Next-Gen NCLEX-RN: Identifying Prioritization, Delegation, and Scope of Practice Questions

Prioritization, delegation, and scope of practice questions are some of the most difficult questions to answer for NCLEX candidates. These questions are plentiful on the exam and often challenge test-takers to make safe and sound decisions about the care they are providing. Since these questions ask candidates to make decisions, these are typically higher-level questions and require a great deal of concentration and understanding of the nursing concepts that guide nursing practice. To help you focus on what's most important, let's look at how each of these high-level nursing concepts requires a bit of strategy to stay focused on the bigger picture.

This article is part of a more extensive study guide for the Next-Gen NCLEX-RN:

• Best Free Online Next-Gen NCLEX-RN Study Guide
• The Nursing Process: Everything Next-Gen NCLEX-RN Test-Takers Need to Know
• Next-Gen NCLEX-RN Question Leveling: Recognition, Comprehension, Application, and Analysis
• Next-Gen NCLEX-RN Expert Test-Taking Strategies

Prioritization

When you see the words:

• Most
• Best
• First
• Next
• Initial
• Immediate

These indicate that the test question is focusing on the nursing concept of prioritization. This concept challenges candidates to understand the criteria requiring the nurse to shift priorities as they move through care delivery. To make it easier, the following principles will help set guidelines that should help make decisions and priorities.

Acute vs Chronic

The principle of acute versus chronic can be interpreted as all acute issues or problems always taking priority over chronic issues or problems. For example, a patient that is experiencing a sudden onset of shortness of breath will take priority over a patient that is short of breath due to a COPD exacerbation. The "sudden onset" is a key term that lets the test-taker know it is a new status change. If the question offers several acute issues as possible answer choices, then you must think about the issues separately and determine which one is more severe and requires immediate attention.

Actual vs Potential

The principle of actual versus potential can be interpreted as all actual issues or problems taking priority over potential issues or problems. For example, a patient that is complaining of pain will take priority over a patient that has right-sided weakness and is requesting to go to the commode. Of course, the candidate may consider the possibility of the patient with right-sided weakness falling if they attempt to get up to go to the commode on their own, but as it stands, it remains a potential problem and therefore does not take priority over the person in pain. It is important to always consider the fact that the test questions want the test-taker to focus on the immediate need that needs to be addressed at this moment. One of the biggest challenges for new grad nurses is thinking too deeply about the "what ifs," which can quickly get them to choose the incorrect answer.

Physical vs Psychosocial

The principle of physical versus psychosocial can be interpreted as all physical issues or problems taking priority over psychosocial issues or problems. For example, a patient that is complaining of chills takes priority over a patient that is complaining of pain. Both of these are actual problems; however, on the NCLEX, pain is considered a psychosocial issue. Chills could be related to infection and, therefore, the priority at this moment. Of all the physical needs that a patient may have, you can prioritize those by using Maslow's Hierarchy of Needs.

Physical needs include:

• Airway
• Breathing
• Circulation
• O2
• Fluids
• Nutrition
• Elimination
• Temperature
• Sleep
• Shelter
• Sex

Psychosocial needs include:

• Pain
• Emotional support
• Knowledge

Unstable vs Stable

The principle of unstable versus stable is a little less cut and dry in regard to interpretation. The word unstable in itself is pretty vague and could involve many considerations and factors. To make it easier for candidates to determine if a patient is unstable or not, consider the following:

• Is there a sudden or new onset of a status change? If so, then the patient is unstable.
• Are there any actual issues that require the skill set of the nurse? If so, that patient is unstable.
• Is there a question about the outcome of the patient? If so, then the patient is unstable.
• Is the patient brand new or just returned from a procedure? If so, then the patient is unstable.
• Is the patient emotionally distraught, angry, or fearful? If so, the patient is unstable.
• Does the patient have abnormal vital signs that put them at risk for injury? If so, then the patient is unstable.
• Is the patient at risk of losing life or limb? If so, the patient is unstable.

Stable patients have predictable outcomes, have normal vital signs, are not demonstrating any actual issues or problems at the moment, and are within normal limits of the care plan.

Just remember that if a patient requires a great deal of nursing judgment and close assessment, then that patient can be considered unstable and requires the RN to tend to them first. When establishing priority, you can utilize all of the above principles to help you determine which answer choice best meets the criteria for the prioritization rules.

