (NCSBN, 1995, p. 2).
Assignments are work plans that would include tasks the
delegatee would have been trained to do in their basic
educational program; the nurse “assigns” or distributes
work and also “delegates” nursing care as she or he works
through others. In advanced personnel roles, such as when
certified medication aides are taught to administer medi-
cations or when certified medical assistants give injections,
the NCSBN (2016) asserts that because of the extensive
responsibilities involved, the employers and nurse lead-
ers in the settings where certified medication aides are
employed, such as ambulatory care, skilled nursing homes,
or home health settings, should regard these procedures
as being delegated and AP competencies must be assured
(NCSBN, 2016b, p. 7). ANA designates these certified but
unlicensed individuals as APs rather than UAPs (ANA &
NSCBN 2019). The differences in definitions among states
and the differentiation between delegation and assignment
are perplexing to nurses. Because both processes are simi-
lar in terms of the actions and thinking processes of the
RN from a practical standpoint, this workbook will merge
the definitions to mean that RNs delegate or assign tasks
when they are allocating work to competent trained indi-
viduals, keeping within each state’s scope of practice, rules,
and organizational job descriptions. Whether assigning or
delegating, the RN is accountable for the total nursing care
of the patient and for making choices about which compe-
tent person is permitted to perform each task successfully.
Whether the RN is delegating or assigning, depending on
their state regulations, the expert RN will not ask a team
member to perform a task that is beyond the RN’s own
scope of practice or job description, or a task outside of
any person’s competencies. In all cases the choices made to
allocate work must prioritize which allocation of work is
optimal for the patient’s safe and effective care (Hansten
2020, in Kelly Vana and Tazbir).
Delegation or Assignment and Supervision
The definitions of delegation and assignment offer some
important clues to nursing practice and to the composition
of an effective patient care team. The person who makes
the decision to ask a person to do something (a task or
assignment) must know that the chosen person is com-
petent to perform that task. The RN selects the particular
task, given his or her knowledge of the individual patient’s
condition and that particular circumstance. Because of the
nurse’s preparation, knowledge, and skill, the RN chooses
to render judgments of this kind and stands by the choices
made. According to licensure and statute, the nurse is obli-
gated to delegate or assign based on the unique situation,
patients, and personnel involved and to provide ongoing
follow-up.
Supervision
Whenever nurses delegate or assign, they must also super-
vise. Supervision is defined by the NCSBN as “the pro-
vision of guidance and direction, oversight, evaluation,
and follow up by the licensed nurse for accomplishment
of a nursing task delegated to nursing assistive person-
nel” and by the ANA as “the active process of directing,
guiding, and influencing the outcome of an individual’s
performance of a task” (ANA, 2014; Duffy & McCoy,
p. 23). Each state may use a different explanation, such
as Washington State’s supervision definition: “initial
direction… periodic inspection… and the authority to
require corrective action” (Washington Administrative
Code 246-840-010 Definitions, https://app.leg.wa.gov/w
ac/default.aspx?cite=246-840-010). The act of delegating
or assigning is just the beginning of the RN’s responsibil-
ity. As for the accountability of the delegatees (or people
given the task duty), these individuals are accountable
for a) accepting only the responsibilities that they know
they are competent to complete, b) maintaining their skill
proficiency, c) pursuing ongoing communication with the
team’s leader, and d) completing and documenting the task
appropriately (ANA and NCSBN, 2019, p. 9). For exam-
ple, nursing assistants who are unprepared or untrained to
complete a task should say as much when asked and can
then decline to perform that particular duty. In such a situ-
ation, the RN would determine whether to allocate time
Introduction
PART 1
to perform a specific nursing activity, skill, or procedure
that is beyond the delegatee’s traditional role and is not
routinely performed” (ANA & NCSBN 2019, p. 2).
Nevertheless, the delegatee must be competent to perform
that delegated task as a result of extra training and skill
validation. The ANA specifies that delegation is a transfer
of responsibility or assignment of an activity while retain-
ing the accountability for the outcome and the overall care
(ANA, 2014; Duffy & McCoy, p. 22).
Some state boards have argued that assignment is
the process of directing a nursing assistant to perform a
task such as taking blood pressure, a task on which nurs-
ing assistants are tested in the certified nursing assistant
examination and that would commonly appear in a job
description. Others contend that all nursing care is part
of the RN scope of practice and therefore that such a task
would be delegated rather than assigned. Other nursing
leaders argue that only when a task is clearly within the
RN’s scope of practice, and not included in the role of an
AP, is the task delegated. Regardless of whether the alloca-
tion of tasks to be done is based on assignment or delega-
tion, in this book, assignment means the “work plan” and
connotes the nursing leadership role of human resources
deployment in a manner that most wisely promotes the
patient’s and family’s preferred outcome.
Although states vary in their definitions of the functions
and processes in professional nursing practice, including
that of delegation, the authors use the NCSBN and ANA’s
definition, including the caveat present in the sentence
following the definition: delegation is “transferring to a
competent individual the authority to perform a selected
nursing task in a selected situation. The nurse retains the
accountability for the delegation” (NCSBN, 1995, p. 2).
Assignments are work plans that would include tasks the
delegatee would have been trained to do in their basic
educational program; the nurse “assigns” or distributes
work and also “delegates” nursing care as she or he works
through others. In advanced personnel roles, such as when
certified medication aides are taught to administer medi-
cations or when certified medical assistants give injections,
the NCSBN (2016) asserts that because of the extensive
responsibilities involved, the employers and nurse lead-
ers in the settings where certified medication aides are
employed, such as ambulatory care, skilled nursing homes,
or home health settings, should regard these procedures
as being delegated and AP competencies must be assured
(NCSBN, 2016b, p. 7). ANA designates these certified but
unlicensed individuals as APs rather than UAPs (ANA &
NSCBN 2019). The differences in definitions among states
and the differentiation between delegation and assignment
are perplexing to nurses. Because both processes are simi-
lar in terms of the actions and thinking processes of the
RN from a practical standpoint, this workbook will merge
the definitions to mean that RNs delegate or assign tasks
when they are allocating work to competent trained indi-
viduals, keeping within each state’s scope of practice, rules,
and organizational job descriptions. Whether assigning or
delegating, the RN is accountable for the total nursing care
of the patient and for making choices about which compe-
tent person is permitted to perform each task successfully.
Whether the RN is delegating or assigning, depending on
their state regulations, the expert RN will not ask a team
member to perform a task that is beyond the RN’s own
scope of practice or job description, or a task outside of
any person’s competencies. In all cases the choices made to
allocate work must prioritize which allocation of work is
optimal for the patient’s safe and effective care (Hansten
2020, in Kelly Vana and Tazbir).
Delegation or Assignment and Supervision
The definitions of delegation and assignment offer some
important clues to nursing practice and to the composition
of an effective patient care team. The person who makes
the decision to ask a person to do something (a task or
assignment) must know that the chosen person is com-
petent to perform that task. The RN selects the particular
task, given his or her knowledge of the individual patient’s
condition and that particular circumstance. Because of the
nurse’s preparation, knowledge, and skill, the RN chooses
to render judgments of this kind and stands by the choices
made. According to licensure and statute, the nurse is obli-
gated to delegate or assign based on the unique situation,
patients, and personnel involved and to provide ongoing
follow-up.
Supervision
Whenever nurses delegate or assign, they must also super-
vise. Supervision is defined by the NCSBN as “the pro-
vision of guidance and direction, oversight, evaluation,
and follow up by the licensed nurse for accomplishment
of a nursing task delegated to nursing assistive person-
nel” and by the ANA as “the active process of directing,
guiding, and influencing the outcome of an individual’s
performance of a task” (ANA, 2014; Duffy & McCoy,
p. 23). Each state may use a different explanation, such
as Washington State’s supervision definition: “initial
direction… periodic inspection… and the authority to
require corrective action” (Washington Administrative
Code 246-840-010 Definitions, https://app.leg.wa.gov/w
ac/default.aspx?cite=246-840-010). The act of delegating
or assigning is just the beginning of the RN’s responsibil-
ity. As for the accountability of the delegatees (or people
given the task duty), these individuals are accountable
for a) accepting only the responsibilities that they know
they are competent to complete, b) maintaining their skill
proficiency, c) pursuing ongoing communication with the
team’s leader, and d) completing and documenting the task
appropriately (ANA and NCSBN, 2019, p. 9). For exam-
ple, nursing assistants who are unprepared or untrained to
complete a task should say as much when asked and can
then decline to perform that particular duty. In such a situ-
ation, the RN would determine whether to allocate time
Loading page 14...
Guidelines for Prioritization, Delegation, and Assignment Decisions4Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
to train the AP and review the skill as it is learned, to del-
egate the task to another competent person, to do it herself
or himself, or to make arrangements for later skill train-
ing. The RN’s job continues throughout the performance
and results of task completion, evaluation of the care, and
ongoing feedback to the delegatees.
Scope of Practice for RNs, LPNs/LVNs, and APs
Heretofore this text has discussed national recommendations
for definitions. National trends suggest that nursing is mov-
ing toward standardized licensure through mutual recogni-
tion compacts and multistate licensure, and as of April 2019,
31 states had adopted the nurse license compact allowing
a nurse in a member state to possess one state’s license and
practice in another member state, with several states pend-
ing (NCSBN, 2019a). Standardized and multistate licensure
supports electronic practice and promotes improved practice
flexibility. Each RN must know his or her own state’s regu-
lations, however. Definitions still differ from state to state,
as do regulations about the tasks that nursing assistants or
other APs are allowed to perform in various settings.
For example, APs are delegated tasks for which they
have been trained and that they are currently competent
to perform for stable patients in uncomplicated circum-
stances; these are routine, simple, repetitive, common
activities not requiring nursing judgment, such as activi-
ties of daily living, hygiene, feeding, and ambulation. Some
states have generated statutes and/or rules that list specific
tasks that can or cannot be delegated. Nevertheless, trends
indicate that more tasks will be delegated as research sup-
ports such delegation through evidence of positive out-
comes. Acute care hospital nursing assistants have not
historically been authorized to administer medications.
In some states, specially certified medication assistants
administer oral medications in the community (group
homes) and in some long-term care facilities, although
there is substantial variability in state-designated certi-
fied nursing assistant (CNA) duties (McMullen et al.,
2015). More states are employing specially trained nurs-
ing assistants as CMAs (certified medication assistants)
or MA-Cs (medication assistants-certified) to administer
routine, nonparenteral medications in long-term care or
community settings with training as recommended by the
NCSBN’s Model Curriculum (NCSBN, 2016, p. 7). For
over a decade, Washington state has altered the statute and
related administrative codes to allow trained nursing assis-
tants in home or community-based settings, such as board-
ing homes and adult family homes, to administer insulin
if the patient is an appropriate candidate (in a stable and
predictable condition) and if the nursing assistant has been
appropriately trained and supervised for the first 4 weeks
of performing this task (Revised Code of Washington,
2012). Nationally, consistency of state regulation of AP
medication administration in residential care and adult
day-care settings has been stated to be inadequate to
ensure RN oversight of APs (Carder & O’Keeffe, 2016).
This research finding should serve as a caution for all prac-
ticing in these settings. Other studies of nursing homes
and assisted living facilities show evidence of role confu-
sion among RNs, LPN/LVNs, and APs (Mueller et al.,
2018; Dyck & Novotny, 2018). In ambulatory care set-
tings, medical assistants (MAs) are being used extensively,
supervised by RNs, LPNs (depending on the state), physi-
cians, or other providers, and nurses are cautioned to know
both the state nursing and medical regulations. In some
cases (Maryland, for example), a physician could delegate
peripheral IV initiation to an MA with on-site supervision,
but in some states an LPN is prohibited from this same
task (Maningo and Panthofer, 2018, p.2).
In all states, nursing judgment is used to delegate tasks
that fall within, but never exceed, the nurse’s legal scope
of practice, and an RN always makes decisions based on
the individual patient situation. An RN may decide not
to delegate the task of feeding a patient if the patient is
dysphagic and the nursing assistant is not familiar with
feeding techniques. A “Lessons Learned from Litigation”
article in the American Journal of Nursing in May 2014
describes the hazards of improper RN assignment, del-
egation, and supervision of patient feeding, resulting in a
patient’s death and licensure sanctions (Brous, 2014).
The scope of practice for LPNs or LVNs also differs
from state to state and is continually evolving. For exam-
ple, in Texas, LPNs are prohibited from delegating nurs-
ing tasks; only RNs are allowed to delegate (Texas Board
of Nursing, 2019, http://www.bon.texas.gov/faq_delegati
on.asp#t6), whereas in Washington state an LPN could
delegate to nursing assistants in some settings (listed as
hospitals, nursing homes, clinics, and ambulatory surgery
centers) (Washington Nursing Care Quality Assurance
Commission 2019, https://www.doh.wa.gov/Portals/1/
Documents/6000/NCAO13.pdf ). Although practicing
nurses know that LPNs often review a patient’s condition
and perform data-gathering tasks such as observation and
auscultation, RNs remain accountable for the total assess-
ment of a patient, including the synthesis and analysis of
reported and reviewed information to lead care planning
based on the nursing diagnosis. In their periodic review of
actual practice by LPNs, the NCSBN found that assign-
ing client care or related tasks to other LPNs or APs was
ranked sixth in frequency, with monitoring activities of
APs ranked seventh (NCSBN, 2019, p. 156). IV therapy
and administration of blood products or total parenteral
nutrition by LPNs/LVNs also vary widely. Even in states
where regulations allow LPNs/LVNs to administer blood
products, a given health care organization’s policies or job
descriptions may limit practice and place additional safe-
guards because of the life-threatening risk involved in the
administration of blood products and other medications.
The RN must review the agency’s job descriptions as well
as the state regulations because either is changeable.
LPN/LVN practice continues to evolve, and in any
state, tasks to support the assessment, planning, interven-
tion, and evaluation phases of the nursing process can be
Introduction
PART 1
to train the AP and review the skill as it is learned, to del-
egate the task to another competent person, to do it herself
or himself, or to make arrangements for later skill train-
ing. The RN’s job continues throughout the performance
and results of task completion, evaluation of the care, and
ongoing feedback to the delegatees.
Scope of Practice for RNs, LPNs/LVNs, and APs
Heretofore this text has discussed national recommendations
for definitions. National trends suggest that nursing is mov-
ing toward standardized licensure through mutual recogni-
tion compacts and multistate licensure, and as of April 2019,
31 states had adopted the nurse license compact allowing
a nurse in a member state to possess one state’s license and
practice in another member state, with several states pend-
ing (NCSBN, 2019a). Standardized and multistate licensure
supports electronic practice and promotes improved practice
flexibility. Each RN must know his or her own state’s regu-
lations, however. Definitions still differ from state to state,
as do regulations about the tasks that nursing assistants or
other APs are allowed to perform in various settings.
For example, APs are delegated tasks for which they
have been trained and that they are currently competent
to perform for stable patients in uncomplicated circum-
stances; these are routine, simple, repetitive, common
activities not requiring nursing judgment, such as activi-
ties of daily living, hygiene, feeding, and ambulation. Some
states have generated statutes and/or rules that list specific
tasks that can or cannot be delegated. Nevertheless, trends
indicate that more tasks will be delegated as research sup-
ports such delegation through evidence of positive out-
comes. Acute care hospital nursing assistants have not
historically been authorized to administer medications.
In some states, specially certified medication assistants
administer oral medications in the community (group
homes) and in some long-term care facilities, although
there is substantial variability in state-designated certi-
fied nursing assistant (CNA) duties (McMullen et al.,
2015). More states are employing specially trained nurs-
ing assistants as CMAs (certified medication assistants)
or MA-Cs (medication assistants-certified) to administer
routine, nonparenteral medications in long-term care or
community settings with training as recommended by the
NCSBN’s Model Curriculum (NCSBN, 2016, p. 7). For
over a decade, Washington state has altered the statute and
related administrative codes to allow trained nursing assis-
tants in home or community-based settings, such as board-
ing homes and adult family homes, to administer insulin
if the patient is an appropriate candidate (in a stable and
predictable condition) and if the nursing assistant has been
appropriately trained and supervised for the first 4 weeks
of performing this task (Revised Code of Washington,
2012). Nationally, consistency of state regulation of AP
medication administration in residential care and adult
day-care settings has been stated to be inadequate to
ensure RN oversight of APs (Carder & O’Keeffe, 2016).
This research finding should serve as a caution for all prac-
ticing in these settings. Other studies of nursing homes
and assisted living facilities show evidence of role confu-
sion among RNs, LPN/LVNs, and APs (Mueller et al.,
2018; Dyck & Novotny, 2018). In ambulatory care set-
tings, medical assistants (MAs) are being used extensively,
supervised by RNs, LPNs (depending on the state), physi-
cians, or other providers, and nurses are cautioned to know
both the state nursing and medical regulations. In some
cases (Maryland, for example), a physician could delegate
peripheral IV initiation to an MA with on-site supervision,
but in some states an LPN is prohibited from this same
task (Maningo and Panthofer, 2018, p.2).
In all states, nursing judgment is used to delegate tasks
that fall within, but never exceed, the nurse’s legal scope
of practice, and an RN always makes decisions based on
the individual patient situation. An RN may decide not
to delegate the task of feeding a patient if the patient is
dysphagic and the nursing assistant is not familiar with
feeding techniques. A “Lessons Learned from Litigation”
article in the American Journal of Nursing in May 2014
describes the hazards of improper RN assignment, del-
egation, and supervision of patient feeding, resulting in a
patient’s death and licensure sanctions (Brous, 2014).
The scope of practice for LPNs or LVNs also differs
from state to state and is continually evolving. For exam-
ple, in Texas, LPNs are prohibited from delegating nurs-
ing tasks; only RNs are allowed to delegate (Texas Board
of Nursing, 2019, http://www.bon.texas.gov/faq_delegati
on.asp#t6), whereas in Washington state an LPN could
delegate to nursing assistants in some settings (listed as
hospitals, nursing homes, clinics, and ambulatory surgery
centers) (Washington Nursing Care Quality Assurance
Commission 2019, https://www.doh.wa.gov/Portals/1/
Documents/6000/NCAO13.pdf ). Although practicing
nurses know that LPNs often review a patient’s condition
and perform data-gathering tasks such as observation and
auscultation, RNs remain accountable for the total assess-
ment of a patient, including the synthesis and analysis of
reported and reviewed information to lead care planning
based on the nursing diagnosis. In their periodic review of
actual practice by LPNs, the NCSBN found that assign-
ing client care or related tasks to other LPNs or APs was
ranked sixth in frequency, with monitoring activities of
APs ranked seventh (NCSBN, 2019, p. 156). IV therapy
and administration of blood products or total parenteral
nutrition by LPNs/LVNs also vary widely. Even in states
where regulations allow LPNs/LVNs to administer blood
products, a given health care organization’s policies or job
descriptions may limit practice and place additional safe-
guards because of the life-threatening risk involved in the
administration of blood products and other medications.
The RN must review the agency’s job descriptions as well
as the state regulations because either is changeable.
LPN/LVN practice continues to evolve, and in any
state, tasks to support the assessment, planning, interven-
tion, and evaluation phases of the nursing process can be
Loading page 15...
