NCLEX-RN leadership, delegation, and management of care

Delegation is the transfer of responsibility for the performance of a task to another person while retaining accountability for the outcome. The RN cannot delegate the nursing process (assessment, nursing diagnosis, planning, evaluation) or clinical judgment decisions.

Five rights of delegation: Right task, right circumstances, right person, right direction/communication, right supervision/evaluation.

What RNs CAN delegate to UAP (unlicensed assistive personnel): Routine, stable, repetitive tasks that require minimal clinical judgment. Examples: vital signs on stable patients, ambulation and range of motion, basic hygiene (bathing, oral care), intake and output recording, specimen collection for routine tests, simple dressing changes (as specified by policy), feeding assistance for non-dysphagic patients.

What RNs CANNOT delegate to UAP: Initial assessments, discharge teaching, patient education, care planning, interpretation of data, administration of medications, IV medication administration, insertion of IV lines or tubes, complex wound care requiring nursing judgment, care of unstable patients.

Delegation to LPN/LVN: Broader scope than UAP but narrower than RN. LPN/LVN can typically: administer medications (route restrictions vary by state — typically not IV push except some flush medications), provide basic assessments (data collection — not comprehensive nursing assessment), wound care following an established care plan. LPN/LVN should NOT be assigned to patients requiring complex assessments, teaching that requires clinical judgment, or who are acutely unstable or high-risk.

Assignment is different from delegation — assignment is directing work that falls within the other person's established role. When the charge nurse assigns patients to staff, or the RN accepts or refuses an assignment, several principles apply.

Accepting/refusing assignments: The RN has a professional responsibility to accept assignments within competence. Refusal is appropriate when: the assignment requires skills the nurse does not have, staffing is dangerously inadequate, or the situation places patient safety at risk. Must follow institutional reporting procedures. Document concerns in writing when appropriate.

Correct assignment matching: Most complex/unstable patients → most experienced staff. NCLEX frequently presents a scenario asking which patient to assign to a new graduate nurse, a traveller nurse, or a float pool RN. Correct answer: the most stable patient with the most predictable course. New graduates should not be assigned to the highest-acuity patients.

Float pool and agency nurses: Should not be assigned to the highest-acuity areas without sufficient orientation. Charge nurses should assess competencies before assignment.

Patient rights: NCLEX tests patient autonomy — the right to make decisions about one's own healthcare, including the right to refuse treatment. Patients with decision-making capacity can refuse any treatment, even life-saving treatment. The nurse's role is to ensure the patient has accurate information, not to override their decision.

Informed consent: Three elements: disclosure (information about procedure, risks, benefits, alternatives), comprehension (patient understands), and voluntariness (no coercion). The provider obtaining consent is responsible for the disclosure. The nurse's role is to witness the signature, verify that the patient understands, and notify the provider if the patient expresses confusion or coercion. If a patient expresses doubt before a procedure — the nurse stops the procedure and notifies the provider.

Advance directives: Living wills and healthcare proxies/power of attorney must be followed. DNR orders require a provider's written order — the nurse cannot independently withhold resuscitation. If there is no written DNR order, full resuscitation is initiated. Nurses must know where advance directives are documented and communicate this to the team.

Confidentiality and HIPAA: Patient information shared only with those involved in the patient's care. Visitors, family members (even spouses) require the patient's consent for information sharing. Social media posting of patient information — even without name — is a HIPAA violation.

QSEN competencies: Patient-Centred Care, Teamwork and Collaboration, Evidence-Based Practice, Quality Improvement, Safety, and Informatics. NCLEX tests application of these competencies in clinical scenarios.

SBAR communication: Situation (what is happening right now), Background (relevant history and context), Assessment (what is the problem), Recommendation (what action is needed). Used when communicating handoffs, critical changes to providers, and escalating concerns. NCLEX tests correct SBAR content when presenting patient deterioration.

Error reporting: Errors and near-misses must be reported through incident/occurrence reporting systems. The purpose is systems improvement, not individual punishment (in a Just Culture model). Nurses who discover a medication error must: assess the patient first, notify the provider, document the medication given (not "error"), complete the incident report, and monitor for adverse effects. Do NOT document the incident report in the patient's medical record.

Root cause analysis (RCA): System-level investigation after serious adverse events or near-misses. Identifies contributing factors, not individual blame. Resulting recommendations feed back into policy and procedure changes.