NCLEX Question Strategy: Management of Care Questions

Every three years, the National Council conducts a job analysis study to determine the activities required of a newly licensed registered nurse. Based on this study, the National Council adjusts the content of the test to accurately reflect what is happening in the workplace. This ensures that the NCLEX-RN® exam tests what is needed to be a safe and effective nurse.
The role of the nurse has expanded in today’s health care environment. In addition to providing quality client care, the nurse is also responsible for coordination and supervision of care provided by other health care workers. Many health care settings are staffed by registered nurses, licensed practical nurses/licensed vocational nurses (LPN/LVN), and nursing assis- tive personnel (NAPs) such as nursing assistants and support staff. It is the responsibility of the registered nurse to coordinate the efforts of these health care workers to provide affordable quality client care. Appropriate supervision of LPN/LVN and/or NAPs by the registered professional nurse is essential for safe and effective client care.
To reflect these changes, the NCLEX-RN® exam contains questions about delegation and assignment of client care. There are several reasons why you may find these questions difficult to answer correctly on the NCLEX-RN® exam:
Many nursing schools test the content presented in the management course with essay questions rather than multiple-choice questions.
You may have received lectures regarding management of care, but your clinical rotation in management may have been less than ideal. Regardless, do not choose answers based on decisions you may have observed during your clinical experience in the hospital or clinic setting. Remember, the NCLEX-RN® exam is ivory-tower nursing. Always ask yourself, “Is this textbook nursing care?”
Your experience may have been restricted to caring for one or two clients without any opportunity to supervise others, or you may have spent time on a hospital unit providing client care under the supervision of a preceptor.
Even if you have no direct experience in these areas, the Rules of Management will get you through the test. They will help you choose more right answers when answering management questions on the NCLEX-RN® exam.

The Rules of Management

  • Rule #1: Do not delegate the functions of assessment, evaluation, and nursing judgment.

    During your nursing education, you learned that assessment, evaluation, and nursing judgment are the responsibility of the registered professional nurse. You cannot give this responsibility to someone else.

  • Rule #2: Delegate activities for stable clients with predictable outcomes.

    If the client is unstable, or the outcome of an activity not assured, it should not be delegated.

  • Rule #3: Delegate activities that involve standard, unchanging procedures.

    Activities that frequently reoccur in daily client care can be delegated. Bathing, feeding, dressing, and transferring clients are examples. Activities that are complex or complicated should not be delegated.

  • Rule #4: Remember priorities!

    Remember Maslow, the ABCs, and “stable versus unstable” when determining which client the RN should attend to first. Keep in the mind that you can see only one client or perform one activity when answering questions that require you to establish priorities.

Let’s use the Rules of Management to eliminate answer choices in exam-like Management of Care questions.

Practice Question 1

A child with a compound fracture of the left femur is being admitted to a pediatric unit. Which of the following actions is BEST for the nurse to take?
1. Ask the NAP to obtain the child’s vital signs while the nurse obtains a history from the parents.
2. Ask the LPN/LVN to assess the peripheral pulses of the child’s left leg while the nurse completes the admission forms.
3. Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician.
4. Ask the NAP to obtain equipment for the child’s care while the nurse talks with the child and his parents.

Step 1. Reword the question in your own words.
The question asks what the nurse should do when a child with a fractured femur is first admitted. That question is very broad. To establish exactly what is being asked, you must read the answer choices. In each answer, the RN is delegating tasks to the LPN/LVN or NAP. The real question is, “What is appropriate delegation?”
Step 2. Eliminate answer choices based on the Rules of Management.
(1)  Obtaining vital signs is an important part of assessment. According to Rule #1, the registered nurse cannot delegate assessment. Eliminate this answer choice.
(2)  Checking the peripheral pulses is an important assessment for this client because of the diagnosis of a fractured left femur. The nurse needs to assess the client before delegating activities to someone else. Assessment of the client is much more important than completing paperwork. Eliminate.
(3)  There is no assessment, evaluation, or nursing judgment involved in this option, so leave it in for consideration.
(4)  The nurse is with the child and his parents while the NAP obtains needed equipment. There is no assessment, evaluation, or nursing judgment when gathering equipment, so leave this choice in for consideration.
Step 3. Select an answer from the remaining choices.
You are left with answer choices (3) and (4). You are halfway to the correct answer!
Answer (3) indicates that the nurse is on the phone and the LPN/LVN is with the client. Have you seen this done in the real world? Probably. Is this what nursing textbooks and journals say should be done in this situation? Probably not. Eliminate this answer. Remember, on the NCLEX-RN® exam, emphasis is placed on providing care to clients according to how nursing care is defined in textbooks and journals.
The correct answer is (4). The nurse is caring for the child and his parents while delegating tasks to nursing assistive personnel.
Let’s look at another Management of Care question.

Practice Question 2

Which of the following tasks is appropriate for the nurse to delegate to an experienced NAP?
1. Obtain a 24-hour diet recall from a client recently admitted with anorexia nervosa.
2. Obtain a clean-catch urine specimen from a client suspected of having a urinary tract infection.
3. Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection.
4. Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange.

Step 1. Reword the question. “What task will you assign to an NAP?” The fact that the NAP is “experienced” is a distracter.
Step 2. Eliminate answer choices based on the Rules of Management.
(1)  Obtain 24-hour diet recall from a client with anorexia nervosa. Some students may consider this answer choice because eating is certainly a recurring daily activity, but this answer isn’t about feeding a client. Eating has special significance for a client with anorexia nervosa. An important assessment that the nurse must make is the quantity of food consumed by this client. The nurse cannot delegate assessment. Eliminate.
(2)  Obtain a clean-catch urine specimen from a client with suspected UTI. Rule #4 states, “Delegate activities that involve standard, unchanging procedures.” There is no indication that the client has a catheter, so this is a routine procedure. Keep for consideration.
(3)  Observe bladder irrigation returns after a transurethral resection. The color of the fluid needs to be assessed to determine if hemorrhage is occurring. This is an assessment. Eliminate.
(4)  Observe a newly diagnosed DM client practicing injection techniques. This answer choice involves the evaluation of client teaching. According to Rule #1, the nurse cannot delegate evaluation of client care. Eliminate.
Step 3. Select an answer from the remaining choices. That leaves only answer choice (2), the correct answer.