Guidelines for Prioritization, Delegation, and Assignment Decisions 5Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
allocated. When it is clear that a task could possibly be
delegated to a skilled delegatee according to your state’s
scope of practice rules and is not prohibited by the organi-
zation policies, the principles of delegation and/or assign-
ment remain the same. The totality of the nursing process
remains the responsibility of the RN. Also, the total nursing
care of the patient rests squarely on the RN’s shoulders, no
matter which competent and skilled individual is asked to
perform care activities. To obtain more information about
the statute and rules in a given state and to access decision
trees and other helpful aides to delegation and supervi-
sion, visit the NCSBN website at http://www.ncsbn.org.
The state practice act for each state is linked at that site.
ASSIGNMENT PROCESS
In current hospital environments, the process of assigning
or creating a work plan is dependent on who is available,
present, and accounted for and what their roles and compe-
tencies are for each shift. Assignment has been understood
to be the “work plan” or “the distribution of work that
each staff member is responsible for during a given work
period” (American Nurses Association (ANA), Duffy &
McCoy, 2014, p. 22). Classical care delivery models once
known as total patient care have been transformed into a
combination of team, functional, and primary care nursing,
depending on the projected patient outcomes, the present
patient state, and the available staff. Assignments must be
created with knowledge of the following issues (Hansten
and Jackson, 2009, pp. 207–208, Hansten, 2020 in Kelly
Vana and Tazbir):
• How complex is the patient’s required care?
• What are the dynamics of the patient’s status and
their stability?
• How complex is the assessment and ongoing
evaluation?
• What kind of infection control is necessary?
• Are there any individual safety precautions?
• Is there special technology involved in the care, and
who is skilled in its use?
• How much supervision and oversight will be needed
based on the staff ’s numbers and expertise?
• How available are the supervising RNs?
• How will the physical location of patients affect the
time and availability of care?
• Can continuity of care be maintained?
• Are there any personal reasons to allocate duties for a
particular patient, or are there nurse or patient pref-
erences that should be taken into account? Factors
such as staff difficulties with a particular diagnosis,
patient preferences for an employee’s care on a previ-
ous admission, or a staff member’s need for a particu-
lar learning experience will be taken into account.
• Is there an acuity rating system that will help distrib-
ute care based on a point or number system?
For more information on care delivery modali-
ties, refer to the texts by Hansten and Jackson (2009)
or access Hansten’s webinars related to assignment and
care delivery models at http://learning.hansten.com/ and
Alfaro-LeFevre (2017) listed in the References section.
Whichever type of care delivery plan is chosen for each
particular shift or within your practice arena, the rela-
tionship with the patient and the results that the patient
wants to achieve must be foremost, followed by the plac-
ing together of the right pieces in the form of compe-
tent team members, to compose the complete picture
(Hansten, 2019).
DELEGATION AND ASSIGNMENT: THE FIVE
RIGHTS
As you contemplate the questions in this workbook, you
can use mnemonic devices to order your thinking pro-
cess, such as the “five rights.” The right task is assigned to
the right person in the right circumstances. The RN then
offers the right direction and communication and the right
supervision and evaluation (Hansten and Jackson, 2009,
pp. 205–206; NCSBN, 1995, pp. 2–3; Hansten, 2014a,
p. 70; NCSBN, 2016b, p. 8; ANA & NCSBN, 2019, p. 4).
Right Task
Returning to the guideposts for navigating care, the
patient’s four Ps (purpose, picture, plan, and part), the right
task is a task that, in the nurse’s best judgment, is one that
can be safely delegated for this patient, given the patient’s
current condition (picture) and future preferred outcomes
(purpose, picture), if the nurse has a competent willing
individual available to perform it. Although the RN may
believe that he or she personally would be the best person
to accomplish this task, the nurse must prioritize the best
use of his or her time given a myriad of factors, such as:
What other tasks and processes must I do because I am
the only RN on this team? Which tasks can be delegated
based on state regulations and my thorough knowledge of
job descriptions here in this facility? How skilled are the
personnel working here today? Who else could be avail-
able to help if necessary?
In its draft model language for nursing APs, the
NCSBN lists criteria for determining nursing activities
that can be delegated. The following are recommended
for the nurse’s consideration. It should be kept in mind
that the nursing process and nursing judgment cannot be
delegated.
• Knowledge and skills of the delegatee
• Verification of clinical competence by the employer
• Stability of the patient’s condition
• Service setting variables such as available resources
(including the nurse’s accessibility) and methods of
communication, complexity and frequency of care, and
proximity and numbers of patients relative to staff
Introduction
PART 1
allocated. When it is clear that a task could possibly be
delegated to a skilled delegatee according to your state’s
scope of practice rules and is not prohibited by the organi-
zation policies, the principles of delegation and/or assign-
ment remain the same. The totality of the nursing process
remains the responsibility of the RN. Also, the total nursing
care of the patient rests squarely on the RN’s shoulders, no
matter which competent and skilled individual is asked to
perform care activities. To obtain more information about
the statute and rules in a given state and to access decision
trees and other helpful aides to delegation and supervi-
sion, visit the NCSBN website at http://www.ncsbn.org.
The state practice act for each state is linked at that site.
ASSIGNMENT PROCESS
In current hospital environments, the process of assigning
or creating a work plan is dependent on who is available,
present, and accounted for and what their roles and compe-
tencies are for each shift. Assignment has been understood
to be the “work plan” or “the distribution of work that
each staff member is responsible for during a given work
period” (American Nurses Association (ANA), Duffy &
McCoy, 2014, p. 22). Classical care delivery models once
known as total patient care have been transformed into a
combination of team, functional, and primary care nursing,
depending on the projected patient outcomes, the present
patient state, and the available staff. Assignments must be
created with knowledge of the following issues (Hansten
and Jackson, 2009, pp. 207–208, Hansten, 2020 in Kelly
Vana and Tazbir):
• How complex is the patient’s required care?
• What are the dynamics of the patient’s status and
their stability?
• How complex is the assessment and ongoing
evaluation?
• What kind of infection control is necessary?
• Are there any individual safety precautions?
• Is there special technology involved in the care, and
who is skilled in its use?
• How much supervision and oversight will be needed
based on the staff ’s numbers and expertise?
• How available are the supervising RNs?
• How will the physical location of patients affect the
time and availability of care?
• Can continuity of care be maintained?
• Are there any personal reasons to allocate duties for a
particular patient, or are there nurse or patient pref-
erences that should be taken into account? Factors
such as staff difficulties with a particular diagnosis,
patient preferences for an employee’s care on a previ-
ous admission, or a staff member’s need for a particu-
lar learning experience will be taken into account.
• Is there an acuity rating system that will help distrib-
ute care based on a point or number system?
For more information on care delivery modali-
ties, refer to the texts by Hansten and Jackson (2009)
or access Hansten’s webinars related to assignment and
care delivery models at http://learning.hansten.com/ and
Alfaro-LeFevre (2017) listed in the References section.
Whichever type of care delivery plan is chosen for each
particular shift or within your practice arena, the rela-
tionship with the patient and the results that the patient
wants to achieve must be foremost, followed by the plac-
ing together of the right pieces in the form of compe-
tent team members, to compose the complete picture
(Hansten, 2019).
DELEGATION AND ASSIGNMENT: THE FIVE
RIGHTS
As you contemplate the questions in this workbook, you
can use mnemonic devices to order your thinking pro-
cess, such as the “five rights.” The right task is assigned to
the right person in the right circumstances. The RN then
offers the right direction and communication and the right
supervision and evaluation (Hansten and Jackson, 2009,
pp. 205–206; NCSBN, 1995, pp. 2–3; Hansten, 2014a,
p. 70; NCSBN, 2016b, p. 8; ANA & NCSBN, 2019, p. 4).
Right Task
Returning to the guideposts for navigating care, the
patient’s four Ps (purpose, picture, plan, and part), the right
task is a task that, in the nurse’s best judgment, is one that
can be safely delegated for this patient, given the patient’s
current condition (picture) and future preferred outcomes
(purpose, picture), if the nurse has a competent willing
individual available to perform it. Although the RN may
believe that he or she personally would be the best person
to accomplish this task, the nurse must prioritize the best
use of his or her time given a myriad of factors, such as:
What other tasks and processes must I do because I am
the only RN on this team? Which tasks can be delegated
based on state regulations and my thorough knowledge of
job descriptions here in this facility? How skilled are the
personnel working here today? Who else could be avail-
able to help if necessary?
In its draft model language for nursing APs, the
NCSBN lists criteria for determining nursing activities
that can be delegated. The following are recommended
for the nurse’s consideration. It should be kept in mind
that the nursing process and nursing judgment cannot be
delegated.
• Knowledge and skills of the delegatee
• Verification of clinical competence by the employer
• Stability of the patient’s condition
• Service setting variables such as available resources
(including the nurse’s accessibility) and methods of
communication, complexity and frequency of care, and
proximity and numbers of patients relative to staff
Loading page 16...
Guidelines for Prioritization, Delegation, and Assignment Decisions6Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
APs are not to be allocated the duties of the nursing
process of assessment (except gathering data), nursing
diagnosis, planning, implementation (except those tasks
delegated/assigned), or evaluation. Professional clinical
judgment or reasoning and decision making related to
the manner in which the RN makes sense of the patient’s
data and clinical progress cannot be delegated or assigned
(ANA & NCSBN, 2019, p. 3).
Right Circumstances
Recall the importance of the context in clinical decision
making. Not only do rules and regulations adjust based on
the area of practice (i.e., home health care, acute care, schools,
ambulatory clinics, long-term care), but patient conditions
and the preferred patient results must also be considered. If
information is not available, a best judgment must be made.
Often RNs must balance the need to know as much as pos-
sible and the time available to obtain the information. The
instability of patients immediately postoperatively or in the
intensive care unit (ICU) means that a student nurse will
have to be closely supervised and partnered with an experi-
enced RN. The questions in this workbook give direction as
to context and offer hints to the circumstances.
For example, in long-term care skilled nursing facilities,
LPNs/LVNs often function as “team leaders” with ongo-
ing care planning and oversight by a smaller number of
on-site RNs. Some EDs use paramedics, who may be reg-
ulated by the state emergency system statutes, in different
roles in hospitals. Medical clinics often employ “medical
assistants” who function under the direction and supervi-
sion of physicians, other providers, and RNs. Community
group homes, assisted living facilities, and other health
care providers beyond acute care hospitals seek to create
safe and effective care delivery systems for the growing
number of older adults. Whatever the setting or circum-
stance, the nurse is accountable to know the specific laws
and regulations that apply.
Right Person
Licensure, Certification, and Role Description
One of the most commonly voiced concerns during work-
shops with staff nurses across the nation is, “How can I
trust the delegatees?” Knowing the licensure, role, and
preparation of each member of the team is the first step in
determining competency. What tasks does a patient care
technician (PCT) perform in this facility? What is the role
of an LPN/LVN? Are different levels of LPN/LVN des-
ignated here (LPN I or II)? Nearly 100 different titles for
APs have been developed in care settings across the coun-
try. To effectively assign or delegate, the RN must know the
role descriptions of co-workers as well as his or her own.
Strengths and Weaknesses
The personal strengths and weaknesses of everyday team
members are no mystery. Their skills are discovered
through practice, positive and negative experiences, and
an ever-present but unreliable rumor mill. An expert
RN helps create better team results by using strengths in
assigning personnel to make the most of their gifts. The
most compassionate team members will be assigned work
with the hospice patient and his or her family. The super-
vising nurse helps identify performance flaws and develops
staff by providing judicious use of learning assignments.
For example, a novice nursing assistant can be partnered
with an experienced oncology RN during the assistant’s
first experiences with a terminally ill patient.
When working with students, float nurses, or other tem-
porary personnel, nurses sometimes forget that the assign-
ing RN has the duty to determine competency. Asking
personnel about their previous experiences and about their
understanding of the work duties, as well as pairing them
with a strong unit staff member, is as essential as provid-
ing the ongoing support and supervision needed through-
out the shift. If your mother was an ICU patient and her
nurse was an inexperienced float from the rehabilitation
unit, what level of leadership and direction would that
nurse need from an experienced ICU RN? Many hospitals
delegate only tasks and not overall patient responsibility,
a functional form of assignment, to temporary personnel
who are unfamiliar with the clinical area.
Right Direction and Communication
Now that the right staff member is being delegated the
right task for each particular situation and setting, team
members must find out what they need to do and how
the tasks must be done. Relaying instructions about the
plan for the shift or even for a specific task is not as simple
as it seems. Some RNs believe that a written assignment
board provides enough information to proceed because
“everyone knows his or her job,” but others spend copious
amounts of time giving overly detailed directions to bored
staff. The “four Cs” of initial direction will help clarify the
salient points of this process (Hansten and Jackson, 2009,
pp. 287–288; Hansten, 2021 in Zerwekh and Garneau,
p. 316). Instructions and ongoing direction must be
clear, concise, correct, and complete.
Clear communication is information that is understood
by the listener. An ambiguous question such as: “Can you
get the new patient?” is not helpful when there are several
new patients and returning surgical patients, and “getting”
could mean transporting, admitting, or taking full respon-
sibility for the care of the patient. Asking the delegatee to
restate the instructions and work plan can be helpful to
determine whether the communication is clear.
Concise statements are those that give enough but not
too much additional information. The student nurse who
merely wants to know how to turn on the chemical strip
analyzer machine does not need a full treatise on the tran-
sit of potassium and glucose through the cell membrane.
Too much or irrelevant information confuses the listener
and wastes precious time.
Introduction
PART 1
APs are not to be allocated the duties of the nursing
process of assessment (except gathering data), nursing
diagnosis, planning, implementation (except those tasks
delegated/assigned), or evaluation. Professional clinical
judgment or reasoning and decision making related to
the manner in which the RN makes sense of the patient’s
data and clinical progress cannot be delegated or assigned
(ANA & NCSBN, 2019, p. 3).
Right Circumstances
Recall the importance of the context in clinical decision
making. Not only do rules and regulations adjust based on
the area of practice (i.e., home health care, acute care, schools,
ambulatory clinics, long-term care), but patient conditions
and the preferred patient results must also be considered. If
information is not available, a best judgment must be made.
Often RNs must balance the need to know as much as pos-
sible and the time available to obtain the information. The
instability of patients immediately postoperatively or in the
intensive care unit (ICU) means that a student nurse will
have to be closely supervised and partnered with an experi-
enced RN. The questions in this workbook give direction as
to context and offer hints to the circumstances.
For example, in long-term care skilled nursing facilities,
LPNs/LVNs often function as “team leaders” with ongo-
ing care planning and oversight by a smaller number of
on-site RNs. Some EDs use paramedics, who may be reg-
ulated by the state emergency system statutes, in different
roles in hospitals. Medical clinics often employ “medical
assistants” who function under the direction and supervi-
sion of physicians, other providers, and RNs. Community
group homes, assisted living facilities, and other health
care providers beyond acute care hospitals seek to create
safe and effective care delivery systems for the growing
number of older adults. Whatever the setting or circum-
stance, the nurse is accountable to know the specific laws
and regulations that apply.
Right Person
Licensure, Certification, and Role Description
One of the most commonly voiced concerns during work-
shops with staff nurses across the nation is, “How can I
trust the delegatees?” Knowing the licensure, role, and
preparation of each member of the team is the first step in
determining competency. What tasks does a patient care
technician (PCT) perform in this facility? What is the role
of an LPN/LVN? Are different levels of LPN/LVN des-
ignated here (LPN I or II)? Nearly 100 different titles for
APs have been developed in care settings across the coun-
try. To effectively assign or delegate, the RN must know the
role descriptions of co-workers as well as his or her own.
Strengths and Weaknesses
The personal strengths and weaknesses of everyday team
members are no mystery. Their skills are discovered
through practice, positive and negative experiences, and
an ever-present but unreliable rumor mill. An expert
RN helps create better team results by using strengths in
assigning personnel to make the most of their gifts. The
most compassionate team members will be assigned work
with the hospice patient and his or her family. The super-
vising nurse helps identify performance flaws and develops
staff by providing judicious use of learning assignments.
For example, a novice nursing assistant can be partnered
with an experienced oncology RN during the assistant’s
first experiences with a terminally ill patient.
When working with students, float nurses, or other tem-
porary personnel, nurses sometimes forget that the assign-
ing RN has the duty to determine competency. Asking
personnel about their previous experiences and about their
understanding of the work duties, as well as pairing them
with a strong unit staff member, is as essential as provid-
ing the ongoing support and supervision needed through-
out the shift. If your mother was an ICU patient and her
nurse was an inexperienced float from the rehabilitation
unit, what level of leadership and direction would that
nurse need from an experienced ICU RN? Many hospitals
delegate only tasks and not overall patient responsibility,
a functional form of assignment, to temporary personnel
who are unfamiliar with the clinical area.
Right Direction and Communication
Now that the right staff member is being delegated the
right task for each particular situation and setting, team
members must find out what they need to do and how
the tasks must be done. Relaying instructions about the
plan for the shift or even for a specific task is not as simple
as it seems. Some RNs believe that a written assignment
board provides enough information to proceed because
“everyone knows his or her job,” but others spend copious
amounts of time giving overly detailed directions to bored
staff. The “four Cs” of initial direction will help clarify the
salient points of this process (Hansten and Jackson, 2009,
pp. 287–288; Hansten, 2021 in Zerwekh and Garneau,
p. 316). Instructions and ongoing direction must be
clear, concise, correct, and complete.
Clear communication is information that is understood
by the listener. An ambiguous question such as: “Can you
get the new patient?” is not helpful when there are several
new patients and returning surgical patients, and “getting”
could mean transporting, admitting, or taking full respon-
sibility for the care of the patient. Asking the delegatee to
restate the instructions and work plan can be helpful to
determine whether the communication is clear.
Concise statements are those that give enough but not
too much additional information. The student nurse who
merely wants to know how to turn on the chemical strip
analyzer machine does not need a full treatise on the tran-
sit of potassium and glucose through the cell membrane.
Too much or irrelevant information confuses the listener
and wastes precious time.
Loading page 17...
Guidelines for Prioritization, Delegation, and Assignment Decisions 7Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
Correct communication is that which is accurate and
is aligned to rules, regulations, or job descriptions. Are the
room number, patient name, and other identifiers correct?
Are there two patients with similar last names? Can this
task be delegated to this individual? Correct communi-
cation is not cloudy or confusing (Hansten and Jackson,
2009, pp. 287–288; Hansten, 2021 in Zerwekh and
Garneau, p. 318).
Complete communication leaves no room for doubt on
the part of supervisor or delegatees. Staff members often
say, “I would do whatever the RNs want if they would
just tell me what they want me to do and how to do it.”
Incomplete communication wins the top prize for creat-
ing team strife and substandard work. Assuming that staff
“know” what to do and how to do it, along with what
information to report and when, creates havoc, rework, and
frustration for patients and staff alike. Each staff member
should have in mind a clear map or plan for the day, what
to do and why, and what and when to report to the team
leader. Parameters for reporting and the results that should
be expected are often left in the team leader’s brain rather
than being discussed and spelled out in sufficient detail.
RNs are accountable for clear, concise, correct, and com-
plete initial and ongoing direction.
