Clinical Judgment,
Prioritization, &
Delegation
Chris Garrison, PhD, RN,
CNE,CHSE
Objectives

Learners will be able to:
 Describe how clinical judgment impacts
nursing practice
 Develop a framework for applying clinical
judgment
 Apply frameworks for determining clinical
prioritization when caring for individuals or
groups of clients
 Apply the NCSBN “Five Rights of Delegation”
to client scenarios
Novice Nurse & Clinical
Judgment
Moves beyond rules
 Recognition of aspects of a clinical
situation that are most relevant
 65% of errors are due to poor clinical
decision making

 (Caputi,
2019)
NCSBN Clinical Judgment
Definition
The observed outcome of critical thinking
and decision- making. It is an iterative
process that uses nursing knowledge to
observe and assess presenting situations,
identify a prioritized client concern, and
generate the best possible evidencebased solutions in order to deliver safe
client care.
(NCSBN, 2022)

NextGen NCLEX Case
Studies
Each exam will include 3 clinical
judgment case studies
 Client data presented in context
 6 questions

6 Steps of CJMM






Recognize Cues
 Which data are important?
Analyze Cues
 What does the data mean?
Prioritize Hypotheses
 What is the most likely problem based on the data?
Generate Solutions
 What is my plan?
Take Action
 How do I implement my plan?
Evaluate Outcomes
 Was my plan effective?
Failure to Rescue

Failure to Rescue: “Clinician’s inability to
save a hospitalized patient’s life when he
experiences a complication (a condition
not present on admission)”
 (Clarke

& Aiken, 2003, p. 42-43)
Most Codes are Preventable
Successful Rescue

Surveillance
 Ongoing
interpretation and synthesis
 Recognize emerging complications

Rescue
 Mobilize
resources
SBAR
 Anticipate what is needed
 Rapid Response Team

Examples of Complications
Pneumonia
 Shock
 Cardiac Arrest
 GI Bleed
 DVT/PE
 Respiratory Failure
 Seizures
 Acute Renal Failure

Indicators of Emerging
Complications
Change in LOC
 Pain
 Dyspnea
 Change in Vitals
 Change in Labs
 Urine Output

Questions to ask
What is my patient at risk for?
 How would I detect it?

 What
assessment data should I collect?
 Identify relevant signs and symptoms

What would I do about it?
 Put
the picture together
 What data are relevant?
Case Study

A 73 year old female with a history of
HTN, Type 2 DM, and Renal Insufficiency
was admitted for a Sigmoid Resection and
Colostomy
 What
is she at risk for?
 What would you assess?
Prioritization


Essential aspect of clinical judgment
Frameworks:
 ABCs
 Maslow
 Assess before Intervening
 Systemic before local (“life
 Acute before Chronic
before limb”)
 Actual
before Potential
 Unexpected before Expected

Frameworks are guidelines not black and white
Maslow
NCLEX Question

The nurse receives report on a group of patients.
Which of the following patients should the nurse
assess first?
 A.
A diabetic patient being treated for a COPD
exacerbation with a blood glucose of 290 mg/dL
 B. A patient who is post-op day one after a total hip
replacement with a pain rating of “8”
 C. A patient recently diagnosed with stage 4 lung
cancer who is crying
 D. A patient who is post-op day 2 after a
tracheostomy with an SpO2 of 88%
NCLEX Question

The nurse receives laboratory results on 4
patients. Which result should the nurse address
first?
 A.
A patient being treated for heart failure with a
potassium of 2.6 mEq/L
 B. A patient who is 24 hours S/P Total Knee
Replacement with a hemoglobin of 9.1 mg/dL
 C. A patient on Warfarin for atrial fibrillation with an
INR of 3.3
 D. A dialysis patient with a creatinine of 5.7 mg/dL
NCLEX Question

The nurse is preparing to administer medications
to a group of patients. Which medication should
the nurse give first?
 A.
A PRN dose of lorazepam for a patient
experiencing anxiety
 B. An IV bolus of diltiazem for a patient in atrial
fibrillation with a heart rate of 150
 C. A dose of lisinopril for a patient with hypertension
and a BP of 168/94 mmHg
 D. A dose of sliding scale insulin aspart for a diabetic
patient with a blood glucose of 310 mg/dL
NCLEX Question

The nurse is planning care for a patient with
chronic COPD who is admitted for an acute
myocardial infarction. Which nursing diagnosis
would have the highest priority?
 A.
Risk for ineffective airway clearance R/T excessive
pulmonary secretions AEB productive cough
 B. Ineffective individual coping R/T acute illness AEB
patient statement of distress
 C. Ineffective myocardial tissue perfusion R/T
coronary occlusion AEB elevated troponin
 D. Risk for fall R/T nitroglycerin drip
NCLEX Question

