NCLEX-PN Delegation and Scope — RN, LPN, and UAP Responsibilities

DELEGATION TO UAP (Unlicensed Assistive Personnel — CNAs, aides): APPROPRIATE UAP TASKS (the '5 rights of delegation' and stable/predictable rule): Vital signs on STABLE clients; bathing, hygiene, grooming; feeding (non-dysphagic clients); ambulation and positioning; intake/output measurement; specimen collection; making beds; INAPPROPRIATE for UAP (require nursing judgment/license): Assessment (initial or ongoing clinical assessment); medication administration (most states); care planning; client teaching; evaluating client responses; tasks requiring clinical judgment; THE RULE: UAPs perform standardized, routine tasks on STABLE clients with PREDICTABLE outcomes; they do NOT assess, teach, plan, evaluate, or administer medications; FIVE RIGHTS OF DELEGATION: Right task, right circumstance, right person, right direction/communication, right supervision; the delegating nurse retains accountability; LPN/RN must ensure the UAP is competent for the delegated task and supervise appropriately.

DOSAGE CALCULATION: Desired dose ÷ Available dose per unit = number of units. 0.25 mg (desired) ÷ 0.125 mg (per tablet) = 2 tablets. VERIFICATION: 2 tablets × 0.125 mg = 0.25 mg ✓. MEDICATION SAFETY CHECKS: Always verify the calculation; if a calculation results in an unusual number of tablets (more than 2-3, or fractions of unscored tablets), double-check — it may signal an error; digoxin is a HIGH-ALERT medication — verify dose, check apical pulse before administration (hold if < 60 bpm), watch for toxicity; THE 'RIGHTS' of medication administration: right patient, right drug, right dose, right route, right time, right documentation, plus right reason, right response, right to refuse; calculation errors are a leading cause of medication errors — when in doubt, have a second nurse verify, especially for high-alert medications and pediatric doses.

LPN SCOPE — APPROPRIATE ASSIGNMENTS: LPNs care for STABLE clients with PREDICTABLE outcomes. APPROPRIATE for LPN: Stable clients with chronic, stable conditions; routine medication administration (oral, subcutaneous, IM — IV varies by state); reinforcing teaching the RN already initiated; routine wound care; data collection and monitoring; INAPPROPRIATE for LPN (RN responsibility): Initial/admission assessment (the comprehensive assessment requires RN); unstable clients needing ongoing assessment and judgment; blood transfusion initiation (most states — RN only); IV push medications (most states); developing or modifying the care plan; initial client teaching for new diagnoses; clients with unpredictable, complex needs; THE PRINCIPLE: Stable + predictable = LPN appropriate; unstable + requires assessment/judgment = RN; ASSIGNMENT vs DELEGATION: Assignment transfers responsibility for total care within scope; delegation transfers a specific task; charge nurse role: match client acuity to staff scope and competency.

ACCOUNTABILITY IN DELEGATION: When a nurse delegates a task, the nurse RETAINS ACCOUNTABILITY for ensuring the task is completed correctly and safely. Delegation transfers the RESPONSIBILITY for performing the task, but NOT the ACCOUNTABILITY for the outcome. THE DELEGATING NURSE MUST: Ensure the UAP is competent for the task; provide clear direction; supervise appropriately; evaluate the outcome; intervene if needed; FIVE RIGHTS OF DELEGATION: Right task (delegatable, within UAP scope); Right circumstance (stable client, predictable outcome); Right person (competent UAP); Right direction/communication (clear, specific instructions); Right supervision (monitor, evaluate, follow up); WHAT CANNOT BE DELEGATED: Assessment, nursing judgment, evaluation, teaching, care planning, unstable client care; CONSEQUENCES: If a delegated task goes wrong, the delegating nurse may share liability if delegation was inappropriate or supervision inadequate; KEY: 'You can delegate the task, but not the accountability'; LPN/RN role: delegate appropriately, supervise, retain accountability.

LPN/LVN scope of practice is more limited than RN scope. The RN is responsible for INITIAL assessments, developing care plans, and providing initial teaching. The LPN's role is to REINFORCE existing teaching, contribute to data collection, and provide care within established plans. Key LPN scope principles tested on NCLEX-PN: (1) Cannot perform initial assessments of unstable or complex clients (LPN can reassess stable clients); (2) Cannot create the initial nursing care plan (LPN contributes data, RN creates plan); (3) Cannot provide initial teaching (LPN reinforces RN's teaching); (4) Cannot administer IV push medications in most states (state-specific); (5) Cannot perform triage independently in most settings; (6) Cannot hang blood (in most states); (7) CAN administer most medications, perform routine procedures, monitor stable clients, reinforce teaching, document care. Scope varies by state — when in doubt on NCLEX-PN, choose the answer that keeps the LPN within the traditional supportive role under RN supervision.

Priority-setting questions are heavily tested on NCLEX-PN. Use the ABC framework: Airway, Breathing, Circulation. The client with new-onset shortness of breath and chest pain has potential airway/breathing/circulation compromise — this could be MI, PE, pulmonary edema, or another life-threatening emergency. This client is assessed FIRST. Other clients have non-urgent needs: (1) Pain medication can wait a few minutes for the priority assessment; (2) Hygiene assistance is important but not urgent; (3) Discharge teaching is also important but not urgent. Maslow's hierarchy is another tool: physiological needs (especially airway, breathing, circulation) come before safety, love/belonging, esteem, and self-actualization. When multiple physiological needs compete, ABC + life threats first. Always ask: 'Which client is at greatest risk of harm in the next 5-15 minutes?' That client is first.