Right Supervision and Evaluation
After prioritization, assignment, and delegation have
been considered, determined, and communicated, the
RN remains accountable for the total care of the patients
throughout the tour of duty. Recall that the definition of
supervision includes not only initial direction but also that
“supervision is the active process of directing, guiding, and
influencing the outcome of an individual’s performance of
a task. Similarly, NCSBN defines supervision as “the provi-
sion of guidance or direction, oversight, evaluation and fol-
low-up by the licensed nurse for the accomplishment of a
delegated nursing task by assistive personnel” (ANA, 2014,
in Duffy and McCoy, p. 23). RNs may not actually per-
form each task of care, but they must oversee the ongoing
progress and results obtained, reviewing staff performance.
Evaluation of the care provided, and adequate documenta-
tion of the tasks and outcomes, must be included in this
last of the five rights. On a typical unit in an acute care
facility, assisted living, or long-term care setting, the RN
can ensure optimal performance as the RN begins the shift
by holding a short “second report” meeting with APs, out-
lining the day’s plan and the plan for each patient, and
giving initial direction at that time. Subsequent short team
update or “checkpoint” meetings should be held before
and after breaks and meals and before the end of the shift
(Hansten, 2005, 2008a, 2008b, 2019). During each short
update, feedback is often offered, and plans are altered.
The last checkpoint presents all team members with an
opportunity to give feedback to one another using the
step-by-step feedback process (Hansten, 2008a, pp. 79–84;
Hansten, 2021, in Zerweck and Garneau, pp. 301–302).
This step is often called the “debriefing” checkpoint or
huddle, in which the team’s processes are also examined. In
ambulatory care settings, this checkpoint may be toward
the end of each patient’s visit or the end of the shift; in
home health care, these conversations are often conducted
on a weekly basis. Questions such as, “What would you
recommend I do differently if we worked together tomor-
row on the same group of patients?” and “What can we do
better as a team to help us navigate the patients toward
their preferred results?” will help the team function more
effectively in the future.
1. The team member’s input should be solicited
first. “I noted that the vital signs for the first four
patients aren’t yet on the electronic record. Do you
know what’s been done?” rather than “WHY haven’t
those vital signs been recorded yet?” At the end of
the shift, the questions might be global, as in “How
did we do today?” “What would you do differently if
we had it to do over?” “What should I do differently
tomorrow?”
2. Credit should be given for all that has been accom-
plished. “Oh, so you have the vital signs done, but
they aren’t recorded? Great, I’m so glad they are done
so I can find out about Ms. Johnson’s temperature
before I call Dr. Smith.” “You did a fantastic job with
cleaning Mr. Hu after his incontinence episodes;
his family is very appreciative of our respect for his
dignity.”
3. Observations or concerns should be offered. “The
vital signs are routinely recorded on the electron-
ic medical record (EMR) before patients are sent
for surgery and procedures and before the doctor’s
round so that we can see the big picture of patients’
progress before they leave the unit and to make sure
they are stable for their procedures.” Or, “I think I
should have assigned another RN to Ms. A. I had
no idea that your mother recently died of breast
cancer.”
4. The delegatee should be asked for ideas on how to
resolve the issue. “What are your thoughts on how
you could order your work to get the vital signs on
the EMR before 8:30 AM?” Or, “What would you
like to do with your work plan for tomorrow? Should
we change Ms. A.’s team?”
5. A course of action and plan for the future should
be agreed upon. “That sounds great. Practice use
of the handheld computers today before you leave,
and that should resolve the issue. When we work to-
gether tomorrow, let me know whether that resolves
the time issue for recording; if not, we will go to an-
other plan.” Or, “If you still feel that you want to stay
with this assignment tomorrow after you’ve slept on
it, we will keep it as is. If not, please let me know
first thing tomorrow morning when you awaken so
we can change all the assignments before the staff
arrive.”
Introduction
PART 1
Correct communication is that which is accurate and
is aligned to rules, regulations, or job descriptions. Are the
room number, patient name, and other identifiers correct?
Are there two patients with similar last names? Can this
task be delegated to this individual? Correct communi-
cation is not cloudy or confusing (Hansten and Jackson,
2009, pp. 287–288; Hansten, 2021 in Zerwekh and
Garneau, p. 318).
Complete communication leaves no room for doubt on
the part of supervisor or delegatees. Staff members often
say, “I would do whatever the RNs want if they would
just tell me what they want me to do and how to do it.”
Incomplete communication wins the top prize for creat-
ing team strife and substandard work. Assuming that staff
“know” what to do and how to do it, along with what
information to report and when, creates havoc, rework, and
frustration for patients and staff alike. Each staff member
should have in mind a clear map or plan for the day, what
to do and why, and what and when to report to the team
leader. Parameters for reporting and the results that should
be expected are often left in the team leader’s brain rather
than being discussed and spelled out in sufficient detail.
RNs are accountable for clear, concise, correct, and com-
plete initial and ongoing direction.
Right Supervision and Evaluation
After prioritization, assignment, and delegation have
been considered, determined, and communicated, the
RN remains accountable for the total care of the patients
throughout the tour of duty. Recall that the definition of
supervision includes not only initial direction but also that
“supervision is the active process of directing, guiding, and
influencing the outcome of an individual’s performance of
a task. Similarly, NCSBN defines supervision as “the provi-
sion of guidance or direction, oversight, evaluation and fol-
low-up by the licensed nurse for the accomplishment of a
delegated nursing task by assistive personnel” (ANA, 2014,
in Duffy and McCoy, p. 23). RNs may not actually per-
form each task of care, but they must oversee the ongoing
progress and results obtained, reviewing staff performance.
Evaluation of the care provided, and adequate documenta-
tion of the tasks and outcomes, must be included in this
last of the five rights. On a typical unit in an acute care
facility, assisted living, or long-term care setting, the RN
can ensure optimal performance as the RN begins the shift
by holding a short “second report” meeting with APs, out-
lining the day’s plan and the plan for each patient, and
giving initial direction at that time. Subsequent short team
update or “checkpoint” meetings should be held before
and after breaks and meals and before the end of the shift
(Hansten, 2005, 2008a, 2008b, 2019). During each short
update, feedback is often offered, and plans are altered.
The last checkpoint presents all team members with an
opportunity to give feedback to one another using the
step-by-step feedback process (Hansten, 2008a, pp. 79–84;
Hansten, 2021, in Zerweck and Garneau, pp. 301–302).
This step is often called the “debriefing” checkpoint or
huddle, in which the team’s processes are also examined. In
ambulatory care settings, this checkpoint may be toward
the end of each patient’s visit or the end of the shift; in
home health care, these conversations are often conducted
on a weekly basis. Questions such as, “What would you
recommend I do differently if we worked together tomor-
row on the same group of patients?” and “What can we do
better as a team to help us navigate the patients toward
their preferred results?” will help the team function more
effectively in the future.
1. The team member’s input should be solicited
first. “I noted that the vital signs for the first four
patients aren’t yet on the electronic record. Do you
know what’s been done?” rather than “WHY haven’t
those vital signs been recorded yet?” At the end of
the shift, the questions might be global, as in “How
did we do today?” “What would you do differently if
we had it to do over?” “What should I do differently
tomorrow?”
2. Credit should be given for all that has been accom-
plished. “Oh, so you have the vital signs done, but
they aren’t recorded? Great, I’m so glad they are done
so I can find out about Ms. Johnson’s temperature
before I call Dr. Smith.” “You did a fantastic job with
cleaning Mr. Hu after his incontinence episodes;
his family is very appreciative of our respect for his
dignity.”
3. Observations or concerns should be offered. “The
vital signs are routinely recorded on the electron-
ic medical record (EMR) before patients are sent
for surgery and procedures and before the doctor’s
round so that we can see the big picture of patients’
progress before they leave the unit and to make sure
they are stable for their procedures.” Or, “I think I
should have assigned another RN to Ms. A. I had
no idea that your mother recently died of breast
cancer.”
4. The delegatee should be asked for ideas on how to
resolve the issue. “What are your thoughts on how
you could order your work to get the vital signs on
the EMR before 8:30 AM?” Or, “What would you
like to do with your work plan for tomorrow? Should
we change Ms. A.’s team?”
5. A course of action and plan for the future should
be agreed upon. “That sounds great. Practice use
of the handheld computers today before you leave,
and that should resolve the issue. When we work to-
gether tomorrow, let me know whether that resolves
the time issue for recording; if not, we will go to an-
other plan.” Or, “If you still feel that you want to stay
with this assignment tomorrow after you’ve slept on
it, we will keep it as is. If not, please let me know
first thing tomorrow morning when you awaken so
we can change all the assignments before the staff
arrive.”
Loading page 18...
Guidelines for Prioritization, Delegation, and Assignment Decisions8Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
PRACTICE BASED ON RESEARCH EVIDENCE
Rationale for Maximizing Nursing Leadership Skills at
the Point of Care
If the skills presented in this book are used to save lives
by providing care prioritized to attend to the most unsta-
ble patients first, optimally delegated to be delivered
by the right personnel, and assigned using appropriate
language with the most motivational and conscientious
supervisory follow-up, then clinical outcomes should be
optimal and work satisfaction should flourish. Solid cor-
relational research evidence has been lacking related to
“the best use of personnel to multiply the RN’s ability to
remain vigilant over patient progress and avoid failures
to rescue, but common sense would advise that better
delegation and supervision skills would prevent errors
and omissions as well as unobserved patient decline”
(Hansten, 2008b, 2019).
In an era of value-based purchasing and health care
reimbursement based on clinical results with linkages
for care along the continuum from site to site, an RN’s
accountability has irrevocably moved beyond task orienta-
tion to leadership practices that ensure better outcomes
for patients, families, and populations. The necessity of
efficiency and effectiveness in health care means that RNs
must delegate and supervise appropriately so that all tasks
that can be safely assigned to APs are completed flawlessly.
Patient safety experts have linked interpersonal commu-
nication errors and teamwork communication gaps as
major sources of medical errors and The Joint Commission
associated these as root causes of 70% or more of serious
reportable events (Grant, 2016, p. 11). Severe events that
harm patients (sentinel events) can occur through inad-
equate hand-offs between caregivers and along the health
care continuum as patients are transferred (The Joint
Commission, 2017).
Nurses are accountable for processes as well as out-
comes measures so that insurers will reimburse health care
organizations. If hospital-acquired conditions occur, such
as pressure injuries falls with injury, and some infections,
reimbursement for the care of that condition will be nega-
tively impacted.
• Nurses have been reported to spend more than half
their time on tasks other than patient care, including
searching for team members and internal communi-
cations (Voalte Special Report, 2013). Shift report
at the bedside, along with better initial direction and
a plan for supervision during the day, all ultimately
decrease time wasted when nurses must attempt to
connect with team members when delegation and
assignment processes do not include the five rights.
At one facility in the Midwest, shift hand-offs were
reduced to 10 to 15 minutes per shift per RN as a
result of a planned approach to initial direction and
care planning, which thus saved each RN 30 to
45 minutes per day (Hansten, 2008a, p. 34). Better
use of nursing and AP time can result in more time to
care for patients, giving RNs the opportunity to teach
patients self-care or to maintain functional status.
• When nurses did not appropriately implement the
five rights of delegation and supervision with assis-
tive personnel, errors occurred that potentially could
have been avoided with better RN leadership behav-
iors. Early research about the impact of supervision
on errors showed that about 14% of task errors or
care omissions related to teamwork were because of
lack of RN direction or communication, and approxi-
mately 12% of the issues stemmed from lack of su-
pervision or follow-up (Standing, Anthony, & Hertz,
2001). Lack of communication among staff members
has been an international issue leading to care that
is not completed appropriately (Diab & Ebrahim,
2019). Errors can result in uncompensated condi-
tions or readmissions; unhappy patients and provid-
ers; disgruntled health care purchasers; and a disloyal,
anxious patient community (Hansten, 2019).
• Teamwork and job satisfaction have been found to
be negatively correlated with over-delegation and a
hierarchical relationship between nurses and assis-
tive personnel (Kalisch 2015, p. 266–227), but of-
fering feedback effectively has been shown to im-
prove team thinking and performance (Mizne, D.,
2018, https://www.15five.com/blog/7-employee-
engagement-trends-2018/). Workplace injuries,
expensive employee turnover, and patient safety have
been linked with employee morale. Daily or weekly
feedback has been requested by a majority of teams
and this could be achieved by excellent delegation,
assignment, and supervision shift routines (McNee,
2017, https://www.mcknights.com/blogs/guest-
columns/nurse- morale- and- its- impact- on- ltc/).
Best practices for deployment of personnel include
a connection to patient outcomes, which can oc-
cur during initial direction and debriefing supervi-
sion checkpoints (Hansten, 2021 in LaCharity and
Garneau).
• Unplanned readmissions to acute care within
30 days of discharge are linked to potential penal-
ties and reduced reimbursement. Inadequate RN
initial direction and supervision of APs can lead to
missed mobilization, hydration, and nutrition of pa-
tients, thereby discharging deconditioned patients,
and can be traced to ED visits and subsequent read-
missions. Reimbursement bundling for specific care
pathways such as total joint replacements or acute
exacerbation of chronic obstructive pulmonary disease
requires that team communication and RN supervision
of coworkers along the full continuum must be seam-
less from ambulatory care to acute care, rehabilitation,
and home settings (Kalisch, 2015; Hansten, 2019).
• As public quality transparency and competition for
best value become the norm, ineffective delegation
has been a significant source of missed care, such
Introduction
PART 1
PRACTICE BASED ON RESEARCH EVIDENCE
Rationale for Maximizing Nursing Leadership Skills at
the Point of Care
If the skills presented in this book are used to save lives
by providing care prioritized to attend to the most unsta-
ble patients first, optimally delegated to be delivered
by the right personnel, and assigned using appropriate
language with the most motivational and conscientious
supervisory follow-up, then clinical outcomes should be
optimal and work satisfaction should flourish. Solid cor-
relational research evidence has been lacking related to
“the best use of personnel to multiply the RN’s ability to
remain vigilant over patient progress and avoid failures
to rescue, but common sense would advise that better
delegation and supervision skills would prevent errors
and omissions as well as unobserved patient decline”
(Hansten, 2008b, 2019).
In an era of value-based purchasing and health care
reimbursement based on clinical results with linkages
for care along the continuum from site to site, an RN’s
accountability has irrevocably moved beyond task orienta-
tion to leadership practices that ensure better outcomes
for patients, families, and populations. The necessity of
efficiency and effectiveness in health care means that RNs
must delegate and supervise appropriately so that all tasks
that can be safely assigned to APs are completed flawlessly.
Patient safety experts have linked interpersonal commu-
nication errors and teamwork communication gaps as
major sources of medical errors and The Joint Commission
associated these as root causes of 70% or more of serious
reportable events (Grant, 2016, p. 11). Severe events that
harm patients (sentinel events) can occur through inad-
equate hand-offs between caregivers and along the health
care continuum as patients are transferred (The Joint
Commission, 2017).
Nurses are accountable for processes as well as out-
comes measures so that insurers will reimburse health care
organizations. If hospital-acquired conditions occur, such
as pressure injuries falls with injury, and some infections,
reimbursement for the care of that condition will be nega-
tively impacted.
• Nurses have been reported to spend more than half
their time on tasks other than patient care, including
searching for team members and internal communi-
cations (Voalte Special Report, 2013). Shift report
at the bedside, along with better initial direction and
a plan for supervision during the day, all ultimately
decrease time wasted when nurses must attempt to
connect with team members when delegation and
assignment processes do not include the five rights.
At one facility in the Midwest, shift hand-offs were
reduced to 10 to 15 minutes per shift per RN as a
result of a planned approach to initial direction and
care planning, which thus saved each RN 30 to
45 minutes per day (Hansten, 2008a, p. 34). Better
use of nursing and AP time can result in more time to
care for patients, giving RNs the opportunity to teach
patients self-care or to maintain functional status.
• When nurses did not appropriately implement the
five rights of delegation and supervision with assis-
tive personnel, errors occurred that potentially could
have been avoided with better RN leadership behav-
iors. Early research about the impact of supervision
on errors showed that about 14% of task errors or
care omissions related to teamwork were because of
lack of RN direction or communication, and approxi-
mately 12% of the issues stemmed from lack of su-
pervision or follow-up (Standing, Anthony, & Hertz,
2001). Lack of communication among staff members
has been an international issue leading to care that
is not completed appropriately (Diab & Ebrahim,
2019). Errors can result in uncompensated condi-
tions or readmissions; unhappy patients and provid-
ers; disgruntled health care purchasers; and a disloyal,
anxious patient community (Hansten, 2019).
• Teamwork and job satisfaction have been found to
be negatively correlated with over-delegation and a
hierarchical relationship between nurses and assis-
tive personnel (Kalisch 2015, p. 266–227), but of-
fering feedback effectively has been shown to im-
prove team thinking and performance (Mizne, D.,
2018, https://www.15five.com/blog/7-employee-
engagement-trends-2018/). Workplace injuries,
expensive employee turnover, and patient safety have
been linked with employee morale. Daily or weekly
feedback has been requested by a majority of teams
and this could be achieved by excellent delegation,
assignment, and supervision shift routines (McNee,
2017, https://www.mcknights.com/blogs/guest-
columns/nurse- morale- and- its- impact- on- ltc/).
Best practices for deployment of personnel include
a connection to patient outcomes, which can oc-
cur during initial direction and debriefing supervi-
sion checkpoints (Hansten, 2021 in LaCharity and
Garneau).
• Unplanned readmissions to acute care within
30 days of discharge are linked to potential penal-
ties and reduced reimbursement. Inadequate RN
initial direction and supervision of APs can lead to
missed mobilization, hydration, and nutrition of pa-
tients, thereby discharging deconditioned patients,
and can be traced to ED visits and subsequent read-
missions. Reimbursement bundling for specific care
pathways such as total joint replacements or acute
exacerbation of chronic obstructive pulmonary disease
requires that team communication and RN supervision
of coworkers along the full continuum must be seam-
less from ambulatory care to acute care, rehabilitation,
and home settings (Kalisch, 2015; Hansten, 2019).
• As public quality transparency and competition for
best value become the norm, ineffective delegation
has been a significant source of missed care, such
Loading page 19...
Guidelines for Prioritization, Delegation, and Assignment Decisions 9Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
as lack of care planning, lack of turning or ambula-
tion, delayed or missed nutrition, and lack of hygiene
(Bittner et al., 2011; Kalisch, 2015, pp. 266–270).
These care omissions can be contributing factors
for the occurrence of unreimbursed “never events”
(events that should never occur), such as pressure ul-
cers and pneumonia, as well as prolonged lengths of
stay. Other nurse-sensitive quality indicators such as
catheter-associated urinary tract infections could be
correlated to omitted perineal hygiene and inatten-
tion to discontinuation of catheters. Useful models
that link delegation with care omissions and ensu-
ing care hazards such as thrombosis, pressure inju-
ries, constipation, and infection, combined with a
Swiss Cheese Safety Model showing defensive steps
against health care–acquired conditions and errors
through excellence in RN leadership, can be ac-
cessed in the August 2014 Nurse Leader at https://d
oi.org/10.1016/j.mnl.2013.10.007 (Hansten, 2014a;
Hansten, 2020 in Kelly Vana and Tazbir).
