Stage 2 — Analyze cues. For each care need, select the single safest responsibility category based on current stability, task predictability, jurisdiction, facility policy, and verified competency.
Matrix
Choose your responses, then check the answer.
Explanation
Responsibility analysis Patient A's acute hypoxemia and suspected PE require immediate RN assessment and escalation. Patient D's new disorientation from baseline requires prompt RN follow-up after immediate help is secured for A. Patient B's oral medication and established teaching reinforcement may be assigned to an eligible LPN/VN. Stable routine intake and output measurement and assisted toileting or fall-prevention activity may be delegated to a competent UAP with clear directions and RN review.
Step 1 — Sort by client stability Clinical deterioration and a new cognitive change require RN judgment. Patient A comes first because breathing and oxygenation are threatened; Patient D follows promptly.
Step 2 — Sort by task Medication administration and reinforcement of established teaching for a stable client may fit LPN/VN practice when permitted. Measurement, toileting, and observation are UAP-appropriate only when the RN defines what to do and what to report.
Step 3 — Keep the boundary explicit The RN does not delegate initial assessment, prioritization, clinical judgment, or evaluation. Scope varies, so the nurse verifies the nurse practice act, facility policy, and competency rather than memorizing one universal list.
NCLEX rule Match the current client and exact task to the team member, then retain supervision and evaluation.
Scenario (Stage 2 — Analyze cues)The RN has identified urgent changes in Patients A and D and stable established care for Patients B and C.
Clinical judgment targetSeparate RN judgment from assignable licensed care and delegable non-assessment activities.
Assignment — Distribution of work within a team member's authorized scope and role; exact permissions depend on jurisdiction and policy.
Delegation — Authorizing a competent person to perform a selected activity while the licensed nurse retains accountability for the decision and follow-up.
Clinical judgment boundary — Initial assessment, prioritization, interpretation of change, and evaluation require licensed nursing judgment and are not delegated to UAP.