Delegation

Nursing students often struggle with delegation simply because they do not get enough opportunities throughout their schooling to practice the art and science of safe and effective delegation. Despite having first-hand experience or not, if candidates understand the fundamental principles and guidelines of delegation, then they can correctly answer NCLEX questions surrounding this concept.

Rules of Delegation

Nursing delegation can begin anytime after the RN has assessed the patient, and after the patient's condition and needs have been considered. The RN will prioritize the patient's needs based on their condition and differentiate between nursing and non-nursing tasks.

Tasks such as obtaining a set of vital signs on a stable patient could be delegated to allow the RN to do other tasks that require the skill set of an RN.

The NCLEX is mainly concerned with the candidate's understanding of what the nurse should not delegate. The functions of the nurse that cannot be delegated include:

• Assessment
• Evaluation
• Teaching
• Nursing Judgement

For RNs, this is limited to initial assessment, initial evaluation, and initial teaching. PNs are perfectly capable of doing ongoing assessments, reinforcing patient education, and evaluating the effectiveness of the care they are providing. However, they must follow the same principles as an RN and not delegate the functions of the nurse to a nursing assistant or unlicensed assistive personnel.

Another thing to consider when determining if it is safe to delegate is the person's ability to complete the task safely and whether or not the delegating nurse will be available to supervise and intervene if necessary. If the nurse is not available to assist in the event that there is a complication or unexpected outcome, then the nurse should not delegate the task as it would be considered to violate the rules of safe and effective delegation.

When In Doubt, Check It Out

Sometimes situations are difficult and require much discernment to determine if we are upholding the highest standards of patient safety and nursing practice. NCLEX questions can be very challenging and require candidates to carefully consider the best, safest, and most appropriate actions related to the situation provided. In many cases, this task is difficult because there may be a lot of questions or there isn't enough information to make a sound decision about what to do.

When nurses run into situations where they do not know what to do next, they rely on assessment to figure it out. So when test-takers are confused or uncertain of what to do next, they can rely on assessment to help guide them.

Let's take a look at how being unsure or not having enough information can guide a candidate into using assessment to select the correct answer:

A mother calls the clinic to report that her child has been nauseated and vomiting and that her child has type I diabetes. What should the nurse tell the mother?

1. Give the child foods with simple sugars
2. Give all medications as prescribed
3. Check the blood glucose every three to four hours
4. Give small, frequent meals

The correct answer is 3.

This question does not provide enough information for the candidate to make a safe and informed decision regarding the care of the patient. Several things could relate to nausea and vomiting that may or may not be related to diabetes. Therefore, the only answer that would help the nurse make a better, informed decision is to use assessment to obtain more data that can be analyzed.

Frequent blood sugar readings will help the nurse determine if the patient is stable enough to be treated at home or if they need to report to the nearest healthcare facility for treatment.

Assessment is always the first step in The Nursing Process and therefore becomes the default when nurses are unsure what to do next or if they require more information to make an informed decision.

Here is another example of how being unsure or not having enough information can guide a candidate into using assessment to select the correct answer:

The nurse responds to a Rapid Response. When the nurse arrives to assist in the rapid response, a nursing assistant tells the nurse that the patient started to complain of chest pain before they fell to the floor. Which of the following actions, if taken by the nurse, would be most appropriate?

1. Help the nursing assistant move the patient from the floor to the bed
2. Ask the nursing assistant what the patient was doing before the chest pain started
3. Tell the nursing assistant to get supplies for supplemental oxygen therapy
4. Ask the patient if they are okay

The correct answer is 4.

This question does not provide enough information for the candidate to make a safe and informed decision regarding the care of the patient. When nurses do not have enough information, they should always default to assessment. In this case, the nurse needs to assess the patient to determine what level of care they may need. Are they alert? Responsive? Do they look injured? Do they require emergent intervention? The nurse must first assess the patient before they can decide what to do next.

Scope of Practice

Nurses have a very special role within the healthcare team. Nurses spend the most time with their patients. They are with their patients during the most intimate of situations. Nurses are on the front lines of patient care delivery, patient satisfaction, patient safety, and patient outcomes.

The NCLEX challenges candidates to fully understand the scope of practice, including ability and limitations. Just as test-takers must be able to answer questions about The Nursing Process correctly, they must also be able to answer scope of practice questions successfully. RNs and PNs must be able to distinguish between the differences within their scope of practice.

Let's review the key differences between each scope and give examples of how the NCLEX may challenge this nursing concept.