• In perioperative nursing, such omissions as lack of
warming, oral care, head elevation and deep breath-
ing, can lead to postoperative pneumonia and lack of
optimal healing (Ralph and Viljoen, 2018). Many of
these interventions could be delegated or assigned.
Evidence does indicate that appropriate nursing judg-
ment in prioritization, delegation, and supervision can save
time and improve communication and thereby improve
care, patient safety, clinical outcomes, and job satisfaction,
potentially saving patient-days and absenteeism and recruit-
ment costs. Patient satisfaction, staff satisfaction, and clinical
results decline when nursing care is poor. Potential reim-
bursement is lost, patients and families suffer, and the health
of our communities decays when RNs do not assume the
leadership necessary to work effectively with all team mem-
bers (Bittner et al., 2011, Kalisch, 2015, Hansten, 2019).
PRINCIPLES FOR IMPLEMENTATION OF
PRIORITIZATION, DELEGATION, AND
ASSIGNMENT
Return to our goalposts of the four Ps (purpose, picture,
plan, and part) as a framework as you answer the questions
in this workbook and further develop your own expertise
and recall the following principles:
• The RN should always start with the patient’s and
family’s preferred outcomes in mind. The RN is first
clear about the patient’s purpose for accessing care
and his or her picture for a successful outcome.
• The RN should refer to the applicable state nursing
practice statute and rules as well as the organization’s
job descriptions for current information about roles
and responsibilities of RNs, LPNs/LVNs, and APs.
(These are the roles or the parts that people play.)
• Student nurses, novices, float nurses, and other infre-
quent workers also require variable levels of supervi-
sion, guidance, or support (The workers’ abilities and
roles become a piece of the plan.) (NCSBN, 2016b).
• The RN is accountable for nursing judgment deci-
sions and for ongoing supervision of any care that is
delegated or assigned.
• The RN cannot delegate the nursing process (in
particular the assessment, planning, and evaluation
phases) or clinical judgment to a non-RN. Some in-
terventions or data-gathering activities may be del-
egated based on the circumstances.
• The RN must know as much as practical about the
patients and their conditions, as well as the skills and
competency of team members, to prioritize, delegate,
and assign. Decisions must be specifically individual-
ized to the patient, the delegatees, and the situation.
• In a clinical situation, everything is fluid and shift-
ing. No priority, assignment, or delegation is written
indelibly and cannot be altered. The RN in charge of
a unit, a team, or one patient is accountable to choose
the best course to achieve the patient’s and family’s
preferred results.
Best wishes in completing this workbook! The authors
invite you to use the questions as an exercise in assem-
bling the pieces to the puzzle that will become a picture of
health-promoting practice.
REFERENCES
Alfaro-Lefevre R: Critical thinking, clinical reasoning, and clinical
judgment: a practical approach, ed 6, St Louis, 2017, Saunders.
American Nurses Association. National Guidelines for Nursing
Delegation. Effective 4/1/2019, by ANA Board of Directors/
NCSBN Board of Directors. Retrieved April 12, 2019 from
https://www.nursingworld.org/practice- policy/nursing-
excellence/official-position-statements/id/joint-statement-on-
delegation-by-ANA-and-NCSBN/ [file available to members
only at https://www.nursingworld.org/globalassets/practiceand
policy/nursing-excellence/ana-position-statements-secure/ana-
ncsbn-joint-statement-on-delegation.pdf, accessed April 12,
2019.]
American Nurses Association, Duffy M, Fields McCoy S: Delegation
and YOU: when to delegate and to whom, Silver Springs, MD,
2015. ANA.
Bittner N, Gravlin G, Hansten R, Kalisch B: Unraveling care
omissions, J Nurs Adm 41(12):510–512, 2011.
Brous E: Lessons learned from litigation: the case of Bernard
Travaglini, Am J Nurs (114):5:68–70, 2014 5.
Carder PC, O’Keeffe J: State regulation of medication administration
by unlicensed assistive personnel in residential care and adult day
services settings, Res Gerontol Nurs 7:1–14, 2016.
Diab G, Ebrahim R: Factors leading to missed nursing care among
nurses at selected hospitals, Am J Nurs Res 7 (2): 136-147, 2019.
Dyck M, Novotny N: Exploring reported practice habits of
registered nurses and licensed practical nurses at Illinois nursing
homes, J Nurs Reg 9 (2): 18-30, 2018.
Grant V: Sharpening your legal IQ: safeguarding your license,
Viewpoint 38(3):10–12, 2016.
Introduction
PART 1
as lack of care planning, lack of turning or ambula-
tion, delayed or missed nutrition, and lack of hygiene
(Bittner et al., 2011; Kalisch, 2015, pp. 266–270).
These care omissions can be contributing factors
for the occurrence of unreimbursed “never events”
(events that should never occur), such as pressure ul-
cers and pneumonia, as well as prolonged lengths of
stay. Other nurse-sensitive quality indicators such as
catheter-associated urinary tract infections could be
correlated to omitted perineal hygiene and inatten-
tion to discontinuation of catheters. Useful models
that link delegation with care omissions and ensu-
ing care hazards such as thrombosis, pressure inju-
ries, constipation, and infection, combined with a
Swiss Cheese Safety Model showing defensive steps
against health care–acquired conditions and errors
through excellence in RN leadership, can be ac-
cessed in the August 2014 Nurse Leader at https://d
oi.org/10.1016/j.mnl.2013.10.007 (Hansten, 2014a;
Hansten, 2020 in Kelly Vana and Tazbir).
• In perioperative nursing, such omissions as lack of
warming, oral care, head elevation and deep breath-
ing, can lead to postoperative pneumonia and lack of
optimal healing (Ralph and Viljoen, 2018). Many of
these interventions could be delegated or assigned.
Evidence does indicate that appropriate nursing judg-
ment in prioritization, delegation, and supervision can save
time and improve communication and thereby improve
care, patient safety, clinical outcomes, and job satisfaction,
potentially saving patient-days and absenteeism and recruit-
ment costs. Patient satisfaction, staff satisfaction, and clinical
results decline when nursing care is poor. Potential reim-
bursement is lost, patients and families suffer, and the health
of our communities decays when RNs do not assume the
leadership necessary to work effectively with all team mem-
bers (Bittner et al., 2011, Kalisch, 2015, Hansten, 2019).
PRINCIPLES FOR IMPLEMENTATION OF
PRIORITIZATION, DELEGATION, AND
ASSIGNMENT
Return to our goalposts of the four Ps (purpose, picture,
plan, and part) as a framework as you answer the questions
in this workbook and further develop your own expertise
and recall the following principles:
• The RN should always start with the patient’s and
family’s preferred outcomes in mind. The RN is first
clear about the patient’s purpose for accessing care
and his or her picture for a successful outcome.
• The RN should refer to the applicable state nursing
practice statute and rules as well as the organization’s
job descriptions for current information about roles
and responsibilities of RNs, LPNs/LVNs, and APs.
(These are the roles or the parts that people play.)
• Student nurses, novices, float nurses, and other infre-
quent workers also require variable levels of supervi-
sion, guidance, or support (The workers’ abilities and
roles become a piece of the plan.) (NCSBN, 2016b).
• The RN is accountable for nursing judgment deci-
sions and for ongoing supervision of any care that is
delegated or assigned.
• The RN cannot delegate the nursing process (in
particular the assessment, planning, and evaluation
phases) or clinical judgment to a non-RN. Some in-
terventions or data-gathering activities may be del-
egated based on the circumstances.
• The RN must know as much as practical about the
patients and their conditions, as well as the skills and
competency of team members, to prioritize, delegate,
and assign. Decisions must be specifically individual-
ized to the patient, the delegatees, and the situation.
• In a clinical situation, everything is fluid and shift-
ing. No priority, assignment, or delegation is written
indelibly and cannot be altered. The RN in charge of
a unit, a team, or one patient is accountable to choose
the best course to achieve the patient’s and family’s
preferred results.
Best wishes in completing this workbook! The authors
invite you to use the questions as an exercise in assem-
bling the pieces to the puzzle that will become a picture of
health-promoting practice.
REFERENCES
Alfaro-Lefevre R: Critical thinking, clinical reasoning, and clinical
judgment: a practical approach, ed 6, St Louis, 2017, Saunders.
American Nurses Association. National Guidelines for Nursing
Delegation. Effective 4/1/2019, by ANA Board of Directors/
NCSBN Board of Directors. Retrieved April 12, 2019 from
https://www.nursingworld.org/practice- policy/nursing-
excellence/official-position-statements/id/joint-statement-on-
delegation-by-ANA-and-NCSBN/ [file available to members
only at https://www.nursingworld.org/globalassets/practiceand
policy/nursing-excellence/ana-position-statements-secure/ana-
ncsbn-joint-statement-on-delegation.pdf, accessed April 12,
2019.]
American Nurses Association, Duffy M, Fields McCoy S: Delegation
and YOU: when to delegate and to whom, Silver Springs, MD,
2015. ANA.
Bittner N, Gravlin G, Hansten R, Kalisch B: Unraveling care
omissions, J Nurs Adm 41(12):510–512, 2011.
Brous E: Lessons learned from litigation: the case of Bernard
Travaglini, Am J Nurs (114):5:68–70, 2014 5.
Carder PC, O’Keeffe J: State regulation of medication administration
by unlicensed assistive personnel in residential care and adult day
services settings, Res Gerontol Nurs 7:1–14, 2016.
Diab G, Ebrahim R: Factors leading to missed nursing care among
nurses at selected hospitals, Am J Nurs Res 7 (2): 136-147, 2019.
Dyck M, Novotny N: Exploring reported practice habits of
registered nurses and licensed practical nurses at Illinois nursing
homes, J Nurs Reg 9 (2): 18-30, 2018.
Grant V: Sharpening your legal IQ: safeguarding your license,
Viewpoint 38(3):10–12, 2016.
Loading page 20...
Guidelines for Prioritization, Delegation, and Assignment Decisions10Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 1
Hansten R: Relationship and results-oriented healthcare: evaluate
the basics, J Nurs Adm 35(12):522–524, 2005.
Hansten R: Leadership at the point of care: nursing delegation,
2011. Retrieved May 31, 2012, from http://www.MyFreeCE
.com.
Hansten R: Relationship and results oriented healthcare™ planning
and implementation manual, Port Ludlow, Wash, 2008a, Hansten
Healthcare PLLC.
Hansten R: Why nurses still must learn to delegate, Nurse Leader
6(5):19–26, 2008b.
Hansten R, Jackson M: Clinical delegation skills: a handbook for
professional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.
Hansten R: The master coach manual for the relationship & results
oriented healthcare program, Port Ludlow, Wash, 2014b, Hansten
Healthcare PLLC.
Hansten R: Coach as chief correlator of tasks to results through
delegation skill and teamwork development, Nurse Leader, 12
(4):69–73, 2014a.
Hansten R: Another Look at RN leadership skill level
and patient outcomes. LinkedIn Pulse. Retrieved April
21, 2019 from https://www.linkedin.com/pulse/anoth
er-look-rn-leadership-skill-level-patient-hansten-rn-mba-phd.
Hansten R: Delegation, assignment, and supervision in Kelly Vana
P & Tazbir J, ed. Nursing leadership and management, 4th Ed.
Hoboken, NJ. 2020 (in press), Wiley.
Hansten R: Delegation in the clinical setting. In Zerwekh J, Garneau
A, editors: Nursing today: transitions and trends, ed 10, St Louis,
2021, Elsevier.
Interprofessional Education Collaborative. Core competencies
for interprofessional collaborative practice: 2016 update.
Washington, DC: Interprofessional Education Collaborative.
Retrieved April 16, 2019 from 780E69ED19E2B3A5&dispos
ition=0&alloworigin=1.
Kalisch B: Errors of Omission: How missed nursing care imperils
patents. Silver Springs, MD., 2015, ANA.
Kalisch B: Missed nursing care, J Nurs Care Qual 21(4):306–313,
2006.
Maningo MJ, Panthofer N: Appropriate delegation in an ambulatory
care setting AAACN Viewpoint 40 (1): 1-2, 2018.
McMullen TL, Resnick B, Chin-Hansen J, et al: Certified nurse
aide scope of practice: state-by-state differences in allowable
delegated activities, J Am Med Dir Assoc 6(1):20–24, 2015.
Mizne D. 7 fascinating employee engagement trends
for 2018. 15Five.com. Retrieved April 21, 2019 from
https://www.15five.com/blog/7- employee- engagement-
trends-2018/, pp. 1-11, 2018.
McNee B. Nurse morale and its impact on LTC, McKnights Long
-Term Care News, June 28, 2017. Retrieved April 21, 2019
from https://www.mcknights.com/blogs/guest-columns/nurse-
morale-and-its-impact-on-ltc/, pp. 1-2, 2017
Mueller C, Vogelsmeier A, Anderson R, McConnell E, & Corazzini K.
Interchangeability of licensed nurses in nursing homes: perspective
of directors of nursing. The End to End Journal, 1, 1-27, 2018.
National Council of State Boards of Nursing: Delegation: concepts
and decision-making process, Issues December:1–4, 1995.
National Council of State Boards of Nursing. 2018 LPN/VN
Practice Analysis: Linking the NCLEX-PN Examination to
Practice. NCSBN Research Brief vol. 75: March 2019. Retrieved
April 17, 2019 from https://www.ncsbn.org/13443.htm.m 2019.
National Council of State Boards of Nursing: National guidelines
for nursing delegation. J Nurs Reg 7(1):5–14, 2016b. Accessed
April 21, 2019 at https://www.ncsbn.org/NCSBN_Delegation
_Guidelines.pdf
National Council of State Boards of Nursing: Participating states in
the nurse licensure compact implementation. Retrieved April 17,
2019 from https://www.ncsbn.org/compacts.htm., 2019.
QSEN Institute: QSEN Institute Website: QSEN Competencies.
Retrieved April 19, 2019 from http://qsen.org/competencies/
graduate-ksas/.
Ralph N, Viljoen B. Fundamentals of missed care: Implications for
the perioperative environment, ACORN Journal of Perioperative
Nursing 31 (3): Spring, 3-4, 2018.
Revised Code of Washington, Title 18, Chapter 18.79, Section
18.79.260, Registered nurse—activities allowed—delegation of
tasks. Retrieved April 18, 2019 from http://apps.leg.wa.gov/
RCW/default.aspx?cite=18.79.260.
Silvestri L, Silvestri A. Saunders 2018-2019 Strategies for Test
Success: p. 63. St Louis, 2018, Elsevier.
Standing T, Anthony M, Hertz J: Nurses’ narratives of outcomes
after delegation to unlicensed assistive personnel, Outcomes
Manag Nurs Pract 5(1):18–23, 2001.
The Joint Commission. Inadequate hand-off communication.
Sentinel Event Alert Issue 58, September 12, 2017.
Texas Board of Nursing 2013. “Frequently Asked Questions:
Delegation:” P. 2 (1-7), 2013. Retrieved April 21, 2019 from
http://www.bon.texas.gov/faq_delegation.asp#t6.
Voalte: Special Report top 10 clinical communication
trends 2013 pp. 1-16. Retrieved April 24, 2019 from
https://www.voalte.com/press- releases/new- survey- finds-
hospital-nurses-spend-half-shift-tasks-patient-care.
Washington State Administrative Code 246-840-010 Definitions.
Retrieved April 19, 2019 from https://app.leg.wa.gov/wac/defau
lt.aspx?cite=246-840-010, 2019.
Washington State Department of Health Nursing Care Quality
Assurance Commission Advisory Opinion 13.01 2019 Registered
Nurse and Licensed Practical Nurse Scope of Practice, 3-8-2019:
p. 4 (1-12). Retrieved April 25, 2019 from https://www.doh.wa
.gov/Portals/1/Documents/6000/NCAO13.pdf.
RECOMMENDED RESOURCES
Alfaro-Lefevre R: Critical thinking, clinical reasoning, and clinical
judgment: a practical approach, ed 6, St Louis, 2017, Saunders.
Hansten R: The master coach manual for the relationship & results
oriented healthcare program, Port Ludlow, Wash, 2014, Hansten
Healthcare PLLC.
Hansten R: Relationship and results oriented healthcare™ planning
and implementation manual, Port Ludlow, Wash, 2008, Hansten
Healthcare PLLC.
Hansten R, Jackson M: Clinical delegation skills: a handbook for
professional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.
Hansten R. Coach as chief correlator of tasks to results through dele-
gation skill and teamwork development. Nurse Leader 12(4): 69–73.
Hansten Healthcare PLLC website, http://www.Hansten.com
or http://www.RROHC.com. Check for new delegation/
supervision resources, online delegation, and assignment
education modules at http://learning.Hansten.com/.
National Council of State Boards of Nursing website,
http://www.ncsbn.org. Contains links to state boards and
abundant resources relating to delegation and supervision. Also
download the ANA and NCSBN Joint Statement on Delegation.
The decision trees and step-by-step process through the five
rights are exceptionally clear and a great review to prepare for
the NCLEX at https://www.ncsbn.org/NCSBN_Delegation_
Guidelines.pdf and https://www.ncsbn.org/Delegation_joint_st
atement_NCSBN-ANA.pdf
Introduction
PART 1
Hansten R: Relationship and results-oriented healthcare: evaluate
the basics, J Nurs Adm 35(12):522–524, 2005.
Hansten R: Leadership at the point of care: nursing delegation,
2011. Retrieved May 31, 2012, from http://www.MyFreeCE
.com.
Hansten R: Relationship and results oriented healthcare™ planning
and implementation manual, Port Ludlow, Wash, 2008a, Hansten
Healthcare PLLC.
Hansten R: Why nurses still must learn to delegate, Nurse Leader
6(5):19–26, 2008b.
Hansten R, Jackson M: Clinical delegation skills: a handbook for
professional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.
Hansten R: The master coach manual for the relationship & results
oriented healthcare program, Port Ludlow, Wash, 2014b, Hansten
Healthcare PLLC.
Hansten R: Coach as chief correlator of tasks to results through
delegation skill and teamwork development, Nurse Leader, 12
(4):69–73, 2014a.
Hansten R: Another Look at RN leadership skill level
and patient outcomes. LinkedIn Pulse. Retrieved April
21, 2019 from https://www.linkedin.com/pulse/anoth
er-look-rn-leadership-skill-level-patient-hansten-rn-mba-phd.
Hansten R: Delegation, assignment, and supervision in Kelly Vana
P & Tazbir J, ed. Nursing leadership and management, 4th Ed.
Hoboken, NJ. 2020 (in press), Wiley.
Hansten R: Delegation in the clinical setting. In Zerwekh J, Garneau
A, editors: Nursing today: transitions and trends, ed 10, St Louis,
2021, Elsevier.
Interprofessional Education Collaborative. Core competencies
for interprofessional collaborative practice: 2016 update.
Washington, DC: Interprofessional Education Collaborative.
Retrieved April 16, 2019 from 780E69ED19E2B3A5&dispos
ition=0&alloworigin=1.
Kalisch B: Errors of Omission: How missed nursing care imperils
patents. Silver Springs, MD., 2015, ANA.
Kalisch B: Missed nursing care, J Nurs Care Qual 21(4):306–313,
2006.
