Nursing Measurements Guide
A Guide to Deep Tendon Reflexes
Recent NCLEX® topics are primarily focused on delegation, prioritization and leadership. Among those that were mentioned, delegation type questions are going to be a huge part of nursing schools.
Fortunately, Mike is here to provide the gist and the important keywords that you have to watch out for every time you encounter delegation and management questions on your comprehensive exams, especially on your NCLEX®.
The PACET Method
When dealing with client and task delegations, there are five things that you cannot entrust to other people and that is broken down into the acronym, PACET (pronounced as “paket”). As a registered nurse, you cannot delegate the nursing process which is also known in other schools as SOAPIE, ADPIE, or DAR. Mike simplifies this as PACET.
P for Planning
If you are an RN, one of your main tasks is to plan and collaborate for client goals; thus you cannot delegate planning to an LPN or a CNA. This is because it is expected of you, as a registered nurse, to take on full responsibility of your client and you cannot share that responsibility with other healthcare teams.
A for Assessment
Secondary assessments can be delegated; however, you cannot pass primary assessments to anybody. That said, can you pick which is the right answer to the question below?
Q: Which of the following clients would you delegate?
- A post-op client who just came out from the operating room
- New admissions
- Three-day-old chest pain
When picking the right answer, you always have to remember that nurses do the first assessment. Now, among the three situations given above, which do you think needs first assessment?
Answer: The client who just came out of the operating room is unstable and needs initial assessment which is also termed as vigilant assessment. On the other hand, nurses are required to gather more information from new admissions. Therefore, both post-op (A) and new admissions (B) are NOT to be delegated.
So now, you’re left with the post-operative client who’s already been in the hospital for a couple of days and is considered stable. So the answer for the question above is “C”.
C for Collaboration
Collaboration is for working with other members of the healthcare team to achieve client goals. Some of the collaborations inside the hospital are wound consult, social services, dietary services, and if the client needs a respiratory therapist. Only the RN does this kind of collaboration, not the LVNs.
E for Evaluation
LPNs and CNAs can take note of the pain scale and vital signs but are not allowed to evaluate because it’s specifically the RN’s role – to think critically and evaluate efficiently. Therefore, the nurse should evaluate:
- Care plans
- Client goals
- Vital signs
- Pain scale
T for Teaching
Primary education or client teaching cannot be delegated. LVNs can reinforce education but they are not responsible for providing exemplary client education to decrease complications that might occur after discharge.
During the exam
Keep in mind, during your NCLEX®, that if you see any of the PACET keywords the multiple choice questions, it’s automatically the correct answer under the topic of delegation. Once again, those that you should not delegate and are your primary responsibilities are:
As registered nurses, you have to assume obligation and accountability for the five keywords mentioned above. Furthermore, being keen on identifying if it’s primary or secondary evaluation can help you quickly point out the right answer to your NCLEX®.
Don’t forget PACET.
For more information and other easy-to-understand nursing lectures and videos, visit our website at SimpleNursing.com.
See you in the next video!