NCLEX-RN - High-Yield Clinical Prioritization, Delegation & Safe Care Flashcards

Question 1

ABCs Prioritization Framework

Accepted Answer

Airway > Breathing > Circulation. Used to determine immediate life threats. *Exception*: In cardiac arrest, CPR follows C-A-B (Circulation, Airway, Breathing).

Question 2

Maslow's Hierarchy of Needs in Nursing

Accepted Answer

Physiological needs (oxygen, fluids, nutrition, elimination, body temperature) take priority over Safety/Security, Love/Belonging, Esteem, and Self-Actualization.

Question 3

Acute vs. Chronic Prioritization Rule

Accepted Answer

Acute conditions (new onset, sudden change, unexpected distress) take priority over chronic, predictable, or long-standing conditions.

Question 4

Stable vs. Unstable Prioritization Rule

Accepted Answer

Unstable patients (fluctuating vitals, acute pain, unexpected lab results, post-op < 24 hours) take priority over stable patients (predictable discharge, expected symptoms).

Question 5

Five Rights of Delegation

Accepted Answer

1. Right Task
2. Right Circumstance
3. Right Person
4. Right Direction/Communication
5. Right Supervision/Evaluation

Question 6

RN Delegation Scope (The 'EAT' Rule)

Accepted Answer

The RN **cannot** delegate tasks involving **E**valuation, **A**ssessment (initial/admission), or **T**eaching/Treatment planning (EAT). RNs manage unstable patients and complex IV push medications.

Question 7

LPN / LVN Delegation Scope

Accepted Answer

LPNs care for *stable* patients with predictable outcomes. Scope includes: focused assessments, oral/SQ/IM medications, sterile dressing changes, Foley catheter insertion, and reinforcing teaching.

Question 8

UAP Delegation Scope

Accepted Answer

Unlicensed Assistive Personnel handle non-invasive activities of daily living (ADLs) on *stable* patients: routine vitals, hygiene, feeding (without aspiration risk), ambulation, and measuring I&O.

Question 9

Airborne Precautions: Requirements & Pathogens

Accepted Answer

• **Pathogens**: Measles, Tuberculosis, Varicella (chickenpox), Disseminated Herpes Zoster (MTV).
• **Requirements**: N95 respirator or PAPR, negative-pressure room (AIIR), keep door closed.

Question 10

Droplet Precautions: Requirements & Pathogens

Accepted Answer

• **Pathogens**: Influenza, Pertussis, Mumps, Rubella, Bacterial Meningitis, RSV.
• **Requirements**: Surgical mask when within 3–6 feet, private room (or cohorting with same pathogen).

Question 11

Contact Precautions: Requirements & Pathogens

Accepted Answer

• **Pathogens**: *C. difficile*, MRSA, VRE, Scabies, RSV.
• **Requirements**: Gown and gloves. Dedicated single-patient equipment.
• *Special C. diff rule*: Must perform hand hygiene using soap and water; alcohol rub is ineffective against spores.

Question 12

Sequence for Donning PPE

Accepted Answer

1. Gown
2. Mask or Respirator
3. Goggles or Face Shield
4. Gloves (over gown cuffs)

Question 13

Sequence for Doffing PPE

Accepted Answer

1. Gloves
2. Goggles or Face Shield
3. Gown
4. Mask or Respirator (remove *after* leaving airborne isolation room)

*(Tip: Doff in alphabetical order: Gloves, Goggles, Gown, Mask)*

Question 14

High-Alert Medication: Potassium Chloride (IV)

Accepted Answer

**NEVER** administer IV Push or bolus (causes fatal dysrhythmias). Always dilute in IV fluids and administer via an infusion pump at a rate not exceeding $10	ext{ mEq/hr}$ on a peripheral line.

Question 15

High-Alert Medication: IV Unfractionated Heparin

Accepted Answer

Requires a two-RN independent double-check. Monitor **aPTT** (therapeutic range: 1.5–2.5 $	imes$ baseline, ~60–80 seconds). Antidote: **Protamine Sulfate**.

Question 16

High-Alert Medication: Warfarin (Coumadin)

Accepted Answer

Monitor **PT/INR** (therapeutic INR: 2.0–3.0 for most conditions; 2.5–3.5 for mechanical heart valves). Antidote: **Vitamin K** (Phytonadione) and Fresh Frozen Plasma (FFP).

Question 17

SBAR Communication Framework

Accepted Answer

• **S**ituation: State problem/reason for calling.
• **B**ackground: Relevant clinical context.
• **A**ssessment: Current findings/vitals.
• **R**ecommendation: Specific action requested.

Question 18

Surgical Time-Out Protocol

Accepted Answer

Conducted immediately prior to incision by the whole surgical team to confirm: correct patient, correct surgical procedure, correct site/side, and correct equipment/implants.

Question 19

Mass Casualty START Triage Categories

Accepted Answer

• **Red (Immediate)**: Life-threatening injuries with high survival chance (e.g., airway compromise, tension pneumothorax).
• **Yellow (Delayed)**: Major injuries requiring care within 1–2 hours (e.g., stable open fracture).
• **Green (Minimal)**: Walking wounded.
• **Black (Expectant)**: Dead or injuries incompatible with life.

Question 20

Digoxin Toxicity & Nursing Priorities

Accepted Answer

• **Therapeutic Range**: $0.5 - 2.0	ext{ ng/mL}$.
• **Signs of Toxicity**: Nausea/vomiting, anorexia, bradycardia ($HR < 60	ext{ bpm}$), yellow-green visual halos.
• **Risk Factor**: **Hypokalemia** ($K^+ < 3.5	ext{ mEq/L}$) drastically increases digoxin toxicity risk.

NCLEX-RN - High-Yield Clinical Prioritization, Delegation & Safe Care

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