Maningo MJ, Panthofer N: Appropriate delegation in an ambulatory
care setting AAACN Viewpoint 40 (1): 1-2, 2018.
McMullen TL, Resnick B, Chin-Hansen J, et al: Certified nurse
aide scope of practice: state-by-state differences in allowable
delegated activities, J Am Med Dir Assoc 6(1):20–24, 2015.
Mizne D. 7 fascinating employee engagement trends
for 2018. 15Five.com. Retrieved April 21, 2019 from
https://www.15five.com/blog/7- employee- engagement-
trends-2018/, pp. 1-11, 2018.
McNee B. Nurse morale and its impact on LTC, McKnights Long
-Term Care News, June 28, 2017. Retrieved April 21, 2019
from https://www.mcknights.com/blogs/guest-columns/nurse-
morale-and-its-impact-on-ltc/, pp. 1-2, 2017
Mueller C, Vogelsmeier A, Anderson R, McConnell E, & Corazzini K.
Interchangeability of licensed nurses in nursing homes: perspective
of directors of nursing. The End to End Journal, 1, 1-27, 2018.
National Council of State Boards of Nursing: Delegation: concepts
and decision-making process, Issues December:1–4, 1995.
National Council of State Boards of Nursing. 2018 LPN/VN
Practice Analysis: Linking the NCLEX-PN Examination to
Practice. NCSBN Research Brief vol. 75: March 2019. Retrieved
April 17, 2019 from https://www.ncsbn.org/13443.htm.m 2019.
National Council of State Boards of Nursing: National guidelines
for nursing delegation. J Nurs Reg 7(1):5–14, 2016b. Accessed
April 21, 2019 at https://www.ncsbn.org/NCSBN_Delegation
_Guidelines.pdf
National Council of State Boards of Nursing: Participating states in
the nurse licensure compact implementation. Retrieved April 17,
2019 from https://www.ncsbn.org/compacts.htm., 2019.
QSEN Institute: QSEN Institute Website: QSEN Competencies.
Retrieved April 19, 2019 from http://qsen.org/competencies/
graduate-ksas/.
Ralph N, Viljoen B. Fundamentals of missed care: Implications for
the perioperative environment, ACORN Journal of Perioperative
Nursing 31 (3): Spring, 3-4, 2018.
Revised Code of Washington, Title 18, Chapter 18.79, Section
18.79.260, Registered nurse—activities allowed—delegation of
tasks. Retrieved April 18, 2019 from http://apps.leg.wa.gov/
RCW/default.aspx?cite=18.79.260.
Silvestri L, Silvestri A. Saunders 2018-2019 Strategies for Test
Success: p. 63. St Louis, 2018, Elsevier.
Standing T, Anthony M, Hertz J: Nurses’ narratives of outcomes
after delegation to unlicensed assistive personnel, Outcomes
Manag Nurs Pract 5(1):18–23, 2001.
The Joint Commission. Inadequate hand-off communication.
Sentinel Event Alert Issue 58, September 12, 2017.
Texas Board of Nursing 2013. “Frequently Asked Questions:
Delegation:” P. 2 (1-7), 2013. Retrieved April 21, 2019 from
http://www.bon.texas.gov/faq_delegation.asp#t6.
Voalte: Special Report top 10 clinical communication
trends 2013 pp. 1-16. Retrieved April 24, 2019 from
https://www.voalte.com/press- releases/new- survey- finds-
hospital-nurses-spend-half-shift-tasks-patient-care.
Washington State Administrative Code 246-840-010 Definitions.
Retrieved April 19, 2019 from https://app.leg.wa.gov/wac/defau
lt.aspx?cite=246-840-010, 2019.
Washington State Department of Health Nursing Care Quality
Assurance Commission Advisory Opinion 13.01 2019 Registered
Nurse and Licensed Practical Nurse Scope of Practice, 3-8-2019:
p. 4 (1-12). Retrieved April 25, 2019 from https://www.doh.wa
.gov/Portals/1/Documents/6000/NCAO13.pdf.
RECOMMENDED RESOURCES
Alfaro-Lefevre R: Critical thinking, clinical reasoning, and clinical
judgment: a practical approach, ed 6, St Louis, 2017, Saunders.
Hansten R: The master coach manual for the relationship & results
oriented healthcare program, Port Ludlow, Wash, 2014, Hansten
Healthcare PLLC.
Hansten R: Relationship and results oriented healthcare™ planning
and implementation manual, Port Ludlow, Wash, 2008, Hansten
Healthcare PLLC.
Hansten R, Jackson M: Clinical delegation skills: a handbook for
professional practice, ed 4, Sudbury, Mass, 2009, Jones & Bartlett.
Hansten R. Coach as chief correlator of tasks to results through dele-
gation skill and teamwork development. Nurse Leader 12(4): 69–73.
Hansten Healthcare PLLC website, http://www.Hansten.com
or http://www.RROHC.com. Check for new delegation/
supervision resources, online delegation, and assignment
education modules at http://learning.Hansten.com/.
National Council of State Boards of Nursing website,
http://www.ncsbn.org. Contains links to state boards and
abundant resources relating to delegation and supervision. Also
download the ANA and NCSBN Joint Statement on Delegation.
The decision trees and step-by-step process through the five
rights are exceptionally clear and a great review to prepare for
the NCLEX at https://www.ncsbn.org/NCSBN_Delegation_
Guidelines.pdf and https://www.ncsbn.org/Delegation_joint_st
atement_NCSBN-ANA.pdf
Loading page 21...
Copyright © 2022, Elsevier Inc. All rights reserved.11Prioritization, Delegation, and Assignment in Common
Health ScenariosPART 1
CHAPTER 1
Pain
Questions
1. Based on the principles of pain treatment, which con-
sideration comes first?
1. Treatment is based on patient goals.
2. A multidisciplinary approach is needed.
3. Patient’s perception of pain must be accepted.
4. Drug side effects must be prevented and managed.
2. According to Centers for Disease Control and
Prevention (CDC) guidelines for opioid use for pa-
tients with chronic pain, which actions are part of the
nurse’s responsibility related to the current opioid cri-
sis? Select all that apply.
1. Recognize that negative attitudes toward substance
abusers is a barrier to patient compliance.
2. Access electronic prescription drug monitor-
ing program whenever patients receive an opioid
prescription.
3. Learn to recognize the signs and symptoms of opi-
oid overdose and the proper use of naloxone.
4. Use a tone of voice and facial expression that con-
vey acceptance and understanding of patients who
are addicted.
5. Report health care providers who fail to safely pre-
scribe opioids according to the guidelines.
3. On the first day after surgery, a patient who is on a
patient-controlled analgesia pump reports that the
pain control is inadequate. Which action would the
nurse take first?
1. Deliver the bolus dose per standing order.
2. Contact the health care provider (HCP) to increase
the dose.
3. Try nonpharmacologic comfort measures.
4. Assess the pain for location, quality, and intensity.
4. The team is providing emergency care to a patient
who received an excessive dose of opioid pain medica-
tion. Which task is best to assign to the LPN/LVN?
1. Calling the health care provider (HCP) to re-
port SBAR (situation, background, assessment,
recommendation)
2. Giving naloxone and evaluating response to therapy
3. Monitoring the respiratory status for the first 30
minutes
4. Applying oxygen per nasal cannula as ordered
5. What is the best way to schedule medication for a
patient with constant pain?
1. As needed at the patient’s request
2. Before painful procedures
3. IV bolus after pain assessment
4. Around-the-clock
6. Which patient is at greatest risk for respiratory de-
pression when receiving opioids for analgesia?
1. Older adult patient with chronic pain related to
joint immobility
2. Patient with a heroin addiction and back pain
3. Young female patient with advanced multiple
myeloma
4. Opioid-naïve adolescent with an arm fracture and
cystic fibrosis
7. The home health nurse is interviewing an older patient
with a history of rheumatoid arthritis who reports
“feeling pretty good, except for the pain and stiffness
in my joints when I first get out of bed.” Which mem-
ber of the health care team would be notified to aid in
the patient’s pain?
1. Health care provider to review the dosage and fre-
quency of pain medication
2. Physical therapist for evaluation of function and
possible exercise therapy
3. Social worker to locate community resources for
complementary therapy
4. Home health aide to help patient with a warm
shower in the morning
8. A patient with diabetic neuropathy reports a burn-
ing, electrical-type pain in the lower extremities that
is worse at night and not responding to nonsteroidal
antiinflammatory drugs. Which medication will the
nurse advocate for first?
1. Gabapentin
Health ScenariosPART 1
CHAPTER 1
Pain
Questions
1. Based on the principles of pain treatment, which con-
sideration comes first?
1. Treatment is based on patient goals.
2. A multidisciplinary approach is needed.
3. Patient’s perception of pain must be accepted.
4. Drug side effects must be prevented and managed.
2. According to Centers for Disease Control and
Prevention (CDC) guidelines for opioid use for pa-
tients with chronic pain, which actions are part of the
nurse’s responsibility related to the current opioid cri-
sis? Select all that apply.
1. Recognize that negative attitudes toward substance
abusers is a barrier to patient compliance.
2. Access electronic prescription drug monitor-
ing program whenever patients receive an opioid
prescription.
3. Learn to recognize the signs and symptoms of opi-
oid overdose and the proper use of naloxone.
4. Use a tone of voice and facial expression that con-
vey acceptance and understanding of patients who
are addicted.
5. Report health care providers who fail to safely pre-
scribe opioids according to the guidelines.
3. On the first day after surgery, a patient who is on a
patient-controlled analgesia pump reports that the
pain control is inadequate. Which action would the
nurse take first?
1. Deliver the bolus dose per standing order.
2. Contact the health care provider (HCP) to increase
the dose.
3. Try nonpharmacologic comfort measures.
4. Assess the pain for location, quality, and intensity.
4. The team is providing emergency care to a patient
who received an excessive dose of opioid pain medica-
tion. Which task is best to assign to the LPN/LVN?
1. Calling the health care provider (HCP) to re-
port SBAR (situation, background, assessment,
recommendation)
2. Giving naloxone and evaluating response to therapy
3. Monitoring the respiratory status for the first 30
minutes
4. Applying oxygen per nasal cannula as ordered
5. What is the best way to schedule medication for a
patient with constant pain?
1. As needed at the patient’s request
2. Before painful procedures
3. IV bolus after pain assessment
4. Around-the-clock
6. Which patient is at greatest risk for respiratory de-
pression when receiving opioids for analgesia?
1. Older adult patient with chronic pain related to
joint immobility
2. Patient with a heroin addiction and back pain
3. Young female patient with advanced multiple
myeloma
4. Opioid-naïve adolescent with an arm fracture and
cystic fibrosis
7. The home health nurse is interviewing an older patient
with a history of rheumatoid arthritis who reports
“feeling pretty good, except for the pain and stiffness
in my joints when I first get out of bed.” Which mem-
ber of the health care team would be notified to aid in
the patient’s pain?
1. Health care provider to review the dosage and fre-
quency of pain medication
2. Physical therapist for evaluation of function and
possible exercise therapy
3. Social worker to locate community resources for
complementary therapy
4. Home health aide to help patient with a warm
shower in the morning
8. A patient with diabetic neuropathy reports a burn-
ing, electrical-type pain in the lower extremities that
is worse at night and not responding to nonsteroidal
antiinflammatory drugs. Which medication will the
nurse advocate for first?
1. Gabapentin
Loading page 22...
CHAPTeR 1 Pain12Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
2. Corticosteroids
3. Hydromorphone
4. Lorazepam
9. When an analgesic is titrated to manage pain, what is
the priority goal?
1. Titrate to the smallest dose that provides relief
with the fewest side effects.
2. Titrate upward until the patient is pain free or an
acceptable level is reached.
3. Titrate downward to prevent toxicity, overdose, and
adverse effects.
4. Titrate to a dosage that is adequate to meet the
patient’s subjective needs.
10. According to recent guidelines from the American
Pain Society in collaboration with the American
Society of Anesthesiologists, which pain management
strategies are important for postsurgical patients?
Select all that apply.
1. Acetaminophen and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) for management of
postoperative pain in adults and children without
contraindications
2. Surgical site–specific peripheral regional anesthetic
techniques in adults and children for procedures
3. Neuraxial (epidural) analgesia for major thoracic
and abdominal procedures if the patient has risk
for cardiac complications or prolonged ileus
4. Multimodal therapy that could include opioids
and nonopioid therapies, regional anesthetic tech-
niques, and nonpharmacologic therapies
5. IV administration of opioids, rather than oral opi-
oids, for postoperative analgesia
6. Pain specialists to manage the postoperative pain
for all surgical patients
11. When a patient stoically abides with his parent’s en-
couragement to “tough out the pain” rather than risk
an addiction to opioids, the nurse recognizes that the
sociocultural dimension of pain is the current pri
ority for the patient. Which question will the nurse
ask?
1. “Where is the pain located, and does it radiate to
other parts of your body?”
2. “How would you describe the pain, and how is it
affecting you?”
3. “What do you believe about pain medication and
drug addiction?”
4. “How is the pain affecting your activity level and
your ability to function?”
12. Which patient is most likely to receive opioids for ex-
tended periods of time?
1. A patient with fibromyalgia
2. A patient with phantom limb pain in the leg
3. A patient with progressive pancreatic cancer
4. A patient with trigeminal neuralgia
13. The nurse is caring for a postoperative patient who re-
ports pain. Based on recent evidence-based guidelines,
which approach would be best?
1. Multimodal strategies
2. Standing orders by protocol
3. Intravenous patient-controlled analgesia (PCA)
4. Opioid dosage based on valid numerical scale
14. A newly graduated RN has correctly documented
dose and time of medication, but there is no docu-
mentation regarding nonpharmaceutical measures.
What action should the charge nurse take first?
1. Make a note in the nurse’s file and continue to ob-
serve clinical performance.
2. Refer the new nurse to the in-service education
department.
3. Quiz the nurse about knowledge of pain manage-
ment and pharmacology.
4. Give praise for documenting dose and time and
discuss documentation deficits.
15. Which patients must be assigned to an experienced
RN? Select all that apply.
1. Patient who was in an automobile crash and sus-
tained multiple injuries
2. Patient with chronic back pain related to a work-
place injury
3. Patient who has returned from surgery and has a
chest tube in place
4. Patient with abdominal cramps related to food
poisoning
5. Patient with a severe headache of unknown origin
6. Patient with chest pain who has a history of
arteriosclerosis
16. Which postoperative patient is manifesting the
most serious negative effect of inadequate pain
management?
1. Demonstrates continuous use of call bell related to
unsatisfied needs and discomfort
2. Develops venous thromboembolism because of im-
mobility caused by pain and discomfort
3. Refuses to participate in physical therapy because
of fear of pain caused by exercises
4. Feels depressed about loss of function and hopeless
about getting relief from pain
17. The nurse is considering seeking clarification for sev-
eral prescriptions of pain medication. Which patient
circumstance is the priority concern?
1. A 35-year-old opioid-naïve adult will receive a
basal dose of morphine via IV patient-controlled
analgesia.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
2. Corticosteroids
3. Hydromorphone
4. Lorazepam
9. When an analgesic is titrated to manage pain, what is
the priority goal?
1. Titrate to the smallest dose that provides relief
with the fewest side effects.
2. Titrate upward until the patient is pain free or an
acceptable level is reached.
3. Titrate downward to prevent toxicity, overdose, and
adverse effects.
4. Titrate to a dosage that is adequate to meet the
patient’s subjective needs.
10. According to recent guidelines from the American
Pain Society in collaboration with the American
Society of Anesthesiologists, which pain management
strategies are important for postsurgical patients?
Select all that apply.
1. Acetaminophen and/or nonsteroidal anti-
inflammatory drugs (NSAIDs) for management of
postoperative pain in adults and children without
contraindications
2. Surgical site–specific peripheral regional anesthetic
techniques in adults and children for procedures
3. Neuraxial (epidural) analgesia for major thoracic
and abdominal procedures if the patient has risk
for cardiac complications or prolonged ileus
4. Multimodal therapy that could include opioids
and nonopioid therapies, regional anesthetic tech-
niques, and nonpharmacologic therapies
5. IV administration of opioids, rather than oral opi-
oids, for postoperative analgesia
6. Pain specialists to manage the postoperative pain
for all surgical patients
11. When a patient stoically abides with his parent’s en-
couragement to “tough out the pain” rather than risk
an addiction to opioids, the nurse recognizes that the
sociocultural dimension of pain is the current pri
ority for the patient. Which question will the nurse
ask?
1. “Where is the pain located, and does it radiate to
other parts of your body?”
2. “How would you describe the pain, and how is it
affecting you?”
3. “What do you believe about pain medication and
drug addiction?”
4. “How is the pain affecting your activity level and
your ability to function?”
12. Which patient is most likely to receive opioids for ex-
tended periods of time?
1. A patient with fibromyalgia
2. A patient with phantom limb pain in the leg
3. A patient with progressive pancreatic cancer
4. A patient with trigeminal neuralgia
13. The nurse is caring for a postoperative patient who re-
ports pain. Based on recent evidence-based guidelines,
which approach would be best?
1. Multimodal strategies
2. Standing orders by protocol
3. Intravenous patient-controlled analgesia (PCA)
4. Opioid dosage based on valid numerical scale
14. A newly graduated RN has correctly documented
dose and time of medication, but there is no docu-
mentation regarding nonpharmaceutical measures.
What action should the charge nurse take first?
1. Make a note in the nurse’s file and continue to ob-
serve clinical performance.
2. Refer the new nurse to the in-service education
department.
3. Quiz the nurse about knowledge of pain manage-
ment and pharmacology.
4. Give praise for documenting dose and time and
discuss documentation deficits.
15. Which patients must be assigned to an experienced
RN? Select all that apply.
1. Patient who was in an automobile crash and sus-
tained multiple injuries
2. Patient with chronic back pain related to a work-
place injury
3. Patient who has returned from surgery and has a
chest tube in place
4. Patient with abdominal cramps related to food
poisoning
5. Patient with a severe headache of unknown origin
6. Patient with chest pain who has a history of
arteriosclerosis
16. Which postoperative patient is manifesting the
most serious negative effect of inadequate pain
management?
1. Demonstrates continuous use of call bell related to
unsatisfied needs and discomfort
2. Develops venous thromboembolism because of im-
mobility caused by pain and discomfort
3. Refuses to participate in physical therapy because
of fear of pain caused by exercises
4. Feels depressed about loss of function and hopeless
about getting relief from pain
17. The nurse is considering seeking clarification for sev-
eral prescriptions of pain medication. Which patient
circumstance is the priority concern?
1. A 35-year-old opioid-naïve adult will receive a
basal dose of morphine via IV patient-controlled
analgesia.
Loading page 23...
CHAPTeR 1 Pain 13Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
2. A 65-year-old adult will be discharged with a pre-
scription for nonsteroidal antiinflammatory drugs
(NSAIDs).
3. A 25-year-old adult is prescribed as-needed intra-
muscular (IM) analgesic for pain.
4. A 45-year-old adult is taking oral fluids and foods
and has orders for IV morphine.
18. Which patient has the most immediate need for IV
access to deliver analgesia with rapid titration?
