# NCLEX-RN — Prioritization, Delegation (RN vs LPN vs UAP), Infection Control & Clinical Judgment > Comprehensive NCLEX-RN review covering delegation principles (RN vs LPN/LVN vs UAP/CNA), Maslow and ABC prioritization, standard, contact, droplet, and airborne precautions, PPE donning/doffing, and the NCSBN Clinical Judgment Measurement Model (NCJMM). - **Canonical URL:** https://flashcards.world/flashcards/sets/4b5aa93f-729e-4b02-a162-7ac03c93d614/ - **Markdown URL:** https://flashcards.world/flashcards/sets/4b5aa93f-729e-4b02-a162-7ac03c93d614.md - **Level:** basic - **Languages:** en → en - **Total Cards:** 32 ## Flashcards (32 Cards) | # | Front (Term / Prompt) | Back (Definition / Answer) | Example | Multiple-Choice Options | | :--- | :--- | :--- | :--- | :--- | | 1 | What responsibilities can NEVER be delegated by an RN to an LPN or UAP ('EAT' mnemonic)? | E — Evaluate client outcomes and therapeutic response; A — Assess (initial admission assessment, unstable client assessments, post-procedure assessment); T — Teach (initial health education, discharge planning, complex instruction). Clinical judgment and care plan formulation remain RN-exclusive. | | | | 2 | Prioritization triage: Which client should the medical-surgical nurse assess first among 4 options? | The nurse assesses first the client with unexpected, acute, or airway/breathing/circulatory compromise (e.g., a post-thyroidectomy client with stridor or a client receiving heparin with sudden black tarry stools), rather than clients with expected chronic manifestations (e.g., COPD with SpO2 90% or osteoarthritis with morning stiffness). | | | | 3 | What tasks can a Registered Nurse (RN) safely delegate to an Unlicensed Assistive Personnel (UAP / CNA)? | Routine, non-invasive tasks for stable clients: vital signs (on stable patients), activities of daily living (bathing, toileting, feeding non-dysphagic clients), measuring intake and output (I&O), ambulation (subsequent to initial RN assessment), repositioning, and empty drainage containers. | | | | 4 | What constitutes a HIPAA violation regarding electronic health records (EHR) and client confidentiality? | Accessing medical records of family members, friends, celebrities, or clients not directly under the nurse's assigned care; sharing login credentials; leaving active computer screens unattended; discussing patient clinical details in public hospital areas (elevators, cafeteria, hallway); posting clinical information on social media. | | | | 5 | What are the essential elements of Neutropenic Precautions (Protective / Reverse Isolation)? | Absolute Neutrophil Count (ANC) < 1,000/mm3 (severe < 500/mm3). Interventions: Private room, strict hand hygiene, avoid all fresh flowers/potted plants, avoid raw fruits/vegetables (cooked foods only), avoid sick visitors, no rectal temperatures or enemas, and dedicated sanitized medical equipment. | | | | 6 | Why are acute conditions prioritized over chronic conditions on the NCLEX? | Clients experiencing acute physiological changes (new-onset chest pain, acute shortness of breath, sudden mental status change, post-op fever) have higher risk of rapid hemodynamic collapse than clients with stable chronic diseases (longstanding COPD, controlled hypertension, chronic renal disease). | | | | 7 | What fall prevention interventions should be implemented for a client assessed as high fall risk? | Place client near the nurses' station; keep bed in lowest position with wheels locked; activate bed/chair exit alarms; place non-skid socks; keep call light and personal items within reach; provide 2 to 3 side rails up (all 4 rails up is legally considered a restraint); ensure adequate pathway lighting; schedule regular toileting. | | | | 8 | What are the 6 cognitive steps of the NCSBN Clinical Judgment Measurement Model (NCJMM)? | 1. Recognize Cues (identify relevant clinical data); 2. Analyze Cues (link cues to patient condition); 3. Prioritize Hypotheses (evaluate urgency); 4. Generate Solutions (identify expected outcomes and interventions); 5. Take Action (implement nursing interventions); 6. Evaluate Outcomes (compare observed vs expected responses). | | | | 9 | Can an LPN administer IV push medications or titrate vasoactive continuous cardiac infusions? | No. Intravenous push (IV bolus) medications and the titration of continuous critical care vasoactive or antiarrhythmic infusions (e.g., Norepinephrine, Dopamine, Nitroglycerin) require complex immediate clinical assessment and are restricted strictly to the Registered Nurse. | | | | 10 | What are droplet precautions protocols, and what common pathogens necessitate them ('PIMP' / 'SPIDERMAN')? | Pathogens: Pertussis, Influenza, Meningococcal pneumonia/meningitis, Parvovirus B19, Rubella, Mumps. Precautions: Private room (or cohort with same pathogen), surgical mask within 3–6 feet of client, eye protection/goggles if splashing is anticipated, and client wears surgical mask during transport. | | | | 11 | What is the primary legal and ethical role of the Registered Nurse regarding Informed Consent? | The nurse acts as a witness to the client's voluntary signature, confirms that the client is alert and competent (not under sedatives/narcotics), and verifies that the healthcare provider explained the procedure, risks, benefits, and alternatives. The nurse does NOT explain surgical risks or alternatives. | | | | 12 | What specific nursing actions during blood transfusion can be delegated vs RN-reserved? | RN must: verify blood product with a second licensed nurse, assess client baseline vitals, spike and initiate infusion, remain with client for the critical first 15 minutes, and evaluate for transfusion reactions. UAP may: retrieve blood unit from blood bank and obtain baseline and post-15-minute routine vitals as directed. | | | | 13 | What are the key airborne precautions protocols, and which common diseases require them ('MTV' mnemonic)? | Diseases: Measles (Rubeola), Tuberculosis (Pulmonary TB), Varicella-Zoster (Chickenpox / Disseminated Shingles). Precautions: Negative-pressure private room with 6–12 air exchanges/hour (AIIR), HEPA filtration, N95 respirator mask fitted for healthcare workers, and surgical mask on patient during transport. | | | | 14 | What clinical activities fall within the scope of practice of a Licensed Practical / Vocational Nurse (LPN / LVN)? | Care of stable clients with predictable outcomes: monitoring RN assessment findings, reinforcing client education (not initial teaching), administering standard oral/subcutaneous/IM medications, routine dressing changes, inserting urinary catheters, nasogastric tube patency checks, and performing enteral tube feedings. | | | | 15 | Who should assist a postoperative client ambulate for the first time after surgery? | The Registered Nurse (RN). The initial ambulation after anesthesia and surgical intervention carries a high risk of orthostatic hypotension, syncope, and surgical site compromise; subsequent routine ambulation of a stable patient can be delegated to the UAP. | | | | 16 | What characteristics differentiate an unstable client from a stable client in NCLEX prioritization? | Unstable: New-onset or sudden symptoms, unexpected findings for disease state, abnormal critical vitals, acute pain, bleeding, or < 12–24 hours post-operative. Stable: Chronic condition with expected symptoms, ready for discharge, > 24 hours post-op with expected post-op pain, normal or baseline vital signs. | | | | 17 | What are the essential documentation rules regarding Incident (Occurrence / Variance) Reports? | Complete the report objectively stating facts without opinions or blame; submit it to the risk management department; document the factual assessment, vital signs, interventions, and provider notification in the client's medical record; NEVER write in the medical record that an incident report was completed or filed. | | | | 18 | What are contact precautions protocols, and which conditions require them ('MRS. WEE')? | Pathogens: MRSA, VRE, C. diff, RSV, Scabies, Wound infections with drainage, and major impetigo. Precautions: Private room, gloves and gown donned upon entering, dedicated patient-care equipment (stethoscope, BP cuff), and thorough disinfectant cleaning before equipment leaves room. | | | | 19 | What is the nursing action when a client has systemic anaphylaxis vs a localized allergic drug reaction? | Systemic anaphylaxis (wheezing, stridor, hypotension, facial angioedema): Immediately discontinue offending infusion, administer IM Epinephrine into anterolateral thigh, establish airway/high-flow O2, and give IV fluids. Localized rash/itching: Stop drug, assess vitals, notify provider, and administer antihistamines as ordered. | | | | 20 | What infection control measures are required when transporting a client with active pulmonary tuberculosis? | The client must wear a standard surgical mask during transport through hospital corridors. The receiving department must be notified in advance. Healthcare personnel transporting the client do not need to wear an N95 if the client is masked, but staff at the destination must wear fitted N95 respirators. | | | | 21 | How is Maslow's Hierarchy of Needs applied in NCLEX clinical prioritization scenarios? | Physiological needs (oxygenation, fluid balance, nutrition, elimination, pain relief) take immediate priority over Safety/Security needs (fall precautions, infection control), which in turn supersede Psychosocial needs (love/belonging, self-esteem, self-actualization), unless safety involves life-threatening danger (e.g., suicide attempt). | | | | 22 | What is the difference between a Living Will and a Durable Power of Attorney for Healthcare (Healthcare Proxy)? | Living Will: A legal document specifying the client's specific wishes regarding medical treatments (e.g., ventilators, feeding tubes, CPR) if they become terminally ill or permanently unconscious. Healthcare Proxy (DPA): Designates a surrogate decision-maker to make healthcare decisions on the client's behalf if incapacitated. | | | | 23 | Under what circumstance must a nurse immediately report a colleague to the nursing supervisor or regulatory board? | Impairment by alcohol, narcotics, or drugs during clinical duty; suspected diversion of controlled substances (frequent wasting, unmanaged pain in assigned clients); physical abuse or neglect of a client; severe practice incompetence endangering patient safety. | | | | 24 | What is the correct CDC sequence for doffing (removing) Personal Protective Equipment (PPE)? | Alphabetical order or most-contaminated to least: 1. Gloves (most contaminated, remove first); 2. Goggles/Face shield (handle by headband/earpieces); 3. Gown (unfasten ties, peel away from neck/shoulders touching inside only); 4. Mask/Respirator (remove outside client room by bottom ties, then top); followed immediately by Hand Hygiene. | | | | 25 | What isolation precautions are required for localized Herpes Zoster (Shingles) vs Disseminated Shingles? | Localized Herpes Zoster with covered lesions in an immunocompetent host: Standard Precautions. Disseminated Herpes Zoster (lesions beyond primary dermatome) or localized shingles in an immunocompromised host: Airborne and Contact Precautions until all lesions are crusted. | | | | 26 | What hand hygiene practice is mandatory when caring for a client with Clostridioides difficile (C. diff)? | Washing hands with soap and water (NOT alcohol-based hand rub). C. diff produces resilient bacterial endospores that are not eradicated by alcohol rubs and require physical mechanical friction and rinsing with water. | | | | 27 | What is the correct CDC sequence for donning (putting on) Personal Protective Equipment (PPE)? | 1. Gown (cover torso and wrap around back); 2. Mask or N95 respirator (secure ties/bands and pinch nose wire); 3. Goggles or Face shield; 4. Gloves (extend over wrist cuff of gown). | | | | 28 | What actions must the nurse take when a competent client insists on Leaving Against Medical Advice (AMA)? | Assess the client's decision-making capacity; inform the client of the specific risks of leaving without treatment (including disability or death); notify the healthcare provider; request the client sign the AMA form; remove peripheral IV lines; document the discussion and refusal in the medical record (never detain or restrain the client). | | | | 29 | What are the regulatory guidelines for physical restraints regarding prescription renewal and client assessment? | Restraints require a time-limited provider order (maximum 24 hours total, with renewal requirements based on age: 4 hours for adults 18+). The provider must conduct a face-to-face evaluation within 1 hour of application. Nursing assessments for skin integrity, circulation, neurovascular status, hydration, and toileting must occur every 15–30 minutes. | | | | 30 | How do the ABCs (Airway, Breathing, Circulation) guide prioritization, and what is the key exception in cardiac arrest? | Airway obstruction or stridor is prioritized first, followed by Breathing (dyspnea, hypoxia, hypoventilation), then Circulation (pulse, blood pressure, shock). Exception: In sudden unresponsive cardiac arrest, prioritize CAB (Circulation/Compressions, Airway, Breathing) to immediately restore cerebral and coronary perfusion. | | | | 31 | What are the components of the SBAR clinical communication framework? | S — Situation (client name, room, primary problem/concern); B — Background (admission diagnosis, relevant medical history, dates/treatments); A — Assessment (current vitals, physical findings, clinical impression); R — Recommendation (specific request, need for evaluation, medication, or transfer). | | | | 32 | What are the rules for maintaining a sterile surgical field in nursing practice? | Sterile objects remain sterile only when touched by other sterile items. Keep sterile field in view at or above waist level. The outer 1-inch (2.5 cm) border of the sterile drape is considered contaminated. Any moisture penetrating the sterile drape causes contamination by capillary action (strike-through). Never turn your back or reach across a sterile field. | | | --- Study this deck interactively with FSRS-6 spaced repetition, audio review, and multiple-choice mode at [Flashcards World](https://flashcards.world/flashcards/sets/4b5aa93f-729e-4b02-a162-7ac03c93d614/).