Fundamentals of Nursing Exam

This chapter teaches the frameworks used to decide which client or problem comes first, and the rules for handing tasks to licensed practical nurses and assistive personnel safely. Prioritization and delegation items are some of the most common Management of Care questions on Fundamentals exams.

Nurses rarely care for one client with one problem. Prioritization is deciding what must happen first to prevent harm. Most exam questions give you several clients or several actions that are all reasonable, then ask which comes first. The right answer is the one that addresses the greatest threat to life or safety right now.

Use these frameworks in order. When one framework does not separate the options, move to the next.

Priority-Setting Frameworks

Memory Aid: "Airway, Breathing, Circulation, then Maslow, then New beats Old, Now beats Maybe, Unexpected beats Expected."

Two important refinements apply to the ABCs:

Safety can come first. If a client is in immediate danger (falling, seizing, near a fire), protecting the client from injury may be the first action.

In cardiac arrest, current resuscitation guidance starts with compressions (C-A-B) for adults. On most Fundamentals items, though, the ABC order guides priority for a client who is breathing and has a pulse.

Many first-client questions hinge on whether a finding is expected for the client's condition. A client with chronic obstructive pulmonary disease may normally have an SpO2 of 89%. A client 1 day after abdominal surgery normally has some incisional pain. A client with a new cast normally has some swelling. These are expected. By contrast, a client with a cast who has pain not relieved by medication, pale cool toes and numbness has an unexpected finding that suggests compartment syndrome, a limb-threatening emergency.

Exam Tip: For "which client should the nurse see first," ask two questions about each client: Is this finding life- or limb-threatening? Is it expected for this condition? The client with an unexpected, threatening finding goes first. A client who is uncomfortable but stable can wait briefly.

Clinical Example: The nurse receives report on four clients. Client A has diabetes and a fasting glucose of 128 mg/dL. Client B had a hip replacement yesterday and rates pain 5/10. Client C has pneumonia and is newly confused, with an SpO2 of 88% on 2 L/min oxygen. Client D is awaiting discharge teaching. Client C goes first: new confusion with low oxygen saturation is an acute, unexpected breathing problem.

The crying client receives support as soon as physiologic and safety needs are met, but is not ignored.

Result: Client with asthma first, then the scheduled medication (and the bathroom request delegated), then emotional support.

Time-critical medications follow similar logic. Insulin with meals, antibiotics on schedule, and medications such as anticoagulants or drugs for Parkinson disease or seizures should be given within the window set by facility policy, and they outrank routine tasks such as daily linen changes or a scheduled bath.

When an item describes a change but does not give enough data, the first action is usually to assess. For example, if a client says, "I feel like something is wrong," the nurse first checks vital signs and the client's condition before calling the provider. The exception is an emergency where the data already show a clear threat. If a client has no pulse and is unresponsive, the nurse calls for help and starts compressions rather than doing a full assessment.

Common Trap: "Notify the provider" is rarely the first action. The provider will want current data, and the nurse can often take an immediate independent action first (raise the head of the bed, apply oxygen per protocol, stop an infusion). Choose "notify" first only when the nurse has the data and no nursing action can fix the problem.

The NCSBN and ANA National Guidelines for Nursing Delegation define the key terms.

Assistive personnel (sometimes called unlicensed assistive personnel) include nursing assistants, patient care technicians and similar roles. They are not licensed and work under the direction of a licensed nurse.

The Five Rights of Delegation

Clear directions include the client, the task, the time, specific limits, and what findings to report right away. For example: "Please take Mr. Lee's vital signs at 1000 and 1400 and tell me right away if his systolic BP is below 100 or his pulse is above 110."

The core rule: the RN keeps tasks that require assessment, nursing judgment, teaching, evaluation, and care of unstable clients. These cannot be delegated to AP. LPNs can care for stable clients with predictable outcomes and can collect data, reinforce teaching and perform many skills, but they do not perform the initial assessment, create the care plan, or do initial teaching. Exact LPN skills (such as IV therapy) vary by state nurse practice act and facility policy.

Typical Task Allocation

Common Trap: AP can measure and report, but cannot interpret. An AP can take a client's vital signs, but the RN must interpret them and decide what to do. If an answer choice asks AP to "assess," "evaluate," "teach," or "determine," it is wrong.

Exam Tip: When a delegation item lists four tasks, look for the one that is routine, standardized and involves a stable client. Taking vital signs on a client admitted 2 days ago who is stable is delegable; taking the first set of postoperative vital signs on a client just back from surgery is not, because that client is not yet stable.

Delegating the first instance of a task that requires judgment, such as the first ambulation after surgery or the first feeding after a swallow evaluation.

Giving vague directions such as asking the AP to report "anything unusual," which pushes interpretation onto the AP instead of naming the exact findings to report.

Failing to follow up on reported data, such as accepting a reported low BP without assessing the client.

Delegating to a person who has not shown competence because the unit is busy.

Assigning a client who is unstable or whose condition is changing to an LPN or AP.

If an AP says, "I have never done that," the RN does not delegate the task until the AP has been trained and demonstrates competence, which may mean the RN performs the task now. If an AP does a task incorrectly, the RN intervenes to protect the client first, then addresses the error privately and reports per policy if needed.

After delegating, the RN checks that the task was done, reviews the data reported, and evaluates the client's response. If an AP reports a BP of 86/50, the RN goes to assess the client personally. The RN is responsible for acting on the information.

The chain of command is the formal line of authority for resolving problems. A nurse who has a concern about client safety (for example, a provider's order that seems unsafe, or a provider who does not respond to a deteriorating client) follows the chain: first the provider, then the charge nurse, then the nurse manager or house supervisor, then the department chief or medical director. The nurse documents each contact objectively.

Clinical Example: A nurse calls a provider about a client with a BP of 82/48 and new confusion. The provider says, "Just keep watching." The nurse is concerned the client is deteriorating. The nurse notifies the charge nurse or supervisor and, if available, activates the rapid response team. The nurse does not simply follow an order that leaves the client unsafe.

Use ABCs, then Maslow, then acute over chronic, actual over potential, and unexpected over expected to set priorities.

Assess before acting when data are unclear, but act at once when the data already show an emergency.

The five rights of delegation are right task, circumstance, person, directions and communication, and supervision and evaluation.

LPNs care for stable clients with predictable outcomes; exact skills vary by state.

Use the chain of command when a safety concern is not resolved, and document each step.