1. Patient who has sharp chest pain that increases
with cough and shortness of breath
2. Patient who reports excruciating lower back pain
with hematuria
3. Patient who is having an acute myocardial infarc-
tion with severe chest pain
4. Patient who is having a severe migraine with an
elevated blood pressure
19. A patient received as-needed morphine, lorazepam,
and cyclobenzaprine. The unlicensed assistive person-
nel (AP) reports that the patient has a respiratory rate
of 10 breaths/min. Which action is the priority?
1. Call the health care provider to obtain a prescrip-
tion for naloxone.
2. Assess the patient’s responsiveness and respiratory
status.
3. Obtain a bag-valve mask and deliver breaths at 20
breaths/min.
4. Double-check the prescription to see which drugs
were prescribed.
20. The patient is diagnosed with an acute migraine by the
health care provider (HCP). For which situation is it
most important to have a discussion with the HCP
before medication is prescribed?
1. The HCP is considering dexamethasone, and the
patient has type 2 diabetes.
2. The HCP is considering subcutaneous sumatriptan,
and the patient took ergotamine 3 hours ago.
3. The HCP is considering valproate sodium, and
the patient recently started birth control pills.
4. The HCP is considering prochlorperazine, and the
patient drove himself to the hospital.
21. A patient is crying and grimacing but denies pain and
refuses opioid medication because “my brother is a
drug addict and has ruined our lives.” Which inter-
vention is the priority for this patient?
1. Encourage expression of fears and past experiences.
2. Respect the patient’s wishes and use nonpharma-
cologic therapies.
3. Explain that addiction is unlikely when opioids are
used for acute pain.
4. Seek family assistance to support the prescribed
therapy.
22. A patient’s opioid therapy is being tapered off, and the
nurse is watchful for signs of withdrawal. What is one
of the first signs of withdrawal?
1. Fever
2. Nausea
3. Diaphoresis
4. Abdominal cramps
23. In the care of patients with pain and discomfort,
which task is most appropriate to delegate to unli-
censed assistive personnel (AP)?
1. Assisting the patient with preparation of a sitz
bath
2. Monitoring the patient for signs of discomfort
while ambulating
3. Coaching the patient to deep breathe during pain-
ful procedures
4. Evaluating relief after applying a cold compress
24. The health care provider (HCP) prescribed a placebo
for a patient with chronic pain. The newly hired nurse
feels very uncomfortable administering a placebo.
Which action would the new nurse take first?
1. Prepare the prescribed placebo and hand it to the
HCP.
2. Check the hospital policy regarding the use of a
placebo.
3. Follow a personal code of ethics and refuse to
participate.
4. Contact the charge nurse for advice and
suggestions.
25. For a cognitively impaired patient who cannot accu-
rately report pain, which action would the nurse take
first?
1. Closely assess for nonverbal signs such as grimac-
ing or rocking.
2. Obtain baseline behavioral indicators from family
members.
3. Note the time of and patient’s response to the last
dose of analgesic.
4. Give the maximum as-needed dose within the
minimum time frame for relief.
26. A patient with chronic pain reports to the charge
nurse that the other nurses have not been responding
to requests for pain medication. What is the charge
nurse’s initial action?
1. Check the medication administration records for
the past several days.
2. Ask the nurse educator to provide in-service train-
ing about pain management.
3. Perform a complete pain assessment on the patient
and take a pain history.
4. Have a conference with the staff nurses to assess
their care of this patient.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
2. A 65-year-old adult will be discharged with a pre-
scription for nonsteroidal antiinflammatory drugs
(NSAIDs).
3. A 25-year-old adult is prescribed as-needed intra-
muscular (IM) analgesic for pain.
4. A 45-year-old adult is taking oral fluids and foods
and has orders for IV morphine.
18. Which patient has the most immediate need for IV
access to deliver analgesia with rapid titration?
1. Patient who has sharp chest pain that increases
with cough and shortness of breath
2. Patient who reports excruciating lower back pain
with hematuria
3. Patient who is having an acute myocardial infarc-
tion with severe chest pain
4. Patient who is having a severe migraine with an
elevated blood pressure
19. A patient received as-needed morphine, lorazepam,
and cyclobenzaprine. The unlicensed assistive person-
nel (AP) reports that the patient has a respiratory rate
of 10 breaths/min. Which action is the priority?
1. Call the health care provider to obtain a prescrip-
tion for naloxone.
2. Assess the patient’s responsiveness and respiratory
status.
3. Obtain a bag-valve mask and deliver breaths at 20
breaths/min.
4. Double-check the prescription to see which drugs
were prescribed.
20. The patient is diagnosed with an acute migraine by the
health care provider (HCP). For which situation is it
most important to have a discussion with the HCP
before medication is prescribed?
1. The HCP is considering dexamethasone, and the
patient has type 2 diabetes.
2. The HCP is considering subcutaneous sumatriptan,
and the patient took ergotamine 3 hours ago.
3. The HCP is considering valproate sodium, and
the patient recently started birth control pills.
4. The HCP is considering prochlorperazine, and the
patient drove himself to the hospital.
21. A patient is crying and grimacing but denies pain and
refuses opioid medication because “my brother is a
drug addict and has ruined our lives.” Which inter-
vention is the priority for this patient?
1. Encourage expression of fears and past experiences.
2. Respect the patient’s wishes and use nonpharma-
cologic therapies.
3. Explain that addiction is unlikely when opioids are
used for acute pain.
4. Seek family assistance to support the prescribed
therapy.
22. A patient’s opioid therapy is being tapered off, and the
nurse is watchful for signs of withdrawal. What is one
of the first signs of withdrawal?
1. Fever
2. Nausea
3. Diaphoresis
4. Abdominal cramps
23. In the care of patients with pain and discomfort,
which task is most appropriate to delegate to unli-
censed assistive personnel (AP)?
1. Assisting the patient with preparation of a sitz
bath
2. Monitoring the patient for signs of discomfort
while ambulating
3. Coaching the patient to deep breathe during pain-
ful procedures
4. Evaluating relief after applying a cold compress
24. The health care provider (HCP) prescribed a placebo
for a patient with chronic pain. The newly hired nurse
feels very uncomfortable administering a placebo.
Which action would the new nurse take first?
1. Prepare the prescribed placebo and hand it to the
HCP.
2. Check the hospital policy regarding the use of a
placebo.
3. Follow a personal code of ethics and refuse to
participate.
4. Contact the charge nurse for advice and
suggestions.
25. For a cognitively impaired patient who cannot accu-
rately report pain, which action would the nurse take
first?
1. Closely assess for nonverbal signs such as grimac-
ing or rocking.
2. Obtain baseline behavioral indicators from family
members.
3. Note the time of and patient’s response to the last
dose of analgesic.
4. Give the maximum as-needed dose within the
minimum time frame for relief.
26. A patient with chronic pain reports to the charge
nurse that the other nurses have not been responding
to requests for pain medication. What is the charge
nurse’s initial action?
1. Check the medication administration records for
the past several days.
2. Ask the nurse educator to provide in-service train-
ing about pain management.
3. Perform a complete pain assessment on the patient
and take a pain history.
4. Have a conference with the staff nurses to assess
their care of this patient.
Loading page 24...
CHAPTeR 1 Pain14Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
27. According to recent guidelines from the Center for
Disease Control and Prevention for prescribing/us-
ing opioid medication for chronic pain, which pre-
scriptions would the nurse question because of the
increased risk for opioid overdose? Select all that
apply.
1. Extended-release/long-acting (ER/LA) transder-
mal fentanyl for a patient with fibromyalgia
2. Time-scheduled ER/LA oxycodone for a patient
with chronic low back pain
3. As-needed (PRN) morphine for arthritis pain for
an elderly patient with sleep apnea
4. 90 morphine milligram equivalents/day for a pa-
tient who has a hip fracture
5. ER/LA methadone PRN for a patient with head-
ache pain
6. Patient-controlled analgesia (PCA) morphine for a
patient with postsurgical abdominal pain
28. Which patients can be appropriately assigned to a
newly graduated RN who has recently completed ori-
entation? Select all that apply.
1. Anxious patient with chronic pain who frequently
uses the call button
2. Patient on the second postoperative day who needs
pain medication before dressing changes
3. Patient with acquired immune deficiency syndrome
who reports headache and abdominal and pleuritic
chest pain
4. Patient with chronic pain who is to be discharged
with a new surgically implanted catheter
5. Patient who is reporting pain at the site of a pe-
ripheral IV line
6. Patient with a kidney stone who needs frequent
as-needed pain medication
29. A patient’s spouse comes to the nurse’s station and
says, “He needs more pain medicine. He is still having
a lot of pain.” Which response is best?
1. “The medication is prescribed to be given every 4
hours.”
2. “If medication is given too frequently, there are ill
effects.”
3. “Please tell him that I will be right there to check
on him.”
4. “Let’s wait 40 minutes. If he still hurts, I’ll call the
health care provider.”
30. A patient with pain disorder and depression has
chronic low back pain. He states, “None of these doc-
tors has done anything to help.” Which patient state-
ment is cause for greatest concern?
1. “I twisted my back last night, and now the pain is a
lot worse.”
2. “I’m so sick of this pain. I think I’m going to find a
way to end it.”
3. “Occasionally, I buy pain killers from a guy in my
neighborhood.”
4. “I’m going to sue you and the doctor; you aren’t do-
ing anything for me.”
31. A patient has severe pain and bladder distention re-
lated to urinary retention and possible obstruction;
insertion of an indwelling catheter is prescribed. An
experienced unlicensed assistive personnel (AP) states
that she is trained to do this procedure. Which task
can be delegated to this AP?
1. Assessing the bladder distention and the pain as-
sociated with urinary retention
2. Inserting the indwelling catheter after verifying her
knowledge of sterile technique
3. Evaluating the relief of pain and bladder distention
after the catheter is inserted
4. Measuring the urine output after the catheter is in-
serted and obtaining a specimen
32. The nurse is caring for a young man with a history
of substance abuse who had exploratory abdominal
surgery 4 days ago for a knife wound. There is a pre-
scription to discontinue the morphine via patient-
controlled analgesia and to start oral pain medication.
The patient begs, “Please don’t stop the morphine. My
pain is really a lot worse today than it was yesterday.”
Which response is best?
1. “Let me stop the pump; we can try oral pain medi-
cation to see if it gives relief.”
2. “I realize that you are scared of the pain, but we
must try to wean you off the pump.”
3. “Show me where your pain is and describe how it
feels compared with yesterday.”
4. “Let’s take your vital signs; then I will call the
health care provider.”
33. The nurse is working with a health care provider
who prescribes opioid doses based on a specif-
ic pain intensity rating (dosing to the numbers).
Which patient circumstance is cause for greatest
concern?
1. A 73-year-old frail female patient with a history
of chronic obstructive pulmonary disease is pre-
scribed 4 mg IV morphine for pain of 1 to 3 on a
scale of 0 to 10.
2. A 25-year-old postoperative male patient with a
history of opioid addiction is prescribed one tablet
of oxycodone and acetaminophen for pain of 4 to 5
on a scale of 0 to 10.
3. A 33-year-old opioid-naïve female patient who has
a severe migraine headache is prescribed 5 mg IV
morphine for pain of 7 to 8 on a scale of 0 to 10.
4. A 60-year-old male with a history of rheumatoid
arthritis is prescribed one tablet of hydromorphone
for pain of 5 to 6 on scale of 0 to 10.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
27. According to recent guidelines from the Center for
Disease Control and Prevention for prescribing/us-
ing opioid medication for chronic pain, which pre-
scriptions would the nurse question because of the
increased risk for opioid overdose? Select all that
apply.
1. Extended-release/long-acting (ER/LA) transder-
mal fentanyl for a patient with fibromyalgia
2. Time-scheduled ER/LA oxycodone for a patient
with chronic low back pain
3. As-needed (PRN) morphine for arthritis pain for
an elderly patient with sleep apnea
4. 90 morphine milligram equivalents/day for a pa-
tient who has a hip fracture
5. ER/LA methadone PRN for a patient with head-
ache pain
6. Patient-controlled analgesia (PCA) morphine for a
patient with postsurgical abdominal pain
28. Which patients can be appropriately assigned to a
newly graduated RN who has recently completed ori-
entation? Select all that apply.
1. Anxious patient with chronic pain who frequently
uses the call button
2. Patient on the second postoperative day who needs
pain medication before dressing changes
3. Patient with acquired immune deficiency syndrome
who reports headache and abdominal and pleuritic
chest pain
4. Patient with chronic pain who is to be discharged
with a new surgically implanted catheter
5. Patient who is reporting pain at the site of a pe-
ripheral IV line
6. Patient with a kidney stone who needs frequent
as-needed pain medication
29. A patient’s spouse comes to the nurse’s station and
says, “He needs more pain medicine. He is still having
a lot of pain.” Which response is best?
1. “The medication is prescribed to be given every 4
hours.”
2. “If medication is given too frequently, there are ill
effects.”
3. “Please tell him that I will be right there to check
on him.”
4. “Let’s wait 40 minutes. If he still hurts, I’ll call the
health care provider.”
30. A patient with pain disorder and depression has
chronic low back pain. He states, “None of these doc-
tors has done anything to help.” Which patient state-
ment is cause for greatest concern?
1. “I twisted my back last night, and now the pain is a
lot worse.”
2. “I’m so sick of this pain. I think I’m going to find a
way to end it.”
3. “Occasionally, I buy pain killers from a guy in my
neighborhood.”
4. “I’m going to sue you and the doctor; you aren’t do-
ing anything for me.”
31. A patient has severe pain and bladder distention re-
lated to urinary retention and possible obstruction;
insertion of an indwelling catheter is prescribed. An
experienced unlicensed assistive personnel (AP) states
that she is trained to do this procedure. Which task
can be delegated to this AP?
1. Assessing the bladder distention and the pain as-
sociated with urinary retention
2. Inserting the indwelling catheter after verifying her
knowledge of sterile technique
3. Evaluating the relief of pain and bladder distention
after the catheter is inserted
4. Measuring the urine output after the catheter is in-
serted and obtaining a specimen
32. The nurse is caring for a young man with a history
of substance abuse who had exploratory abdominal
surgery 4 days ago for a knife wound. There is a pre-
scription to discontinue the morphine via patient-
controlled analgesia and to start oral pain medication.
The patient begs, “Please don’t stop the morphine. My
pain is really a lot worse today than it was yesterday.”
Which response is best?
1. “Let me stop the pump; we can try oral pain medi-
cation to see if it gives relief.”
2. “I realize that you are scared of the pain, but we
must try to wean you off the pump.”
3. “Show me where your pain is and describe how it
feels compared with yesterday.”
4. “Let’s take your vital signs; then I will call the
health care provider.”
33. The nurse is working with a health care provider
who prescribes opioid doses based on a specif-
ic pain intensity rating (dosing to the numbers).
Which patient circumstance is cause for greatest
concern?
1. A 73-year-old frail female patient with a history
of chronic obstructive pulmonary disease is pre-
scribed 4 mg IV morphine for pain of 1 to 3 on a
scale of 0 to 10.
2. A 25-year-old postoperative male patient with a
history of opioid addiction is prescribed one tablet
of oxycodone and acetaminophen for pain of 4 to 5
on a scale of 0 to 10.
3. A 33-year-old opioid-naïve female patient who has
a severe migraine headache is prescribed 5 mg IV
morphine for pain of 7 to 8 on a scale of 0 to 10.
4. A 60-year-old male with a history of rheumatoid
arthritis is prescribed one tablet of hydromorphone
for pain of 5 to 6 on scale of 0 to 10.
Loading page 25...
CHAPTeR 1 Pain 15Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
34. Which nursing action is the best example of the prin-
ciple of nonmaleficence as an ethical consideration in
pain management?
1. Patient seems excessively sedated but continues
to ask for morphine, so the nurse conducts fur-
ther assessment and seeks alternatives to opioid
medication.
2. Patient has no known disease disorders and no
objective signs of poor health or injury, but re-
ports severe pain, so nurse advocates for pain
medicine.
3. Patient is older, but he is mentally alert and dem-
onstrates good judgment, so the nurse encourages
the patient to verbalize personal goals for pain
management.
4. Patient repeatedly refuses pain medication but
shows grimacing and reluctance to move, so
the nurse explains the benefits of taking pain
medication.
35. The nurse is assessing a patient who has been receiving
opioid medication via patient-controlled analgesia.
Which early sign alerts the nurse to a possible adverse
opioid reaction?
1. Patient reports shortness of breath.
2. Patient is more difficult to arouse.
3. Patient is more anxious and nervous.
4. Patient reports pain is worsening.
36. The charge nurse of a long-term care facility is review-
ing the methods and assessment tools that are being
used to assess the residents’ pain. Which nurse is using
the best method to assess pain?
1. Nurse A uses a behavioral assessment tool when
the resident is engaged in activities.
2. Nurse B asks a resident who doesn’t speak English
to point to the location of pain.
3. Nurse C uses the same numerical rating scale every
day for the same resident.
4. Nurse D asks the daughter of a confused patient to
describe the resident’s pain.
37. For which of these patients is IV morphine the first-
line choice for pain management?
1. A 33-year-old intrapartum patient needs pain re-
lief for labor contractions.
2. A 24-year-old patient reports severe headache re-
lated to being hit in the head.
3. A 56-year-old patient reports breakthrough bone
pain related to multiple myeloma.
4. A 73-year-old patient reports chronic pain associ-
ated with hip replacement surgery.
38. The patient is prescribed a fentanyl patch for persis-
tent severe pain. Which patient behavior most ur-
gently requires correction?
1. Frequently likes to sit in the hot tub to reduce joint
stiffness
2. Prefers to place the patch only on the upper ante-
rior chest wall
3. Saves and reuses the old patches when he can’t af-
ford new ones
4. Changes the patch every 4 days rather than the
prescribed 72 hours
39. The home health nurse discovers that an older adult
patient has been sharing his pain medication with his
daughter. He acknowledges the dangers of sharing,
but states, “My daughter can’t afford to see a doctor
or buy medicine, so I must give her a few of my pain
pills.” Which member of the health care team would
the nurse consult first?
1. Health care provider to renew the prescription so
that the patient has enough medicine
2. Pharmacist to monitor the frequency of the pre-
scription refills
3. Social worker to help the family locate resources
for health care
4. Home health aide to watch for inappropriate med-
ication usage by family
40. For a postoperative patient, the health care provider
(HCP) prescribed multimodal therapy, which includes
acetaminophen, nonsteroidal antiinflammatory drugs,
as-needed (PRN) opioids, and nonpharmaceutical in-
terventions. The patient continuously asks for the PRN
opioid, and the nurse suspects that the patient may have
a drug abuse problem. Which action by the nurse is best?
1. Administer acetaminophen and spend extra time
with the patient.
2. Explain that opioid medication is reserved for
moderate to severe pain.
3. Give the opioid because the patient deserves relief
and drug abuse is unconfirmed.
4. Ask the HCP to validate suspicions of drug abuse
and alter the opioid prescription.
41. An inexperienced new nurse compares the medication ad-
ministration record (MAR) and the health care provider’s
(HCP’s) prescription for a patient who has a patient-
controlled analgesia (PCA) pump for pain management.
Both the MAR and prescription indicate that larger doses
are prescribed at night compared with doses throughout
the day. Who would the new nurse consult first?