Rules of Management (RNs)

RNs are considered to be "managers" of patient care. With this responsibility falling under the scope of practice for the RNs, candidates taking the NCLEX-RN must be well-versed in the rules that guide their practice. In addition to understanding concepts of nursing leadership, conflict resolution, customer service, and other administrative skills, the NCLEX wants RNs to understand the rules that help them make careful decisions about managing patient care.

Here are the rules of management for RN candidates:

• Always follow the rules of delegation (never delegate what you can E.A.T.). Remember that RNs must do all of the initial assessment, evaluation, and teaching.
• Nursing practice and decision-making must always stem from evidence-based practice and textbook nursing.
• Always follow the rules of Prioritization (ABCs, Maslow's, Actual vs. Potential, etc.)
• RNs are responsible for verifying, validating, and following up with all status changes, new patients, complaints, and unexpected outcomes.
• RNs must never leave their patients until they have been determined to be stable.

Here is an example of how the NCLEX could challenge the RN candidate to answer a question about the rules of management:

A 37-year-old patient is being admitted to the unit for a fracture of the right femur. Which of the following actions by the nurse is best?

1. Tell the nursing assistant to obtain the vital signs while the RN obtains a health history from the patient
2. Tell the PN to go obtain phone orders from the physician while the RN assesses the pedial pulses
3. Tell the PN to stay with the client while the RN goes to get supplies to care for the patient
4. Tell the nursing assistant to fill out the admission forms while the RN goes on a lunch break

The correct answer is 2.

This question challenges the candidate to be able to identify the correct action that falls within the scope of practice for the RN. Following the rules of management as a guide really helps test-takers make decisions about correct and incorrect answer choices. Answer choice 1 violates the rules of management of care because the RN is responsible for all initial assessments. Answer choice 3 violates the rules of management because the RN should never leave the patient until they are determined to be stable. Answer choice 4 violates the rules of management of care because the RN is responsible for documenting their findings during the admission assessment. Also, the RN should not leave the patient until they are determined to be stable.

Here is another example of how the NCLEX could challenge the RN candidate to answer a question about the rules of management:

A nurse is creating the unit assignment for the day. Which of the following clients would be appropriate to assign to an LPN?

1. A 33-year-old patient who had an appendectomy yesterday and is scheduled to be discharged later today
2. A 42-year-old patient who had a bowel resection two days ago and has a nasogastric tube inserted and set to intermittent suction
3. A 68-year-old patient who has lower abdominal pain and is scheduled to have an exploratory endoscopy in the afternoon
4. A 98-year-old patient who is on hospice and is demonstrating agonal breathing

The correct answer is 2.

This question challenges the candidate to identify the correct action that falls with-in the scope of practice for the RN—which, in this case, is appropriate delegation. Following the rules of management as a guide helps test-takers make decisions about correct and incorrect answer choices. Answer choice 1 violates the rules of management of care because the RN is responsible for all initial teaching. Discharge teaching is the responsibility of the RN. Answer choice 3 violates the rules of management of care because the RN is responsible for all initial teaching, assessment, and evaluation. Patients going for procedures should be managed by the RN for these reasons. Answer choice 4 violates the rules of management because the RN should keep patients with complex needs and/or who have unexpected outcomes. Although hospice patients demonstrating agonal breathing is expected in the stages of death and dying, each person's response to death can vary. These patients and their family members may require additional teaching, assessment, and evaluation to provide the best care possible.

Rules of Coordination (PNs)

PNs are considered to be the coordinators of patient care. With this responsibility falling under the scope of practice for the practical nurse, candidates taking the NCLEX-PN must be well-versed in the rules that guide their practice. In addition to understanding concepts of nursing leadership, conflict resolution, customer service, and other administrative skills, the NCLEX wants PNs to understand the rules that help them make careful decisions about coordinating patient care.

Here are the rules of management for PN candidates:

• Always follow the rules of delegation (never delegate what you can E.A.T.). This also applies to PNs, as they cannot delegate these functions to unlicensed assistive personnel. Remember that PNs can do ongoing assessments, evaluation, and teaching after the RN has completed the initial.
• Nursing practice and decision-making must always stem from evidence-based practice and textbook nursing.
• Always follow the rules of prioritization (ABCs, Maslow's, Actual vs. Potential, etc.)
• PNs are responsible for reporting changes in status and unexpected outcomes to the RN so the RN can verify, validate, and follow up.
• PNs must never leave their patients until they have been determined to be stable or unless an RN comes in to take over.

