Delegation and Scope During a Busy Clinic Morning
A nurse practitioner (NP) runs a primary care clinic with one registered nurse (RN), one licensed practical nurse (LPN), and one medical assistant (MA) whose certification permits venipuncture, vital signs, and administrative tasks but not medication administration or patient education. It is a Monday with 34 scheduled patients in 8 hours. Three patients need urgent same-day evaluation: a 58-year-old with chest tightness on exertion, a 4-year-old with a fever of 39.4 °C and lethargy, and a 70-year-old on warfarin with gum bleeding and a supratherapeutic INR from a home monitor. The NP is double-booked and the RN is the only staff member permitted to triage and administer IV medications.
1. How should the NP prioritize the three urgent patients, and what is the reasoning?
Read the worked answer
The 4-year-old with fever and lethargy should be seen first. Lethargy in a febrile child is a red flag for sepsis or meningitis, and young children deteriorate quickly. The child should be brought back immediately for vital signs, including a full set of pediatric vitals, and the NP should assess before any other non-urgent patient.
The 58-year-old with exertional chest tightness is next. Exertional chest pain suggests possible unstable angina or coronary disease and warrants prompt ECG and evaluation, but the patient is stable at rest and can be placed in a monitored area while the child is assessed. The 70-year-old on warfarin with gum bleeding and a supratherapeutic INR is urgent but less likely to decompensate in the next 15 minutes; the patient should be moved to a safe area, kept from further injury, and evaluated as soon as the first two are stabilized. The reasoning is based on acuity and time-to-deterioration, not on arrival order or appointment schedule.
2. Which tasks can be delegated to the MA and LPN, and which must remain with the RN or NP?
Read the worked answer
The MA can obtain vital signs on stable patients, perform venipuncture for the warfarin patient's confirmatory INR, and handle administrative tasks such as checking in patients and updating records. The MA cannot administer medications, perform patient education, or triage.
The LPN can obtain vital signs, collect specimens, and reinforce teaching that the RN or NP has already provided, within state scope and facility policy. The LPN should not independently triage the chest pain or pediatric patient or administer IV medications. The RN should retain triage, IV medication administration, and any patient education that requires clinical judgment, such as explaining an INR result and warfarin precautions. The NP retains diagnosis and treatment decisions. Delegation requires matching the task to the delegate's legal scope, demonstrated competence, and the stability of the patient; the NP remains accountable for the overall plan of care.
3. The MA says she is 'basically a nurse anyway' and offers to give the warfarin patient's vitamin K injection. How should the NP respond?
Read the worked answer
The NP should decline clearly and without shaming the MA, explaining that medication administration is outside the MA's certification and facility policy, and that allowing it would place the patient at risk and expose the MA and the clinic to legal consequences. The NP should affirm the MA's value to the team and redirect her to tasks within her scope, such as obtaining the confirmatory INR and vitals.
The NP should also consider why the request arose: a staffing crunch that pressures staff to work outside scope is a system issue. The NP should document the conversation, notify the practice manager, and review the delegation policy with the team. If vitamin K is indicated, the NP or RN should administer it per protocol. The response protects the patient, the MA, and the clinic, and it reinforces that scope is a legal boundary, not a matter of confidence or willingness.