How Management of Care is tested
Expect "which client first?", "which task can be delegated?", and "which assignment is appropriate?" items, plus legal and ethical scenarios.
For every client in the stem, ask: is this finding expected for this client, and is it a threat to airway, breathing, circulation, or safety right now? The client with an unexpected, life-threatening change is first.
Prioritization rules
Several rules usually agree; when they conflict, the immediate threat to life wins.
| Rule | Higher priority | Lower priority |
|---|---|---|
| Acute vs chronic | New chest pain | Chronic stable angina |
| Unstable vs stable | Falling BP, rising HR | Stable vital signs |
| Unexpected vs expected | Absent pedal pulse after cardiac catheterization | Mild incisional pain after surgery |
| Actual vs potential | Active bleeding | Risk for bleeding |
| Physiological vs psychosocial | Hypoglycemia | Anxiety about discharge |
| Assess vs act | Assess first, unless emergency action is needed now | — |
Maslow's hierarchy places physiological needs first, then safety, then love and belonging, esteem, and self-actualization.
Delegation: the five rights
The 2019 National Guidelines for Nursing Delegation (NCSBN and ANA) define delegation and the licensed nurse's responsibilities.
| Usually appropriate | Assistive personnel (AP/UAP) | LPN/VN (varies by state) | RN only |
|---|---|---|---|
| Examples | Vital signs on stable clients, bathing, feeding, ambulation, I&O, specimen collection, positioning | Care of stable clients, medications other than those restricted by state, wound care, reinforcing teaching, data collection | Initial assessment, care planning, teaching, evaluation, unstable clients, new admissions, most IV push medications, blood transfusion assessment |
The nurse keeps overall accountability for the client; the delegatee is responsible for the delegated activity. Always follow your state's nurse practice act.
Assignments and floating
Assign stable, predictable clients to less experienced staff and complex or unstable clients to the RN.
- A float nurse gets clients whose care is similar to their usual unit (for example, a medical-surgical nurse floated to pediatrics gets the most stable, adult-like clients).
- Do not assign a pregnant staff member to clients with known hazards (for example, certain radiation or infectious exposures).
- Avoid assigning immunocompromised clients with clients who have infections.
- Give clear directions: what to do, when to report, and what findings to report immediately.
NGN-style cases
Both decisions in one place.
The nurse receives report on four clients. Whom should the nurse see first? (A) A client 1 day after hip surgery requesting pain medication, pain 6/10; (B) a client with COPD with SpO₂ 90% on 2 L/min, baseline 89–91%; (C) a client 2 hours after a thyroidectomy reporting a tingling around the mouth and a "tight" voice; (D) a client with diabetes whose glucose is 210 mg/dL before lunch.
- A and D are abnormal but expected or not immediately life-threatening.
- B is at the client's stable baseline.
- C has perioral tingling (possible hypocalcemia from parathyroid injury) and voice change (possible airway swelling or hematoma).
- Airway and a new, unexpected change make C the priority.
Answer. Client C. Possible airway compromise and hypocalcemia after thyroidectomy require immediate assessment.
Which tasks can the RN delegate to assistive personnel? (1) Ambulating a stable client 2 days after surgery; (2) teaching a client to use an incentive spirometer; (3) measuring intake and output; (4) assessing a client who reports new chest pain; (5) obtaining vital signs on a stable client.
- Routine, predictable tasks for stable clients can go to assistive personnel.
- Teaching and assessment require nursing judgment.
- New chest pain is an unstable situation that needs RN assessment.
Answer. Delegate 1, 3, and 5. The RN keeps 2 (teaching) and 4 (assessment of an unstable client).