# Stage 1 — Recognize cues. Review the 0700 handoff for the four-client assignment. Highlight the findings that require the RN's prompt assessment. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617306&lang=en > language: en > subject: Assignment/Delegation/Supervision > category: MOC ## Question Stage 1 — Recognize cues. Review the 0700 handoff for the four-client assignment. Highlight the findings that require the RN's prompt assessment. 0700 handoff. The day RN works with one LPN/VN and one UAP. Patient A, 72, is postoperative day 1 after right total hip arthroplasty and receives prescribed VTE prophylaxis. At 0500 he developed sudden shortness of breath and new right calf tenderness with unilateral swelling. BP is 138/86, HR 110, RR 24, temperature 37.6 C (37.5 C last evening), and SpO2 89 percent on room air; he is anxious, and his breath sounds are clear. Patient B, 68, is improving after community-acquired pneumonia, has been afebrile for 12 hours on oral antibiotics, and needs reinforcement of previously taught discharge instructions; she has crackles in the right base, fewer than on admission, and SpO2 is 96 percent on room air. Patient C, 45, is postoperative day 2 after laparoscopic cholecystectomy; she reports right shoulder pain of 5 out of 10, the same ache from abdominal gas insufflation she described yesterday, three hours after the last PRN analgesic; vital signs are stable, and reassessment is due. Patient D, 81, is being treated for a urinary tract infection; her documented baseline is oriented times three, and she is now oriented to person and place. She repeatedly tried to get out of bed and pulled at her IV overnight. At 0600 she voided 200 mL of cloudy urine, as on each day since admission. BP is 134/82, HR 88, temperature 36.7 C, SpO2 95 percent on room air, and a bed alarm is active. ## Explanation Patient A's sudden dyspnea, new unilateral calf tenderness, and SpO2 89 percent on room air one day after hip arthroplasty require immediate RN assessment for pulmonary embolism, and Patient D's orientation has fallen from her documented baseline of times three, which is an acute change requiring RN assessment for delirium. The distractors look concerning but are expected or unchanged: a low-grade temperature that has not risen since last evening, clear breath sounds, prophylaxis already ordered, Patient B's resolving basilar crackles, Patient C's unchanged referred shoulder pain from gas insufflation with a reassessment due, and Patient D's cloudy urine (unchanged and already being treated), normal temperature, and active bed alarm. ## In-depth explanation Quick answer Highlight **sudden shortness of breath**, **new right calf tenderness**, and **SpO2 89 percent on room air** for Patient A, and **oriented to person and place** for Patient D. Why this is correct Patient A has a new cluster (sudden dyspnea, hypoxemia, unilateral calf findings) after major orthopedic surgery, which threatens oxygenation and cannot be delegated. Patient D's orientation is only abnormal when compared with her documented baseline of oriented times three; an acute decline in an older adult with infection suggests delirium and needs RN assessment even though her vital signs are normal. Both findings require assessment, which is an RN responsibility that cannot be delegated to the LPN/VN or UAP. Easy analogy or mental picture Picture four dashboards: two show steady readings that match yesterday, one shows a small expected blip, and one flashes a new red warning. The RN walks to the flashing one first, then to the one whose normal-looking gauge is actually lower than its own set point. Memory hook New, sudden, or below this client's baseline = RN eyes now. NCLEX decision rule In a multi-client assignment, findings that are new or represent a decline from the client's own baseline require RN assessment; expected, stable, or already-planned findings can be managed through assignment with reporting parameters. Why the other choices are wrong **Temperature 37.6 C** is essentially unchanged from 37.5 C last evening, a common low-grade postoperative day 1 finding that does not explain Patient A's sudden hypoxemia. **Breath sounds are clear** is tempting as reassurance, but clear lungs with new hypoxemia actually argue against pneumonia and toward PE; it is not itself the abnormal finding. **Receives prescribed VTE prophylaxis** does not exclude PE. **Crackles in the right base** are tempting next to Patient A's dyspnea, but they are fewer than on admission in a client who is afebrile with SpO2 96 percent, which fits resolving pneumonia. **Right shoulder pain of 5 out of 10** sounds alarming (cardiac or bleeding), but it is the same referred gas-insufflation ache described yesterday, with stable vital signs and a scheduled licensed-nurse reassessment. **Cloudy urine** is unchanged since admission and reflects the infection already being treated; it is not the new finding in Patient D. **Temperature 36.7 C** is tempting to use to dismiss Patient D's confusion, but older adults with infection often have delirium without fever, and **a bed alarm is active** is an existing safety measure, not a new finding. References 1NCSBN/ANA National Guidelines for Nursing DelegationAssessment of unstable clients and clinical judgment remain RN responsibilities 2NHLBI — Venous ThromboembolismSudden dyspnea and unilateral leg swelling after major surgery suggest DVT with pulmonary embolism ## Clinical scenario Scenario (Stage 1 — Recognize cues) At the start of the day shift, the RN receives four medical-surgical clients with an LPN/VN and a UAP and must identify which findings need RN assessment before assigning care. ## Key concepts - **Pulmonary embolism** — Obstruction of a pulmonary artery, usually by a thrombus from the deep leg veins, presenting with sudden dyspnea, tachycardia, and hypoxemia. - **Delirium** — An acute, fluctuating change in attention and cognition, often from infection or medications in older adults, that differs from the client's baseline. - **Delegation** — Transfer of a specific task to a competent team member; assessment of unstable or changing clients and clinical judgment remain with the RN. ## Related questions - [A 67-year-old client with chronic obstructive pulmonary disease attends a routine primary …](https://mymerci.kr/pages/nclex_q.php?qn_id=360522&lang=en) - [A registered nurse on a medical-surgical unit is delegating tasks at the start of shift. 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