Delegation and the NCLEX

Contrary to what we like to tell ourselves, no nurse can do it all alone. Inevitably, you will need to work closely with LPN/LVNs, unlicensed assistive personnel, nurses from other units, and other nurses with varying degrees of experience to provide the best care possible to your patients. In fact, we all (patients and employees) benefit from strong teamwork. The trick is, which patient assignments are appropriate for these individuals? Delegation involves assigning appropriate patient care tasks to members of the nursing care team that are within their scope of practice. It’s not fair to patients or your coworkers to ask them to perform tasks that are outside of their abilities. However, you wouldn’t want to waste the skills of an experienced nurse on tasks a new nurse can perform with ease. Effectively, delegation is the process of finding the right person for the job and is a common topic of NCLEX questions.

In general, unlicensed assistive personnel refers to patient care technicians, certified nursing assistants, and other individuals who have not graduated from a nursing program. Although their scope of practice can vary between states, you should assume that, in the NCLEX hospital, they are able to obtain vitals and blood glucose levels and ambulate, bathe, feed and assist with the toileting of stable patients. Of course, this is not an exhaustive list. The term stable is quite important here. Unstable patients, like those who are freshly post-op and those in the intensive care units, should be cared for more closely by the RN. Assessments are outside of the UAP’s scope of practice and should never be delegated to them. UAPs can count the heart rate and respiratory rate, but they cannot decide if it is appropriate for the patient. That is your job.

Licensed practical nurses and licensed vocational nurses are able to administer medications, reinforce the teachings of the RN, provide wound care, carry out the interventions in the nursing care plan, and evaluate patients. Additionally, they can perform all the UAP’s tasks. The RN must perform the initial assessment, but the LPN/LVN can perform follow-up assessments and alert the RN to changes in the patient.

Here’s an example:

Which task is appropriate to delegate to an unlicensed assistive personnel?

A. Check pre-prandial blood glucose level of the diabetic patient
B. Administer PRN Tylenol to the patient complaining of increased pain
C. Reposition the patient with increased intracranial pressure and ICP monitoring
D. Assist the patient to use a bedpan following a femoral arterial catheterization

What is this question really asking? You know that unlicensed assistive personnel are allowed to obtain certain vital statistics of patients and provide assistance with activities of daily living to stable patients. With this in mind, we can rephrase the question to say, “Which task is something an unlicensed assistive personnel can successfully do for a stable patient?” We can rule out the Tylenol administration right away because, duh. Medication administration. Big no-no. Also, the patient’s pain is increasing – the nurse needs to assess this patient to determine why the patient’s pain is getting worse. Following a femoral arterial catheterization, patients are at heightened risk for exsanguination should the pressure dressing and clot be dislodged. This patient is not stable. The nurse should assist this patient to use the bedpan if necessary. Although repositioning a patient is within the scope of practice a UAP, a patient ICP monitoring is unstable and should be repositioned by a nurse. By process of elimination, the UAP can be instructed to check the blood glucose level of a diabetic patient before he or she eats.

Here’s another example:

The charge nurse is planning patient care assignments for the day for an unlicensed assistive personnel, a licensed practical nurse, and a nurse who floated to the neurology unit from the medical surgical floor. Which patient assignment is appropriate for the LPN?

A. The patient who requires vitals checks every 2 hours
B. The newly admitted patient who came in through the ED with a stroke
C. The patient with a peripherally inserted central catheter who requires IV push medications
D. The patient with a nasogastric tube who requires NG tube nutrition and medications

You may find it easiest to rank the available nursing care team staff by the level of acuity they can handle and match it to the patient’s acuity and needs. The unlicensed assistive personnel can manage vitals every two hours. An LPN cannot administer IV push medications; therefore, the LPN cannot care for the patient with the PICC and multiple IV push medications. That assignment would be appropriate for the nurse from the med/surg floor. The LPN should be assigned the patient with an NG tube who requires tube feeding and medications.

Ultimately, you are matching the level of care required by the patient with the health care team member who can provide that care. For the NCLEX, it is important to familiarize yourself with the scopes of practice of the UAP, LPN, and RN. With a solid base of this knowledge, dissect each delegation question to determine exactly what the test writers want to know. Are they simply asking, “Which patient is least/ stable?” Or, “Which healthcare team member has the appropriate background to care for this patient?” By breaking the question into manageable parts, you can avoid getting lost in the minutiae. Further, you will use your skills and knowledge of appropriate delegation for the rest of your nursing career.