1. Ask the patient if he typically needs extra medica-
tion in the evening.
2. Ask the HCP to verify that the larger amount is
the correct dose.
3. Ask the pharmacist to confirm the dosage on the
original prescription.
4. Ask the charge nurse if this is a typical dosage for
nighttime PCA.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
34. Which nursing action is the best example of the prin-
ciple of nonmaleficence as an ethical consideration in
pain management?
1. Patient seems excessively sedated but continues
to ask for morphine, so the nurse conducts fur-
ther assessment and seeks alternatives to opioid
medication.
2. Patient has no known disease disorders and no
objective signs of poor health or injury, but re-
ports severe pain, so nurse advocates for pain
medicine.
3. Patient is older, but he is mentally alert and dem-
onstrates good judgment, so the nurse encourages
the patient to verbalize personal goals for pain
management.
4. Patient repeatedly refuses pain medication but
shows grimacing and reluctance to move, so
the nurse explains the benefits of taking pain
medication.
35. The nurse is assessing a patient who has been receiving
opioid medication via patient-controlled analgesia.
Which early sign alerts the nurse to a possible adverse
opioid reaction?
1. Patient reports shortness of breath.
2. Patient is more difficult to arouse.
3. Patient is more anxious and nervous.
4. Patient reports pain is worsening.
36. The charge nurse of a long-term care facility is review-
ing the methods and assessment tools that are being
used to assess the residents’ pain. Which nurse is using
the best method to assess pain?
1. Nurse A uses a behavioral assessment tool when
the resident is engaged in activities.
2. Nurse B asks a resident who doesn’t speak English
to point to the location of pain.
3. Nurse C uses the same numerical rating scale every
day for the same resident.
4. Nurse D asks the daughter of a confused patient to
describe the resident’s pain.
37. For which of these patients is IV morphine the first-
line choice for pain management?
1. A 33-year-old intrapartum patient needs pain re-
lief for labor contractions.
2. A 24-year-old patient reports severe headache re-
lated to being hit in the head.
3. A 56-year-old patient reports breakthrough bone
pain related to multiple myeloma.
4. A 73-year-old patient reports chronic pain associ-
ated with hip replacement surgery.
38. The patient is prescribed a fentanyl patch for persis-
tent severe pain. Which patient behavior most ur-
gently requires correction?
1. Frequently likes to sit in the hot tub to reduce joint
stiffness
2. Prefers to place the patch only on the upper ante-
rior chest wall
3. Saves and reuses the old patches when he can’t af-
ford new ones
4. Changes the patch every 4 days rather than the
prescribed 72 hours
39. The home health nurse discovers that an older adult
patient has been sharing his pain medication with his
daughter. He acknowledges the dangers of sharing,
but states, “My daughter can’t afford to see a doctor
or buy medicine, so I must give her a few of my pain
pills.” Which member of the health care team would
the nurse consult first?
1. Health care provider to renew the prescription so
that the patient has enough medicine
2. Pharmacist to monitor the frequency of the pre-
scription refills
3. Social worker to help the family locate resources
for health care
4. Home health aide to watch for inappropriate med-
ication usage by family
40. For a postoperative patient, the health care provider
(HCP) prescribed multimodal therapy, which includes
acetaminophen, nonsteroidal antiinflammatory drugs,
as-needed (PRN) opioids, and nonpharmaceutical in-
terventions. The patient continuously asks for the PRN
opioid, and the nurse suspects that the patient may have
a drug abuse problem. Which action by the nurse is best?
1. Administer acetaminophen and spend extra time
with the patient.
2. Explain that opioid medication is reserved for
moderate to severe pain.
3. Give the opioid because the patient deserves relief
and drug abuse is unconfirmed.
4. Ask the HCP to validate suspicions of drug abuse
and alter the opioid prescription.
41. An inexperienced new nurse compares the medication ad-
ministration record (MAR) and the health care provider’s
(HCP’s) prescription for a patient who has a patient-
controlled analgesia (PCA) pump for pain management.
Both the MAR and prescription indicate that larger doses
are prescribed at night compared with doses throughout
the day. Who would the new nurse consult first?
1. Ask the patient if he typically needs extra medica-
tion in the evening.
2. Ask the HCP to verify that the larger amount is
the correct dose.
3. Ask the pharmacist to confirm the dosage on the
original prescription.
4. Ask the charge nurse if this is a typical dosage for
nighttime PCA.
Loading page 26...
CHAPTeR 1 Pain16Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
42. Which instruction would the nurse give to the unli-
censed assistive personnel (AP) related to the care of a
patient who has received ketamine for analgesia?
1. Keep the environment calm and quiet.
2. Watch for and report respiratory depression.
3. Offer frequent sips of noncaffeinated fluids.
4. Keep the bed flat and frequently turn patient.
43. The health care provider (HCP) prescribes 7 mg mor-
phine IV as needed. The nursing student prepares the
medication and shows the syringe (see figures below)
to the nursing instructor. Which action would the
nursing instructor take first?
1. Tell the student to review the HCP’s prescription
before administering medication.
2. Waste the medication and tell the student that re-
mediation is required for serious error.
3. Ask the student to demonstrate the calculations
and steps required to prepare the dose.
4. Accompany the student to the patient’s room and
observe as the medication is administered.
10
mL
2
4
1
3
6
8
9
5
7
Scenario: The nurse is caring for a patient who had abdominal surgery
yesterday. The patient is restless and anxious and reports that the pain is
getting worse (8 out of 10) despite morphine via patient-controlled an-
algesia. Physical assessment findings include: T 100.3°F (37.9°C), P 110
beats/min, R 24 breaths/min, and BP 110/70 mmHg. The abdomen is
rigid and tender to the touch with hypoactive bowel sounds. The nurse
tries to make the patient comfortable, and he is willing to wait until the
next scheduled dose of pain medication. However, the nurse decides to
notify the patient’s health care provider (HCP) because the pain warrants
evaluation, possible diagnostic testing, and additional therapies.
Which information would the nurse include in the assessment compo-
nent of the SBAR (situation, background, assessment, recommendation)
report to the HCP?
Instructions: Underline or highlight the
information the nurse would include in
the assessment component of the SBAR
report.
44. Expanded Hot Spot ____________________________________________________________________________
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
42. Which instruction would the nurse give to the unli-
censed assistive personnel (AP) related to the care of a
patient who has received ketamine for analgesia?
1. Keep the environment calm and quiet.
2. Watch for and report respiratory depression.
3. Offer frequent sips of noncaffeinated fluids.
4. Keep the bed flat and frequently turn patient.
43. The health care provider (HCP) prescribes 7 mg mor-
phine IV as needed. The nursing student prepares the
medication and shows the syringe (see figures below)
to the nursing instructor. Which action would the
nursing instructor take first?
1. Tell the student to review the HCP’s prescription
before administering medication.
2. Waste the medication and tell the student that re-
mediation is required for serious error.
3. Ask the student to demonstrate the calculations
and steps required to prepare the dose.
4. Accompany the student to the patient’s room and
observe as the medication is administered.
10
mL
2
4
1
3
6
8
9
5
7
Scenario: The nurse is caring for a patient who had abdominal surgery
yesterday. The patient is restless and anxious and reports that the pain is
getting worse (8 out of 10) despite morphine via patient-controlled an-
algesia. Physical assessment findings include: T 100.3°F (37.9°C), P 110
beats/min, R 24 breaths/min, and BP 110/70 mmHg. The abdomen is
rigid and tender to the touch with hypoactive bowel sounds. The nurse
tries to make the patient comfortable, and he is willing to wait until the
next scheduled dose of pain medication. However, the nurse decides to
notify the patient’s health care provider (HCP) because the pain warrants
evaluation, possible diagnostic testing, and additional therapies.
Which information would the nurse include in the assessment compo-
nent of the SBAR (situation, background, assessment, recommendation)
report to the HCP?
Instructions: Underline or highlight the
information the nurse would include in
the assessment component of the SBAR
report.
44. Expanded Hot Spot ____________________________________________________________________________
Loading page 27...
CHAPTeR 1 Pain 17Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
45. Extended Multiple Response _____________________________________________________________________
Question: Based on the American Society for Pain Management
Nursing recommendations for “As needed” (PRN) range
prescriptions for opioid analgesics, for which prescriptions, does
the nurse need to seek clarification from the health care provider?
Instructions: Place an X in the space provided or
highlight each patient situation where the nurse
would seek clarification for the prescrip-tion. Select
all that apply.
The nurse is reviewing the PRN (as-needed) pain prescriptions for the following patients:
1. ______ Ms. A is a 35-year old female admitted for an acute episode of cholelithiasis. Prescribed: Morphine 1 to 15 mg
IV every 2 hours PRN pain
2. ______ Mr. B is a 75-year old male who had hip surgery yesterday. He has chronic obstructive pulmonary disease.
Prescribed: Morphine 2 to 3 mg IV every 2 hours PRN pain
3. ______ Mr. C is a 55-year old male with acute pancreatitis. He has a history of alcohol and substance abuse. Prescribed:
Morphine 1 to 3 mg IV every 4 hours PRN pain
4. ______ Mrs. D is an 83-year old female with an ankle fracture. She has dementia and is unable to maintain elevation
of the ankle. Prescribed: Meperidine 25 to 50 mg PO PRN pain
5. ______ Mr. E is a 46-year old male admitted for bacterial meningitis. He reports severe headaches. Prescribed:
Codeine 15 mg PO 1-2 tablets every 4 to 6 hours PRN pain
6. ______ Mr. F is a 25-year old male. He has extensive abrasions on the left side of the body sustained in a motorcycle
accident. No other obvious trauma detected in the emergency department. Prescribed: Oxycodone 9 mg PO
every 12 hours; Hydrocodone with acetaminophen 5/325 PO 1 to 2 tablets every 4 to 6 hours PRN pain;
acetaminophen 500 mg 2 tablets PO every 6 to 8 hours PRN pain
7. ______ Ms. G is a 57-year old female who had a hysterectomy yesterday for uterine prolapse. She is opioid naive and
has no preexisting health conditions other than prolapse of the uterus. Prescribed: Fentanyl 50 to 100 mcg IV
every 2 hours PRN for severe pain
8. ______ Mr. H is a 68-year old male; he has pain associated with postherpetic neuralgia. Prescribed: Morphine 2 to
3 mg IV every 4 hours PRN pain
Scenario: The nurse is caring for a 73-year old patient who was admitted
for dehydration and observation for compartment injury. The patient fell
between the toilet and the wall. His right arm was pinned underneath his
body, for several hours before he was discovered by a neighbor. Fractures
and other obvious injuries were ruled out in the emergency department.
Patient received 400 mg ibuprofen for pain in the right arm.
Which nursing actions would the nurse take for suspicion of compart-
ment syndrome?
Instructions: For each potential nurs-
ing action listed below, check to specify
whether the action is anticipated, non-
essential or contraindicated.
Vital signs:
Temperature 98.7F° (37°C)
Pulse 120 beats/min
Respirations 24 breaths/min
Blood pressure 140/70 mmHg
Oxygen saturation 95% (on room air)
Body Mass Index (BMI) 30
Assessment findings: Patient is anxious and tearful. He reports stiff-
ness and soreness in his right leg, but “My leg is okay compared to my
arm. My arm really hurts (9/10 on pain scale). Stretching makes the pain
worse and there is burning and tingling in my fingers. When is that pain
medication supposed to start working?”
46. Matrix ______________________________________________________________________________________
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
45. Extended Multiple Response _____________________________________________________________________
Question: Based on the American Society for Pain Management
Nursing recommendations for “As needed” (PRN) range
prescriptions for opioid analgesics, for which prescriptions, does
the nurse need to seek clarification from the health care provider?
Instructions: Place an X in the space provided or
highlight each patient situation where the nurse
would seek clarification for the prescrip-tion. Select
all that apply.
The nurse is reviewing the PRN (as-needed) pain prescriptions for the following patients:
1. ______ Ms. A is a 35-year old female admitted for an acute episode of cholelithiasis. Prescribed: Morphine 1 to 15 mg
IV every 2 hours PRN pain
2. ______ Mr. B is a 75-year old male who had hip surgery yesterday. He has chronic obstructive pulmonary disease.
Prescribed: Morphine 2 to 3 mg IV every 2 hours PRN pain
3. ______ Mr. C is a 55-year old male with acute pancreatitis. He has a history of alcohol and substance abuse. Prescribed:
Morphine 1 to 3 mg IV every 4 hours PRN pain
4. ______ Mrs. D is an 83-year old female with an ankle fracture. She has dementia and is unable to maintain elevation
of the ankle. Prescribed: Meperidine 25 to 50 mg PO PRN pain
5. ______ Mr. E is a 46-year old male admitted for bacterial meningitis. He reports severe headaches. Prescribed:
Codeine 15 mg PO 1-2 tablets every 4 to 6 hours PRN pain
6. ______ Mr. F is a 25-year old male. He has extensive abrasions on the left side of the body sustained in a motorcycle
accident. No other obvious trauma detected in the emergency department. Prescribed: Oxycodone 9 mg PO
every 12 hours; Hydrocodone with acetaminophen 5/325 PO 1 to 2 tablets every 4 to 6 hours PRN pain;
acetaminophen 500 mg 2 tablets PO every 6 to 8 hours PRN pain
7. ______ Ms. G is a 57-year old female who had a hysterectomy yesterday for uterine prolapse. She is opioid naive and
has no preexisting health conditions other than prolapse of the uterus. Prescribed: Fentanyl 50 to 100 mcg IV
every 2 hours PRN for severe pain
8. ______ Mr. H is a 68-year old male; he has pain associated with postherpetic neuralgia. Prescribed: Morphine 2 to
3 mg IV every 4 hours PRN pain
Scenario: The nurse is caring for a 73-year old patient who was admitted
for dehydration and observation for compartment injury. The patient fell
between the toilet and the wall. His right arm was pinned underneath his
body, for several hours before he was discovered by a neighbor. Fractures
and other obvious injuries were ruled out in the emergency department.
Patient received 400 mg ibuprofen for pain in the right arm.
Which nursing actions would the nurse take for suspicion of compart-
ment syndrome?
Instructions: For each potential nurs-
ing action listed below, check to specify
whether the action is anticipated, non-
essential or contraindicated.
Vital signs:
Temperature 98.7F° (37°C)
Pulse 120 beats/min
Respirations 24 breaths/min
Blood pressure 140/70 mmHg
Oxygen saturation 95% (on room air)
Body Mass Index (BMI) 30
Assessment findings: Patient is anxious and tearful. He reports stiff-
ness and soreness in his right leg, but “My leg is okay compared to my
arm. My arm really hurts (9/10 on pain scale). Stretching makes the pain
worse and there is burning and tingling in my fingers. When is that pain
medication supposed to start working?”
46. Matrix ______________________________________________________________________________________
Loading page 28...
CHAPTeR 1 Pain18Copyright © 2022, Elsevier Inc. All rights reserved.
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
47. Drag and Drop ________________________________________________________________________________
Scenario: The oncoming day shift nurse has received the
shift report from the night nurse. The day shift nurse has
done a quick check on all of the patients and has deter-
mined that all are stable and not in acute distress.
In which order would the nurse care for these patients?
Instructions: Patients are listed in the left-hand column.
In the right- hand column write in the number to indicate
the order of priority for care; 1 being the first and 5 being
the last.
Patients Order of priority
1. 17-year-old adolescent who is alert and oriented. He was admitted 2 days
ago for treatment of meningitis. He reports a continuous headache that is
partially relieved by medication.
2. 65-year-old man who underwent total knee replacement surgery 2 days ago.
He is using the patient-controlled analgesia (PCA) pump frequently and
occasionally asks for a bolus dose.
3. 53-year-old woman who is demanding and frequently calls for assistance. She
was admitted for investigation of functional abdominal pain and is scheduled
for diagnostic testing this morning.
4. 82-year-old woman with advanced Alzheimer disease who requires total care
for all activities of daily living. She will be transferred to a long-term care
facility in a few days after arrangements are finalized.
5. 26-year-old man who was admitted with chest pain secondary to a spontane-
ous pneumothorax. Today, the chest tube will be removed and the PCA pump
will be discontinued.
Potential Nursing Actions Anticipated Nonessential Contraindicated
Assess the location, quality, and intensity of pain
Assess for 5Ps (pain, pallor, pulselessness, paralysis, paresthesia)
Elevate right arm above the level of the heart
Apply an ice pack wrapped in a towel
Assess urine color and output
Wrap the forearm with an elastic bandage
Obtain an order for an x-ray of the arm
Notify health care provider for unrelieved pain and paresthesia
Answer Key for this chapter begins on p. 19Common Health Scenarios
PART 2
47. Drag and Drop ________________________________________________________________________________
Scenario: The oncoming day shift nurse has received the
shift report from the night nurse. The day shift nurse has
done a quick check on all of the patients and has deter-
mined that all are stable and not in acute distress.
In which order would the nurse care for these patients?
Instructions: Patients are listed in the left-hand column.
In the right- hand column write in the number to indicate
the order of priority for care; 1 being the first and 5 being
the last.
Patients Order of priority
1. 17-year-old adolescent who is alert and oriented. He was admitted 2 days
ago for treatment of meningitis. He reports a continuous headache that is
partially relieved by medication.
2. 65-year-old man who underwent total knee replacement surgery 2 days ago.
He is using the patient-controlled analgesia (PCA) pump frequently and
occasionally asks for a bolus dose.
3. 53-year-old woman who is demanding and frequently calls for assistance. She
was admitted for investigation of functional abdominal pain and is scheduled
for diagnostic testing this morning.
4. 82-year-old woman with advanced Alzheimer disease who requires total care
for all activities of daily living. She will be transferred to a long-term care
facility in a few days after arrangements are finalized.
5. 26-year-old man who was admitted with chest pain secondary to a spontane-
ous pneumothorax. Today, the chest tube will be removed and the PCA pump
will be discontinued.
Potential Nursing Actions Anticipated Nonessential Contraindicated
Assess the location, quality, and intensity of pain
Assess for 5Ps (pain, pallor, pulselessness, paralysis, paresthesia)
Elevate right arm above the level of the heart
Apply an ice pack wrapped in a towel
Assess urine color and output
Wrap the forearm with an elastic bandage
Obtain an order for an x-ray of the arm
Notify health care provider for unrelieved pain and paresthesia
Loading page 29...
Copyright © 2022, Elsevier Inc. All rights reserved.
Introduction
PART 118.e1
Answers
1. Ans: 3 The patient must be believed, and his or her
experience of pain must be acknowledged as valid. The
data gathered via patient reports can then be applied
to the other options in developing the treatment plan.
Focus: Prioritization; QSEN: PCC; Concept: Pain;
Cognitive Level: Applying.
2. Ans: 1, 3, 4 The widespread use of opioids and the
increase in mortality and morbidity make it essential
for nurses to recognize any personal negative bias and
work toward conveying acceptance and understand-
ing. This increases the likelihood of patient engage-
ment and success in treatment programs. Learning
about the signs and symptoms of an opioid overdose
and the proper use of naloxone is also a nursing re-
sponsibility. Electronic prescription drug monitoring
programs show promise but are not currently available
nationwide and checking the database for all opioid
prescriptions may be time-consuming and unneces-
sary (short-term opioid prescriptions for acute pain
are less problematic). The nurse would question a
health care provider if an opioid prescription did not
seem safe; however, the CDC recommendations are
not legally binding and deviations are not report-
able. Focus: Prioritization; QSEN: EBP, S; Concept:
Pain; Cognitive Level: Analyzing.
