# A charge nurse on a 24-bed step-down unit receives a float RN from the ambulatory procedure area for the day shift. With the float nurse, 6 RNs are on duty for 22 clients, and the unit staffing plan calls for 1 RN for every 4 clients. Unit policy allows titrated norepinephrine on the step-down unit at doses up to 0.15 mcg/kg/min. Before accepting report, the float nurse tells the charge nurse that competency validation for titratable vasoactive infusions has not been completed. The proposed float assignment is 4 clients: a client receiving norepinephrine at 0.08 mcg/kg/min that has been titrated 4 times in the past 2 hours to keep mean arterial pressure (MAP) between 65 and 70 mm Hg (current MAP 67 mm Hg, urine output 35 mL/hr), and 3 stable clients with predictable care. Complete the diagram by selecting the problem the charge nurse most likely needs to address, 2 actions the charge nurse should take to address that problem, and 2 parameters the charge nurse should monitor in the client receiving norepinephrine to assess whether the revised plan is working.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617360&lang=en  
> language: en  
> subject: Concepts of Management  
> category: MOC

## Question

A charge nurse on a 24-bed step-down unit receives a float RN from the ambulatory procedure area for the day shift. With the float nurse, 6 RNs are on duty for 22 clients, and the unit staffing plan calls for 1 RN for every 4 clients. Unit policy allows titrated norepinephrine on the step-down unit at doses up to 0.15 mcg/kg/min. Before accepting report, the float nurse tells the charge nurse that competency validation for titratable vasoactive infusions has not been completed. The proposed float assignment is 4 clients: a client receiving norepinephrine at 0.08 mcg/kg/min that has been titrated 4 times in the past 2 hours to keep mean arterial pressure (MAP) between 65 and 70 mm Hg (current MAP 67 mm Hg, urine output 35 mL/hr), and 3 stable clients with predictable care. Complete the diagram by selecting the problem the charge nurse most likely needs to address, 2 actions the charge nurse should take to address that problem, and 2 parameters the charge nurse should monitor in the client receiving norepinephrine to assess whether the revised plan is working.

Condition

Select 1
Assignment exceeds the float nurse's validated competence
Unit staffing below the staffing plan
Client acuity beyond the step-down unit's scope
Float nurse's client load exceeds a safe number

Actions to take

Select 2
Have the float nurse review the titration policy first
Request ICU transfer for the client on norepinephrine
Reassign the norepinephrine client to a validated RN
Give the float nurse stable, predictable clients
Keep the assignment and co-sign each titration yourself

Parameters to monitor

Select 2
Mean arterial pressure
Serum potassium level
Oral temperature
Hourly urine output
Pain intensity on a 0–10 scale

## Explanation

Six RNs for 22 clients meets the 1:4 plan, the norepinephrine dose is within the unit's policy limit, and a 4-client assignment is standard, so the problem is a mismatch between an unstable infusion and the float nurse's validated competence. The charge nurse reassigns that client to a validated RN and gives the float nurse stable clients with predictable care. The client's MAP and hourly urine output show whether the titration is now keeping blood pressure and perfusion on target.

## In-depth explanation

Quick answer
Assignment exceeds the float nurse's validated competence. Reassign the norepinephrine client to a validated RN and give the float nurse stable clients with predictable care. Monitor that client's mean arterial pressure and hourly urine output.

Why this is correct
The numbers rule out a staffing shortage: 6 RNs x 4 clients covers 24 beds, and 22 clients are present. The dose of 0.08 mcg/kg/min is below the 0.15 mcg/kg/min policy limit, so the client is within the unit's scope, and 4 clients is the planned load. What does not fit is one nurse and one client: an infusion titrated 4 times in 2 hours needs an RN with current validated competence. After reassignment, a MAP held at 65 to 70 mm Hg and adequate urine output show that the titration is being managed safely.

Easy analogy or mental picture
It is like a skilled driver of automatic cars being handed the keys to a manual race car on a busy highway: the fix is to swap drivers, not to add more cars to the road or read the manual at the on-ramp.

Memory hook
Match the Most unstable client to the Most validated nurse; float nurses get the Most predictable care.

NCLEX decision rule
When a nurse identifies a competence gap before accepting report, reassign the unstable client to a validated nurse and give that nurse clients within validated competence; reading a policy or co-signing does not transfer competence.

Why the other choices are wrong
Understaffing is excluded because 6 RNs meet the 1:4 plan for 22 clients, and a 4-client load is the planned number. The dose is within the unit's policy limit and the MAP is at target, so ICU transfer addresses a scope problem that does not exist. Reviewing the policy before report is education, not validated competence. Keeping the assignment while the charge nurse co-signs titrations leaves the float nurse accountable for a skill not yet validated and pulls the charge nurse away from the unit. Potassium, temperature, and pain are routine findings that do not show whether vasopressor titration is keeping perfusion on target.

References
1NCSBN/ANA National Guidelines for Nursing DelegationAssignments must match the nurse's competence and the client's condition
2NCSBN 2026 NCLEX-RN Test PlanClient Needs category and clinical judgment framework

## Clinical scenario

Scenario
A float RN without validated competency for titratable vasoactive infusions is offered a client whose norepinephrine requires frequent titration on a step-down unit that meets its staffing plan and may titrate norepinephrine by policy.

## Key concepts

- **Validated competence** — Documented, current demonstration that a nurse can safely perform a specific skill.
- **Assignment** — Allocation of client care to staff according to client needs and staff competence.
- **Mean arterial pressure (MAP)** — The average arterial pressure during a cardiac cycle; vasopressors are titrated to a MAP goal such as 65 mm Hg or higher.

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