Client with signs of facial trauma after experiencing a motor vehicle crash.
The client with facial trauma after a motor vehicle crash requires close monitoring to assess for a patent airway, eye functioning, and neurological changes. This is not a stable client and should not be assigned to a nurse with postpartum care experience.
Client diagnosed with heatstroke.
The client diagnosed with heatstroke may be experiencing dehydration and hyperthermia. The client should be placed in an air-conditioned room, lying flat with the legs elevated, and receiving oxygen. This is not a stable client and should not be assigned to a nurse with postpartum care experience.
Client having a systemic reaction to latex.
The client having a systemic reaction to latex may be experiencing an anaphylactic reaction. This is not a stable client and should not be assigned to a nurse with postpartum care experience.
Client diagnosed with progressive systemic sclerosis and experiencing Raynaud phenomenon. (Correct Answer)
Progressive systemic sclerosis is a chronic connective tissue disease that causes inflammation, fibrosis, and sclerosis of the skin and vital organs. This is a stable client with predictable outcomes and who can be assigned the nurse with postpartum care experience.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Delegation Question.
Delegation questions use phrases such as, "Which action is appropriate to delegate to the LPN/LVN, the unlicensed assistive personnel (UAP), etc." Use these steps, based on the DT, to determine the correct answer.
STEP 1: Can you identify the topic of the question?
- Appropriate assignment for the reassigned nurse.
STEPS 2-4: These steps are not relevant to this type of question because you do not need to use the rules for Delegation questions. Move to Step 5.
STEP 5: Apply the rules of delegation to each answer choice
Rules of Delegation:
- RNs cannot delegate assessment, evaluation, nursing judgment, or teaching.
- LPN/LVNs are assigned stable clients with expected outcomes.
- UAPs perform standard, unchanging procedures
Apply the rules:
1. Client with signs of facial trauma after experiencing a motor vehicle crash. Unstable; requires frequent assessment and specialized care. Eliminate.
2. Client diagnosed with heatstroke. Unstable; requires frequent assessment and specialized care. Eliminate.
3. Client having a systemic reaction to latex. Unstable; requires frequent assessment. Eliminate.
4. Client diagnosed with progressive systemic sclerosis and experiencing Raynaud phenomenon. Stable; client requires routine care, and the client has predictable outcomes. The charge nurse can delegate this client assignment to the postpartum care nurse.
Select the best choice:
Is #4 the correct answer? Yes, the client's needs can be met by a reassigned nurse.
Does #4 make sense? Yes, this is the only stable client who does not require specialized care or frequent assessment.