3. Ans: 4 Assess the pain for changes in location,
quality, and intensity, as well as changes in response
to medication. This assessment will guide the next
steps. Focus: Prioritization; QSEN: EBP; Concept:
Pain; Cognitive Level: Applying. Test Taking Tip:
During clinical rotations, you may observe nurses giv-
ing pain medication without performing an adequate
pain assessment. This is an error in clinical perfor-
mance. In postoperative patients, pain could signal
complications, such as hemorrhage, infection, or de-
creased perfusion related to tissue swelling. Always
assess pain first, then make a decision about giving
medication, using nonpharmacologic methods, or
contacting the HCP.
4. Ans: 4 The LPN/LVN is well trained to administer
oxygen per nasal cannula. This patient is considered
unstable; therefore the RN should take responsibil-
ity for administering drugs and monitoring the re-
sponse to therapy, which includes the effects on the
respiratory system. The RN should also take respon-
sibility to communicate with the HCP for ongoing
treatment and therapy. Focus: Assignment; QSEN:
TC; Concept: Clinical Judgment; Cognitive Level:
Analyzing; IPEC: R/R.
5. Ans: 4 If the pain is constant, the best schedule is
around-the-clock to provide steady analgesia and pain
control. The other options may require higher dosages
to achieve control. Focus: Prioritization; QSEN: EBP;
Concept: Pain; Cognitive Level: Applying.
6. Ans: 4 At greatest risk are older adult patients,
opioid-naïve patients, and those with underlying pul-
monary disease. The adolescent has two of the three
risk factors. Focus: Prioritization; QSEN: EBP;
Concept: Pain; Cognitive Level: Applying.
7. Ans: 4 One of the common features of rheumatoid
arthritis is joint pain and stiffness when first rising.
This usually resolves over the course of the day. A non-
pharmaceutical measure is to take a warm shower (or
apply warm packs to joints if pain is limited to one or
two joints). If pain worsens, then the nurse may elect
to contact other members of the health care team for
additional interventions. Focus: Delegation; QSEN:
TC; Concept: Pain; Cognitive Level: Applying;
IPEC: R/R.
8. Ans: 1 Gabapentin is an antiepileptic drug,
but it is also used to treat diabetic neuropathy.
Corticosteroids are for pain associated with inflam-
mation. Hydromorphone is a stronger opioid, and
it is not the first choice for chronic pain that can be
managed with other drugs. Lorazepam is an anxiolyt-
ic that may be prescribed as an adjuvant medication.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Applying.
9. Ans: 1 The goal is to control pain while minimizing
side effects. For severe pain, the medication can be ti-
trated upward until the pain is controlled. Downward
titration occurs when the pain begins to subside.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Applying.
10. Ans: 1, 2, 3, 4 The recommendations of the
American Pain Society, in collaboration with the
American Society of Anesthesiologists, for postopera-
tive patients include: acetaminophen and/or NSAIDs
if there are no contraindications; surgical site–specific
peripheral regional anesthetic for procedures; neuraxi-
al analgesia (also known as epidural analgesia) for ma-
jor thoracic and abdominal procedures, if patient has
risk for cardiac complications or prolonged ileus; and
multimodal therapy, which includes use of different
types of medications and other therapies. Oral opioids
are preferred in the postoperative period. Pain special-
ists should be consulted if patients have inadequately
controlled postoperative pain. Focus: Prioritization;
QSEN: EBP; Concept: Pain; Cognitive Level:
Understanding. Test Taking Tip: Passing a test and
working as a competent nurse requires keeping up to
date with current practice guidelines.
11. Ans: 3 Beliefs, attitudes, and familial influence are
part of the sociocultural dimension of pain. Location
Introduction
PART 118.e1
Answers
1. Ans: 3 The patient must be believed, and his or her
experience of pain must be acknowledged as valid. The
data gathered via patient reports can then be applied
to the other options in developing the treatment plan.
Focus: Prioritization; QSEN: PCC; Concept: Pain;
Cognitive Level: Applying.
2. Ans: 1, 3, 4 The widespread use of opioids and the
increase in mortality and morbidity make it essential
for nurses to recognize any personal negative bias and
work toward conveying acceptance and understand-
ing. This increases the likelihood of patient engage-
ment and success in treatment programs. Learning
about the signs and symptoms of an opioid overdose
and the proper use of naloxone is also a nursing re-
sponsibility. Electronic prescription drug monitoring
programs show promise but are not currently available
nationwide and checking the database for all opioid
prescriptions may be time-consuming and unneces-
sary (short-term opioid prescriptions for acute pain
are less problematic). The nurse would question a
health care provider if an opioid prescription did not
seem safe; however, the CDC recommendations are
not legally binding and deviations are not report-
able. Focus: Prioritization; QSEN: EBP, S; Concept:
Pain; Cognitive Level: Analyzing.
3. Ans: 4 Assess the pain for changes in location,
quality, and intensity, as well as changes in response
to medication. This assessment will guide the next
steps. Focus: Prioritization; QSEN: EBP; Concept:
Pain; Cognitive Level: Applying. Test Taking Tip:
During clinical rotations, you may observe nurses giv-
ing pain medication without performing an adequate
pain assessment. This is an error in clinical perfor-
mance. In postoperative patients, pain could signal
complications, such as hemorrhage, infection, or de-
creased perfusion related to tissue swelling. Always
assess pain first, then make a decision about giving
medication, using nonpharmacologic methods, or
contacting the HCP.
4. Ans: 4 The LPN/LVN is well trained to administer
oxygen per nasal cannula. This patient is considered
unstable; therefore the RN should take responsibil-
ity for administering drugs and monitoring the re-
sponse to therapy, which includes the effects on the
respiratory system. The RN should also take respon-
sibility to communicate with the HCP for ongoing
treatment and therapy. Focus: Assignment; QSEN:
TC; Concept: Clinical Judgment; Cognitive Level:
Analyzing; IPEC: R/R.
5. Ans: 4 If the pain is constant, the best schedule is
around-the-clock to provide steady analgesia and pain
control. The other options may require higher dosages
to achieve control. Focus: Prioritization; QSEN: EBP;
Concept: Pain; Cognitive Level: Applying.
6. Ans: 4 At greatest risk are older adult patients,
opioid-naïve patients, and those with underlying pul-
monary disease. The adolescent has two of the three
risk factors. Focus: Prioritization; QSEN: EBP;
Concept: Pain; Cognitive Level: Applying.
7. Ans: 4 One of the common features of rheumatoid
arthritis is joint pain and stiffness when first rising.
This usually resolves over the course of the day. A non-
pharmaceutical measure is to take a warm shower (or
apply warm packs to joints if pain is limited to one or
two joints). If pain worsens, then the nurse may elect
to contact other members of the health care team for
additional interventions. Focus: Delegation; QSEN:
TC; Concept: Pain; Cognitive Level: Applying;
IPEC: R/R.
8. Ans: 1 Gabapentin is an antiepileptic drug,
but it is also used to treat diabetic neuropathy.
Corticosteroids are for pain associated with inflam-
mation. Hydromorphone is a stronger opioid, and
it is not the first choice for chronic pain that can be
managed with other drugs. Lorazepam is an anxiolyt-
ic that may be prescribed as an adjuvant medication.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Applying.
9. Ans: 1 The goal is to control pain while minimizing
side effects. For severe pain, the medication can be ti-
trated upward until the pain is controlled. Downward
titration occurs when the pain begins to subside.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Applying.
10. Ans: 1, 2, 3, 4 The recommendations of the
American Pain Society, in collaboration with the
American Society of Anesthesiologists, for postopera-
tive patients include: acetaminophen and/or NSAIDs
if there are no contraindications; surgical site–specific
peripheral regional anesthetic for procedures; neuraxi-
al analgesia (also known as epidural analgesia) for ma-
jor thoracic and abdominal procedures, if patient has
risk for cardiac complications or prolonged ileus; and
multimodal therapy, which includes use of different
types of medications and other therapies. Oral opioids
are preferred in the postoperative period. Pain special-
ists should be consulted if patients have inadequately
controlled postoperative pain. Focus: Prioritization;
QSEN: EBP; Concept: Pain; Cognitive Level:
Understanding. Test Taking Tip: Passing a test and
working as a competent nurse requires keeping up to
date with current practice guidelines.
11. Ans: 3 Beliefs, attitudes, and familial influence are
part of the sociocultural dimension of pain. Location
Loading page 30...
18.e2Copyright © 2022, Elsevier Inc. All rights reserved. CHAPTeR 1 PainIntroduction
PART 1
and radiation of pain address the sensory dimension.
Describing pain and its effects addresses the affective
dimension. Activity level and function address the be-
havioral dimension. Asking about knowledge address-
es the cognitive dimension. Focus: Prioritization;
QSEN: PCC; Concept: Pain; Cognitive Level:
Analyzing.
12. Ans: 3 Cancer pain generally worsens with disease
progression, and the use of opioids is more generous.
Fibromyalgia is more likely to be treated with non-
opioid and adjuvant medications. Trigeminal neu-
ralgia is treated with antiseizure medications such
as carbamazepine. Phantom limb pain usually sub-
sides after ambulation begins. Focus: Prioritization;
QSEN: EBP; Concept: Pain; Cognitive Level:
Applying.
13. Ans: 1 Multimodal therapies for postoperative pa-
tients include opioids and nonopioid therapies, re-
gional anesthetic techniques, and nonpharmacologic
therapies. This approach is thought to be the most im-
portant strategy for pain management for most post-
operative patients. Standing orders are less optimal
because there is no consideration of individual needs
or characteristics. PCA is one important element, but
not all patients can manage PCA devices. Assessment
tools are an important part of overall manage-
ment, but basing opioid dose on a numerical scale
does not consider individual patient circumstances.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Understanding.
14. Ans: 4 When supervising a new RN, good per-
formance should be reinforced first and then areas
of improvement can be addressed. Asking the nurse
about knowledge of pain management is also an op-
tion; however, it would be a more indirect and time-
consuming approach. Making a note and watching
does not help the nurse to correct the immediate
problem. In-service training might be considered if
the problem persists. Focus: Supervision; QSEN:
TC, QI; Concept: Leadership; Cognitive Level:
Applying.
15. Ans: 1, 3, 5, 6 Patients with acute conditions that
require close monitoring for complications should be
assigned to an experienced RN. Abdominal cramps
secondary to food poisoning is an acute condition;
however, cramping, vomiting, and diarrhea are usu-
ally self-limiting. The patient with chronic back pain
would be considered physically stable. Although all
patients will benefit from care provided by an experi-
enced RN, the patient with abdominal cramps and the
patient with back pain could be assigned to a new RN,
an LPN/LVN, or a float nurse. Focus: Assignment;
QSEN: TC; Concept: Clinical Judgment; Cognitive
Level: Analyzing; IPEC: T/T. Test Taking Tip:
To determine acuity of patients, use nursing con-
cepts, such as gas exchange and perfusion. Patients 1,
3, 5, and 6 could have potential problems related to
perfusion. The patient with the chest tube could also
have a potential problem related to gas exchange.
16. Ans: 2 Inadequate pain management for postsurgi-
cal patients can affect quality of life, function, recovery,
and postsurgical complication; thus all the manifes-
tations are examples of negative results. Nevertheless,
venous thromboembolism is the most serious because
it can lead to pulmonary embolism, which is an imme-
diate life-threatening concern. The nurse also needs
to implement interventions to resolve unsatisfied
needs, fear of pain, and hopelessness related to pain
and function. Focus: Prioritization; QSEN: PCC, S;
Concept: Pain; Cognitive Level: Analyzing. Test
Taking Tip: Physiologic needs are the first concern.
In this case, venous thromboembolism is the most
serious physiologic outcome secondary to inadequate
pain management.
17. Ans: 1 The nurse would consider questioning all of
the medication prescriptions, but the opioid-naïve
adult has the greatest immediate risk because use of
a basal dose has been associated with an increased in-
cidence of respiratory depression in opioid-naïve pa-
tients. Older adults are frequently prescribed NSAIDs;
however, they are used with caution, and the patient’s
history should be reviewed for potential problems,
such as a history of gastrointestinal bleeding, cardiac
disease, or renal dysfunction. Many medications such
as anticoagulants, oral hypoglycemics, diuretics, and
antihypertensives can also cause adverse drug–drug
interactions with NSAIDs. IM injections cause pain,
absorption is unreliable, and there are no advantages
over other routes of administration. If a patient is able
to tolerate oral foods and fluids, oral medications are
preferred because the efficacy of the oral route is equal
to the IV route. Focus: Prioritization; QSEN: EBP,
S; Concept: Pain; Cognitive Level: Analyzing. Test
Taking Tip: It is worthwhile to study the purposes,
pharmacologic actions, and side effects of commonly
used medications. Morphine is considered the proto-
type of the opioid medications. For opioid-naïve pa-
tients, the priority concern is respiratory depression.
For patients who need opioids for long-term pain
management, the primary side effect is constipation.
18. Ans: 3 The patient with an acute myocardial infarc-
tion has the greatest need for IV access and is likely
to receive morphine, which will relieve pain and in-
crease venous capacitance. The other patients may also
need IV access for delivery of pain medication, other
drugs, or IV fluids, but the need is less urgent. Focus:
Prioritization; QSEN: EBP; Concept: Clinical
Judgment; Cognitive Level: Analyzing.
19. Ans: 2 The AP has correctly reported findings, but
the nurse is ultimately responsible to assess first and
then determine the correct action. Based on assess-
ment findings, the other options may also be appro-
priate. Focus: Prioritization; QSEN: EBP; Concept:
Clinical Judgment; Cognitive Level: Applying.
PART 1
and radiation of pain address the sensory dimension.
Describing pain and its effects addresses the affective
dimension. Activity level and function address the be-
havioral dimension. Asking about knowledge address-
es the cognitive dimension. Focus: Prioritization;
QSEN: PCC; Concept: Pain; Cognitive Level:
Analyzing.
12. Ans: 3 Cancer pain generally worsens with disease
progression, and the use of opioids is more generous.
Fibromyalgia is more likely to be treated with non-
opioid and adjuvant medications. Trigeminal neu-
ralgia is treated with antiseizure medications such
as carbamazepine. Phantom limb pain usually sub-
sides after ambulation begins. Focus: Prioritization;
QSEN: EBP; Concept: Pain; Cognitive Level:
Applying.
13. Ans: 1 Multimodal therapies for postoperative pa-
tients include opioids and nonopioid therapies, re-
gional anesthetic techniques, and nonpharmacologic
therapies. This approach is thought to be the most im-
portant strategy for pain management for most post-
operative patients. Standing orders are less optimal
because there is no consideration of individual needs
or characteristics. PCA is one important element, but
not all patients can manage PCA devices. Assessment
tools are an important part of overall manage-
ment, but basing opioid dose on a numerical scale
does not consider individual patient circumstances.
Focus: Prioritization; QSEN: EBP; Concept: Pain;
Cognitive Level: Understanding.
14. Ans: 4 When supervising a new RN, good per-
formance should be reinforced first and then areas
of improvement can be addressed. Asking the nurse
about knowledge of pain management is also an op-
tion; however, it would be a more indirect and time-
consuming approach. Making a note and watching
does not help the nurse to correct the immediate
problem. In-service training might be considered if
the problem persists. Focus: Supervision; QSEN:
TC, QI; Concept: Leadership; Cognitive Level:
Applying.
15. Ans: 1, 3, 5, 6 Patients with acute conditions that
require close monitoring for complications should be
assigned to an experienced RN. Abdominal cramps
secondary to food poisoning is an acute condition;
however, cramping, vomiting, and diarrhea are usu-
ally self-limiting. The patient with chronic back pain
would be considered physically stable. Although all
patients will benefit from care provided by an experi-
enced RN, the patient with abdominal cramps and the
patient with back pain could be assigned to a new RN,
an LPN/LVN, or a float nurse. Focus: Assignment;
QSEN: TC; Concept: Clinical Judgment; Cognitive
Level: Analyzing; IPEC: T/T. Test Taking Tip:
To determine acuity of patients, use nursing con-
cepts, such as gas exchange and perfusion. Patients 1,
3, 5, and 6 could have potential problems related to
perfusion. The patient with the chest tube could also
have a potential problem related to gas exchange.
16. Ans: 2 Inadequate pain management for postsurgi-
cal patients can affect quality of life, function, recovery,
and postsurgical complication; thus all the manifes-
tations are examples of negative results. Nevertheless,
venous thromboembolism is the most serious because
it can lead to pulmonary embolism, which is an imme-
diate life-threatening concern. The nurse also needs
to implement interventions to resolve unsatisfied
needs, fear of pain, and hopelessness related to pain
and function. Focus: Prioritization; QSEN: PCC, S;
Concept: Pain; Cognitive Level: Analyzing. Test
Taking Tip: Physiologic needs are the first concern.
In this case, venous thromboembolism is the most
serious physiologic outcome secondary to inadequate
pain management.
17. Ans: 1 The nurse would consider questioning all of
the medication prescriptions, but the opioid-naïve
adult has the greatest immediate risk because use of
a basal dose has been associated with an increased in-
cidence of respiratory depression in opioid-naïve pa-
tients. Older adults are frequently prescribed NSAIDs;
however, they are used with caution, and the patient’s
history should be reviewed for potential problems,
such as a history of gastrointestinal bleeding, cardiac
disease, or renal dysfunction. Many medications such
as anticoagulants, oral hypoglycemics, diuretics, and
antihypertensives can also cause adverse drug–drug
interactions with NSAIDs. IM injections cause pain,
absorption is unreliable, and there are no advantages
over other routes of administration. If a patient is able
to tolerate oral foods and fluids, oral medications are
preferred because the efficacy of the oral route is equal
to the IV route. Focus: Prioritization; QSEN: EBP,
S; Concept: Pain; Cognitive Level: Analyzing. Test
Taking Tip: It is worthwhile to study the purposes,
pharmacologic actions, and side effects of commonly
used medications. Morphine is considered the proto-
type of the opioid medications. For opioid-naïve pa-
tients, the priority concern is respiratory depression.
For patients who need opioids for long-term pain
management, the primary side effect is constipation.
18. Ans: 3 The patient with an acute myocardial infarc-
tion has the greatest need for IV access and is likely
to receive morphine, which will relieve pain and in-
crease venous capacitance. The other patients may also
need IV access for delivery of pain medication, other
drugs, or IV fluids, but the need is less urgent. Focus:
Prioritization; QSEN: EBP; Concept: Clinical
Judgment; Cognitive Level: Analyzing.
19. Ans: 2 The AP has correctly reported findings, but
the nurse is ultimately responsible to assess first and
then determine the correct action. Based on assess-
ment findings, the other options may also be appro-
priate. Focus: Prioritization; QSEN: EBP; Concept:
Clinical Judgment; Cognitive Level: Applying.
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Subject
National Council Licensure Examination