15–21% of the NCLEX-RN

NCLEX Management of Care

How you run the care of several clients at once: who you see first, what you hand to the LPN or the assistive personnel, when you advocate, and what the law and ethics require of you.

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What it covers

  • Prioritization and assignment
  • Delegation and supervision
  • Advocacy and client rights
  • Informed consent and advance directives
  • Legal and ethical practice, confidentiality
  • Continuity of care, referrals and case management

Three ways candidates lose points

  • Delegating anything that needs nursing judgment. Assessment, teaching, evaluation and the care plan stay with the RN, even when the task looks simple.
  • Choosing the most dramatic client instead of the least stable one. "Who first" is decided by airway, breathing and circulation, then by what is new or unexpected, not by who is loudest.
  • Treating an order as the end of the question. A client with capacity can refuse; an unsafe order is questioned before it is carried out.

How to approach it

Read the stem for the client's stability, then for the scope of the person receiving the task. For priority questions, sort every option into expected (chronic, predictable) or unexpected (new, acute, worsening); the unexpected airway, breathing or circulation problem goes first. For delegation, ask whether the task has a standard procedure and a predictable outcome. If it needs judgment at any point, it stays with you.

Free chapters to read

Openly licensed textbooks written by nursing faculty, free to read online. Read the sections your misses point to, not the whole book.

Try three real questions

From WriteSpan’s own bank, the same questions students practice with. Answer first; the explanation opens after.

Question 1Restraints

A nurse is documenting the use of a wrist restraint applied to a client who attempted to remove their endotracheal tube. Which elements must the nurse include in the documentation to meet legal and regulatory standards?

The answer is D

Correct! Comprehensive restraint documentation must include all elements required by CMS and Joint Commission standards: the specific behavior that necessitated the restraint, alternatives that were attempted and failed, the type of restraint, its location, circulation and skin integrity assessments every two hours, the client's response to the restraint, provider notification, and ongoing documentation of the continued need for the restraint. Incomplete documentation creates legal and regulatory exposure.

Clinical pearl: Clinical Pearl: Restraint documentation checklist: (1) Specific behavior requiring restraint, (2) Alternatives tried and failed, (3) Type and location of restraint, (4) Provider order and time, (5) Client and family education about the restraint, (6) Circulation, sensation, skin integrity every 2 hours, (7) Release and repositioning every 2 hours, (8) Needs offered (toileting, hydration, ROM), (9) Client response, (10) Continued need assessment.

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Question 2Delegation and Supervision

A registered nurse (RN) is working the night shift on a medical-surgical unit with one licensed practical nurse (LPN) and two unlicensed assistive personnel (UAP). The nurse is caring for the following four clients: a 68-year-old client with stable heart failure receiving oral furosemide, a 54-year-old client with pneumonia receiving IV antibiotics whose temperature is 38.9°C, a 45-year-old client post-appendectomy on day one who is ambulating with assistance, and a 72-year-old client with a new diagnosis of type 2 diabetes mellitus requiring initial insulin teaching. Which task should the nurse assign to the LPN?

The answer is A

Correct! Administering IV medications is within the LPN scope of practice in most states and is appropriate for a client with a stable infection receiving a scheduled antibiotic. The LPN can safely administer this medication while the RN focuses on higher-acuity tasks requiring nursing judgment. This delegation meets all five rights — the task is appropriate, the circumstances are stable, the LPN is competent, and direction and supervision are provided.

Clinical pearl: Clinical Pearl: On the NCLEX, remember that initial teaching and initial assessment always belong to the RN. The LPN may reinforce teaching that has already been established. IV medication administration is generally within LPN scope, but always apply the five rights of delegation before assigning any task.

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Question 3NGN: Newborn Assessment Matrix

A nurse is assessing a 2-hour-old newborn who was born at 39 weeks gestation via spontaneous vaginal delivery. The mother is group B streptococcus positive and received two doses of IV penicillin during labor — the first dose was given 90 minutes before delivery. The following assessment findings are noted. For each finding indicate whether it is Expected and Normal, Requires Monitoring and Parent Education, or Requires Immediate Intervention.

The answer is C

AXILLARY TEMPERATURE 36.4°C — REQUIRES MONITORING: Normal newborn temperature is 36.5-37.5°C. A temperature of 36.4°C is slightly below normal (hypothermia threshold is less than 36.5°C). Mild hypothermia requires warming measures and monitoring, and parent education about skin-to-skin contact for temperature regulation. This is also a risk factor given the GBS exposure and inadequate intrapartum prophylaxis. RESPIRATORY RATE 68 WITH SUBCOSTAL RETRACTIONS — REQUIRES IMMEDIATE INTERVENTION: Normal newborn RR is 30-60 breaths/minute. An RR of 68 exceeds the upper limit AND the presence of subcostal retractions indicates increased work of breathing. This combination requires immediate assessment for transient tachypnea of the newborn, respiratory distress syndrome, or early-onset sepsis (especially given GBS exposure and inadequate prophylaxis). BLOOD GLUCOSE 38 WITH JITTERINESS — REQUIRES IMMEDIATE INTERVENTION: Symptomatic hypoglycemia (glucose less than 40-47 mg/dL plus symptoms) requires immediate treatment. ACROCYANOSIS — EXPECTED: Blue discoloration of hands and feet in the first hours of life is normal as peripheral circulation is not yet fully established. CAPUT SUCCEDANEUM — EXPECTED: Soft scalp edema crossing suture lines from birth canal pressure resolves in 2-3 days. HEART RATE 168 DURING CRYING — EXPECTED: Normal newborn HR during crying can reach 160-180 bpm.

Clinical pearl: Clinical Pearl: Inadequate intrapartum GBS prophylaxis (less than 4 hours of penicillin before delivery) requires: close monitoring of the newborn for 48 hours for signs of early-onset GBS sepsis. Signs: respiratory distress, temperature instability, poor feeding, jitteriness. If sepsis is suspected: CBC, blood culture, and empiric ampicillin plus gentamicin. Do not delay treatment while awaiting culture results.

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