Transmission-based precautions for NCLEX-PN: (1) AIRBORNE — for organisms transmitted by very small droplet nuclei suspended in air: TB, measles, varicella (chickenpox), disseminated zoster, COVID-19 in high-risk procedures, SARS, MERS. Requires: private NEGATIVE-PRESSURE room with door closed, N95 respirator (fit-tested) for all staff entering, client wears surgical mask when transported. (2) DROPLET — for larger droplets traveling shorter distances: influenza, pertussis (whooping cough), mumps, rubella, meningococcal infections, group A strep. Requires: private room (or cohort), surgical mask within 3-6 feet, client wears surgical mask when transported. (3) CONTACT — for direct or indirect contact with skin/wounds/surfaces: C. difficile, MRSA, VRE, scabies, RSV, hepatitis A in diapered patients. Requires: gown and gloves on entry, dedicated equipment, hand hygiene with soap and water for C. diff (alcohol-based sanitizer doesn't kill C. diff spores). Standard precautions apply to ALL clients regardless of diagnosis: hand hygiene, gloves when contacting body fluids, mask/eye protection if splashing risk. Memorize the categories and which organisms fit each — heavily tested on NCLEX.

Restraint use is heavily regulated due to patient safety, dignity, and legal concerns. CMS, Joint Commission, and state laws require strict protocols. Key principles: (1) LAST RESORT — only after less restrictive measures (reorientation, distraction, family presence, bed/chair alarms, environmental modifications, sitter) have failed; (2) ORDER REQUIRED — physician/APN order within specified timeframe (varies); cannot be PRN (as-needed) standing orders; must be specific (type, reason, duration); (3) LEAST RESTRICTIVE — use the minimum restraint needed (e.g., one-point first before four-point); (4) TIME-LIMITED — orders limited to specific timeframes: 4 hours for adults, 2 hours for ages 9-17, 1 hour for under 9; (5) MONITORING — check every 15-30 minutes; assess skin integrity, circulation, respiratory status, hydration, hygiene, ROM, behavioral status, need for continued restraint; (6) RELEASE — every 2 hours minimum for ROM, toileting, hydration, repositioning; (7) ATTACHMENT — to bed FRAME, not side rails (side rails can be raised/lowered, injuring the patient); quick-release knots; (8) DOCUMENTATION — type, time, reason, alternatives tried, checks, releases, removal criteria; (9) CONTINUOUS REASSESSMENT — discontinue ASAP when criteria for removal met. Chemical restraints (medications used to restrict movement, not for medical condition) are also regulated. Side rails as restraints: all four rails up = restraint; partial rails for mobility assistance = not restraint.

Fire safety in healthcare facilities uses the RACE acronym: R = RESCUE — clients in immediate danger first; move ambulatory clients first, then assistive clients, then non-ambulatory; A = ALARM — pull the nearest fire alarm, dial the facility emergency code, notify other staff; C = CONTAIN — close doors and windows to contain fire and smoke (a closed door significantly slows fire spread); E = EXTINGUISH (if small and safe) using the PASS technique for fire extinguishers, OR EVACUATE if fire is too large. PASS for fire extinguishers: P = Pull the pin, A = Aim at the base of the fire, S = Squeeze the handle, S = Sweep side to side. Extinguisher types: Class A (ordinary combustibles - paper, wood), Class B (flammable liquids - oil, gas), Class C (electrical), Class D (combustible metals), Class K (kitchen - cooking oils/fats); ABC extinguishers are most common in hospitals. Evacuation priority: ambulatory first (they can move themselves), wheelchair/assisted next, bedridden last (using sheets/blankets to slide them, evacuation chairs). Horizontal evacuation (to next fire compartment) before vertical (down stairs). Never use elevators during a fire.

Delegation to Unlicensed Assistive Personnel (UAP/CNA) follows the 'Five Rights of Delegation' (NCSBN): RIGHT TASK, RIGHT CIRCUMSTANCE, RIGHT PERSON, RIGHT DIRECTION/COMMUNICATION, RIGHT SUPERVISION. UAPs CAN typically perform: routine vital signs on stable clients; bathing/hygiene/ADLs; ambulation assistance; positioning; toileting; feeding (stable clients); measuring intake/output; weights; basic skin care; transport. UAPs CANNOT perform: medication administration (in most states); assessments (only data collection, not interpretation); teaching; sterile procedures; care of unstable clients; tasks requiring nursing judgment. The LPN must consider the UAP's training/competency, the client's stability, and state regulations. Even when delegating, the nurse remains accountable for the outcome. Common NCLEX delegation pitfalls: (1) Delegating to UAP what only an RN can do; (2) LPN trying to delegate something outside their own scope; (3) Assuming any UAP can do everything every UAP can do (training varies); (4) Failing to give clear instructions and verify understanding; (5) Failing to follow up and supervise. When in doubt, retain the task yourself or escalate to RN.