The nurse is caring for a patient with heart
failure. The patient reports worsened
shortness of breath. Which of the following
actions should the nurse take first?
 A.
Increase the flow rate of the O2
 B. Check the SpO2 and auscultate the lungs
 C. Request an order for a stat dose of IV
furosemide
 D. Encourage the patient to use pursed lip
breathing
Delegation
Delegation: “Transferring the authority to
perform a selected nursing task in a
selected situation to another team member
while maintaining accountability”
 Assignment: “Transferring the authority,
accountability, and responsibility to
another member of the health care team”
 (ATI, 2013, p. 13)

The NCSBN 5 Rights of
Delegation

Right Task


Right Circumstances


Specific instructions
Right Supervision


Consider skills and abilities of individual
Right Communication


Consider patient’s condition and degree of supervision required
Right Person


Consider credentials, nurse practice act, agency policy
Monitoring and evaluation of patient and staff member
performance
(National Council of State Boards of Nursing, 1997)
Scope of Practice Issues (Right
Task)
NCLEX will address national norms
 RN:

 Care
of complex or unstable patients or care
with uncertain outcomes
 Initiate the Nursing process
 Client education
 Blood products
 IV Push
Scope of Practice Issues

LPN:
 Care
of stable client
 Gather data
 Contribute to care plan
 Reinforce teaching
 Perform skills with predictable outcomes
 Administer medications (no IVP, chemo,
blood products, TPN)
Scope of Practice Issues

Unlicensed Assistive Personnel (UAP)
 Stable
client
 Obtain vital signs
 Record I & O
 Hygiene care
 Positioning and Ambulation
 Feeding
Delegation

The RN cannot delegate “what you can
EAT”
 Evaluation
 Assessment
 Teaching
Right Communication

The RN is caring for a patient with
endocarditis. The nurse is concerned
about the patient’s risk of developing
sepsis and asks an experienced UAP to
take vital signs
 Example
A: Take vitals signs on Mrs. Jones
 Example B: Take vital signs on Mrs. Jones
every two hours. Notify me immediately if
temp is > 38, pulse > 90, or SBP < 90
NCLEX Question

The charge nurse is planning client care for a
patients on a cardiac unit. Which patient is most
appropriate for the LPN to care for?
 A.
A patient scheduled for cardiac catheterization
today
 B. A patient with coronary artery disease who had an
episode of chest pain last night
 C. A patient being discharged today after successful
insertion of a pacemaker two days ago
 D. A patient with heart failure being treated with PO
furosemide and digoxin
NCLEX Question

The nurse is planning care for a patient who
is post-op day 1 after an Abdominal Aortic
Aneurysm (AAA) repair. Which of the
following activities is appropriate to delegate
to the unlicensed assistive personnel (UAP)
 A.
Record vital signs
 B. Monitor hourly urine output
 C. Change the surgical dressing
 D. Teach the patient how to use the incentive
spirometer
NCLEX Question

The nurse is planning care for a patient
who is post-op day 2 after a laryngectomy.
Which of the following activities is
appropriate to delegate to the LPN?
 A.
Observe the patient’s ability to swallow
 B. Evaluate the patient’s Spo2
 C. Suction the laryngectomy tube
 D. Interpret the patient’s CBC
NCLEX Question

The nurse is planning care for a patient with
neutropenia. Which of the following can be
appropriately delegated to the unlicensed
assistive personnel? (Select All that Apply)
 A.
Take vital signs
 B. Report temperature above 38 degrees Celsius
 C. Assess for signs or symptoms of infection
 D. Instruct the family on reverse isolation
procedure
 E. Place Isolation supplies outside the room
NCLEX Question

The nurse is planning care for a patient who is
post-op day one after a thoracotomy for lung
cancer. Which intervention can be delegated to
the unlicensed assistive personnel (UAP)?
 A. Assist the patient to sit in an upright
position
 B. Instruct the patient to cough effectively
 C. Teach the patient to use the incentive
spirometer
 D. Monitor chest tube output
NCLEX Question

The nurse is planning care for a patient
who is 12 hours post-op after a
thoracotomy. Which of the following
actions can be delegated to the LPN?
 A.
Assess the patient’s pain
 B. Auscultate breath sounds
 C. Review CBC for signs of post-op
hemorrhage
 D. Evaluate the functioning of the chest tube
References
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ATI (2013). The comprehensive NCLEX-RN Review. Leawood Kansas:
Assessment Technologies Incorporated.
Caputi, L. (2019). Teaching Clinical Judgment. Workshop, Altoona, PA.
Clarke, S. P. & Aiken, L. H. (2003). Failure to rescue: Needless deaths are
prime examples of the need for more nurses at the bedside. American
Journal of Nursing, 103(1), 42-47.
National Council of State Boards of Nursing (1997). The five rights of
delegation. https://www.ncsbn.org/fiverights.pdf
National Council of State Boards of Nursing (2022). The NCSBN Annual
Meeting.
Tanner, C. A. (2006). Thinking like a nurse: A research-based model of
clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211