Here is an example of how the NCLEX could challenge the PN candidate to answer a question about the rules of management:

The nurse is caring for a 22-year-old patient who has been admitted for a fracture of the right femur. The nursing assistant reports to the nurse that the patient is complaining of a headache. Which of the following actions by the nurse is best?

1. Have the nursing assistant obtain vital signs while the nurse calls the physician
2. The nurse obtains a full set of vital signs, assesses the patient, and reports the findings to the RN in charge
3. The nurse tells the nursing assistant to stay with the patient while the nurse goes to get medication for the patient
4. Have the nursing assistant go give a report to the RN in charge while the nurse goes on a lunch break.

The correct answer is 2.

This question challenges the candidate to identify the correct action that falls within the scope of practice for the PN. Following the rules of coordination as a guide helps test-takers make decisions about correct and incorrect answer choices. Answer choice 1 violates the rules of coordination of care because the PN is responsible for all initial assessments before reporting to the RN to validate their findings. Answer choice 3 violates the rules of coordination because the PN should never leave the patient until they are determined to be stable. Answer choice 4 violates the rules of coordination of care because the PN is responsible for reporting their findings to the RN so that the RN can assess the patient and be determined stable before the PN goes on a lunch break.

Here is another example of how the NCLEX could challenge the PN candidate to answer a question about the rules of management:

The nurse is caring for an 87-year-old patient admitted for failure to thrive. Which care tasks would be appropriate for the PN to delegate to an experienced nursing assistant?

1. Have the nursing assistant ask the patient's family how much the patient has eaten in the past 24 hours.
2. Ask the nursing assistant to look at the patient's skin for breakdown or open areas.
3. Tell the nursing assistant to provide information to the patient and family regarding the use of the remote, call bell, and bed controls.
4. Have the nursing assistant gather equipment that will be needed to care for the patient.

The correct answer is 4.

This question challenges the candidate to identify the correct action that falls within the scope of practice for the PN. Following the rules of coordination as a guide helps test-takers decide on correct and incorrect answer choices. Answer choice 1 violates the rules of coordination of care because the PN is responsible for all initial assessments before reporting to the RN to validate their findings. Answer choice 2 violates the rules of coordination because the PN cannot delegate the functions of assessment. Answer choice 3 violates the rules of coordination of care because the PN cannot delegate the function of teaching.

Therapeutic Communication

Both RNs and PNs are responsible for responding to others in a professional and therapeutic manner. Whether the nurse is speaking with patients, family members, visitors, colleagues, or other members of the healthcare team, they must follow the rules of therapeutic communication at all times. The NCLEX challenges candidates to understand these rules and often places distractors and traps in questions that challenge this nursing concept. To help candidates better understand how to answer therapeutic communication questions successfully, let's first list out the answer types that are always incorrect.

The following answer choice options are incorrect for therapeutic communication questions:

• Authoritative answers (telling the patient or others what to do because you know best)
• Asking "why?” (asking "why?” causes patients and others to become defensive)
• Focusing on self rather than the patient or other (it's not about the nurse, it's about the patient or other person)
• False reassurance (everything will be fine, you're going to be okay)
• Asking closed-ended questions (limits the opportunity for the patient or other to talk about what they want to)

None of the above answer types should even be considered as an option for the correct answer to therapeutic communication questions. These responses typically cause further emotional conflict and do not promote a positive outcome.

Documentation

All nursing students leave school understanding the importance of documentation. It serves a legal purpose, as well as serves as the primary method of communication for all members of the healthcare team. The NCLEX challenges candidates to understand this concept fully and often writes questions that ask test-takers to identify good or bad documentation samples.

Although this nursing concept is pretty straightforward, test anxiety or feelings of test fatigue can often be a barrier when candidates try to pull from their memory banks. To help, we've listed out the rules of "good" documentation to make it easier to recall when needed.

Here are the rules of "good" nursing documentation:

1. Documentation must be objective
2. Documentation must be specific
3. Documentation must be descriptive
4. Documentation must be measurable

Here is an example of how an NCLEX question can challenge the nurse regarding nursing documentation:

The nurse is caring for a 12-year-old patient brought to the emergency department by their parents with a fractured pelvic bone. When asked how the injury occurred, the parents state that the child fell down the stairs while chasing their family dog. Upon assessment, the nurse notes several large bruises and three large scratches on the child's inner thighs. How should the nurse document these findings?

