# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=en  
> language: en  
> subject: System-Specific Assessments  
> category: ROR

## Question

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.

|  | Immediate RN assessment and escalation | Prompt RN follow-up after Patient A is stabilized | Eligible LPN/VN assignment if scope and policy allow | UAP delegation with clear directions and RN review |
| --- | --- | --- | --- | --- |
| Patient A: sudden dyspnea, SpO2 89 percent, tachycardia, and new unilateral calf findings |  |  |  |  |
| Patient D: orientation declined from baseline times three to person and place with unsafe bed-exit attempts |  |  |  |  |
| Patient B: scheduled oral antibiotic and reinforcement of an established discharge-teaching plan |  |  |  |  |
| Patient C: routine intake and output measurement with defined findings to report |  |  |  |  |
| Patient D after RN assessment: assisted toileting and specified fall-prevention activity |  |  |  |  |

## 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.

## In-depth explanation

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.

## Clinical scenario

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 target
Separate RN judgment from assignable licensed care and delegable non-assessment activities.

## Key concepts

- **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.

## Related questions

- [A nurse on a medical-surgical unit reviews the morning labs for a 67-year-old male client …](https://mymerci.kr/pages/nclex_q.php?qn_id=361711&lang=en)
- [A 6-year-old client is on the pediatric surgical unit on postoperative day 1 following ton…](https://mymerci.kr/pages/nclex_q.php?qn_id=361812&lang=en)
- [A 45-year-old female client with severe iron-deficiency anemia is receiving the first unit…](https://mymerci.kr/pages/nclex_q.php?qn_id=361898&lang=en)
- [A 72-year-old male client is receiving a continuous IV heparin infusion for a left lower-e…](https://mymerci.kr/pages/nclex_q.php?qn_id=362064&lang=en)
- [A nurse is monitoring an adult client 4 hours after an open abdominal hysterectomy. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=363990&lang=en)
- [A nurse is teaching a 65-year-old client recovering from open upper abdominal surgery how …](https://mymerci.kr/pages/nclex_q.php?qn_id=363997&lang=en)
- [A nurse is conducting morning rounds on adult medical-surgical clients. Which clients shou…](https://mymerci.kr/pages/nclex_q.php?qn_id=364014&lang=en)
- [A nurse is administering a unit of packed red blood cells to a client. Twenty minutes afte…](https://mymerci.kr/pages/nclex_q.php?qn_id=364947&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=566996&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._