1. "Multiple marks on child's legs"
2. "Three large purple-colored bruises and one large scratch noted on right inner thigh, and two large purple-colored bruises and two large scratches noted on left inner thigh"
3. "Several large bruises and scratches caused by abuse"
4. "Multiple bruises and scratches noted on bilateral inner thighs, caused by falling down the stairs"

The correct answer is 2.

This question challenges candidates to follow the rules of good documentation when choosing the correct answer. The only option that meets the criteria for the rules is answer choice 2 because it is objective, specific, descriptive, and measurable. That means that anyone else could read that documentation and validate these findings.

Answer choice 1 is not descriptive enough. Answer choice 3 is assuming that it was abuse, and nurses must remain objective. We do not know for sure whether it was caused by abuse or not, so one cannot document that in the chart. Answer choice 4 also assumes that the injuries were sustained from falling down the stairs, which the nurse cannot prove or disprove, so therefore, it should not be documented as a definitive reason.

Caring And Compassion

While providing safe and effective patient care, it is part of the nurse's role also to provide that care in a caring and compassionate manner. Although caring and compassion can come at varying degrees of personal investment, a fundamental rule must be followed at all times. On the NCLEX, this fundamental rule isn't so much about compassion as it is about caring. It is important that candidates understand that no matter how complex and overwhelming patient care can become with all the various care equipment, such as heart monitors, traction, wound vacs, IV pumps, chest tubes, central lines, surgical drains, etc.—always take care of the patient first.

Here is an example of how the NCLEX can take this fundamental rule and put it into a test question:

The nurse is caring for a 48-year-old patient in skeletal traction who sustained a fractured femur from a car accident. The patient reports to the nurse that they have terrible pain in the affected extremity. Which action by the nurse is best?

1. Check that the weights are in line and hanging free
2. Check that the traction sling is correctly positioned
3. Ask the client to describe the location and characteristics of their pain
4. Ask the nursing assistant to reposition the client to ease their pain

The correct answer is 3.

The principle of caring for the patient first can be related to the first step of The Nursing Process and the statement, "When in doubt, check it out." When a patient states that they are having pain, difficulty breathing, dizziness, or provides any other subjective symptom, it is the responsibility of the nurse to assess further so that they can address the patient's complaints and immediately begin working towards meeting the patient's needs. Answer 1 is incorrect because the equipment may or may not be causing the pain, so asking the patient is more important. Answer 2 is incorrect for the same reason as answer 1. Answer 4 is incorrect because the nurse has not yet determined if the patient is stable and therefore should not delegate tasks to unstable patients.

When thinking about caring for patients, always remember to "Put the needs of your patients second to the needs of your own, and in all other possible circumstances, take care of your patients first,” according to Damion Keith Jenkins, RN, MSN.

Teaching And Learning Considerations

Since much of what nurses do is teaching and counseling patients, families, communities, students, and staff, the NCLEX challenges candidates' understanding of teaching and learning principles. 

The first way to ensure that a nurse will teach effectively is to be confident in speaking to the content. Many of the NCLEX questions surrounding this nursing concept are written in a way that asks test-takers to identify correct or incorrect information regarding a particular topic. This type of question helps to determine if a candidate is competent in determining if teaching is effective or if further teaching is necessary.

Here is an example of how the NCLEX can write questions that challenge candidates to understand teaching and learning principles:

The nurse is caring for a patient admitted to the labor suite for premature contractions. The treatment was successful, and the patient is scheduled to be discharged later today. The nurse provides discharge teaching regarding a new prescription for terbutaline. The nurse understands that teaching was effective if the patient states which of the following?

1. I can be certain that I will not have my baby prematurely while on this medication
2. I will take this medication every day unless I am feeling really tired
3. I will remain on bedrest so this medication can work
4. I may feel mild muscle tremors while on this medication

The correct answer is 4.

This question challenges the candidate to know the correct information regarding the medication terbutaline. If the candidate is unfamiliar with this medication, then it is possible that they may answer this question incorrectly. The best way to approach these questions is to carefully look at each answer choice for clues. Answer choice 1 is incorrect because it includes the absolute term - "certain." We cannot be certain of anything in healthcare as each person responds differently to treatment. This is similar to giving false reassurance, which we cannot do. Answer choice 2 is incorrect because the medication should be taken all the time unless the doctor says otherwise. Answer choice 3 is incorrect because bedrest does not affect whether or not medication will be effective. Additionally, this patient is being discharged home, which rarely includes mandatory bed rest.