Master the toughest questions on the exam with the RAGRS “Unstable vs. Stable” rule.
If you ask any NCLEX passer what the hardest part of the exam was, they usually won’t say “pharmacology” or “pediatrics.” They will almost always say: “Prioritization and Delegation.”
These questions make up a significant portion of the Management of Care category, which often accounts for 15-20% of your entire exam. More importantly, these are the “passing standard” questions. Getting them wrong signals to the computer that you may not be a safe practitioner.
For Filipino nurses, this topic can be tricky because hospital culture in the Philippines is different. In many local settings, we rely heavily on watchers (family members) or we do everything ourselves because “it’s faster.” On the NCLEX, however, you must follow strict US nursing standards of scope and delegation.
At Ray A. Gapuz Review System (RAGRS), we use a simple, proven framework to help you answer any prioritization or delegation question correctly—even if you’ve never heard of the disease in the scenario.
1. The Golden Rule: Unstable vs. Stable
The most critical skill in prioritization is determining which patient is the priority. The rule is simple:
Never prioritize a stable patient over an unstable one.
But how do you define “unstable” in NCLEX terms?
🚩 Signs of an UNSTABLE Patient (The Priority)
These patients must be seen by the RN immediately.
- Newly Admitted: Anyone admitted less than 12-24 hours ago is considered unstable/undiagnosed.
- Changing Condition: New or sudden onset of symptoms (e.g., “new onset chest pain,” “sudden confusion”).
- Acute Illness: Acute is always higher priority than chronic (e.g., Appendicitis > COPD).
- Unexpected Findings: A post-op patient with a fever of 104°F (not expected) vs. a post-op patient with pain 5/10 (expected).
- Critical Labs/Vitals: Hypoglycemia (blood sugar <70), Hemorrhage, High Fever (>105°F), Respiratory Distress.
✅ Signs of a STABLE Patient (Not the Priority)
These patients can wait or be delegated.
- Ready for Discharge: By definition, they are stable.
- Chronic Conditions: COPD, CHF, or Renal Failure patients who are at their “baseline.”
- Expected Findings: A patient with kidney stones complaining of severe flank pain (expected).
- Post-op > 12 Hours: Especially simple procedures with local/regional anesthesia.
RAGRS Tip: Even if a patient is in pain, if it is expected for their condition (e.g., chronic back pain), they are usually stable. Prioritize the patient with the unexpected symptom first.
2. The Assessment Frameworks: ABCs & Maslow
When you have two unstable patients, how do you decide who to see first? Use these frameworks.
A. The ABCs (Airway, Breathing, Circulation)
- Airway: Is there an obstruction? Stridor? Burns to the face/neck? (Highest Priority)
- Breathing: Is the rate abnormal? O2 sat <90%? Retractions?
- Circulation: Hypotension? Tachycardia? Active bleeding?
- Disability: Neuro status changes (Stroke symptoms).
- Exposure: Remove the cause (e.g., stop the chemical burn).
Exception: In CPR/Unknown Unresponsive victims, we use CAB (Compressions first). But for prioritization of living patients on the floor, Airway is king.
B. Maslow’s Hierarchy of Needs
- Physiological: Oxygen, Fluids, Nutrition, Temperature, Elimination, Shelter, Rest. (Life & Limb)
- Safety: Security, Protection, Freedom from Fear.
- Psychosocial: Love, Belonging, Self-Esteem.
Application: Never choose a “psychosocial” answer (comforting a crying patient) over a “physiological” need (giving fluids to a dehydrated patient), no matter how cruel it feels. The NCLEX is about safety, not just kindness.
3. Delegation: The Scope of Practice Grid
Delegation is transferring the responsibility for the performance of an activity while retaining accountability for the outcome.
The “EAT” Rule: Do NOT delegate what you can EAT:
- E – Evaluate (e.g., trending vitals, judging pain relief)
- A – Assess (Initial admission assessments, unstable patients)
- T – Teach (Initial teaching/discharge planning)
👩⚕️ Registered Nurse (RN) – YOU
- Scope: Everything. You manage the care plan.
- Must Do: Blood products, IV Push medications, Initial assessments, Care planning, Discharge education, Unstable patients.
🩺 LPN / LVN (Licensed Practical/Vocational Nurse)
Note: In the Philippines, we don’t have LPNs (the closest equivalent is an underboard nurse or midwife), so this is often a knowledge gap.
- Scope: Stable patients with predictable outcomes. “Technical” nursing.
- Can Do: Reinforce teaching (not initial), Administer meds (Oral, SubQ, IM), Standard procedures (Foley, dressing changes on stable wounds), Trach care and suctioning (on stable patients), Listen to lung sounds (data collection, not interpretation).
- Cannot Do: IV Push, Blood, Initial Assessment, Create Care Plan.
🛏️ UAP (Unlicensed Assistive Personnel) / CNA
Also known as: Tech, Nursing Assistant, Orderly.
- Scope: Routine, stable, non-invasive procedures.
- Can Do: ADLs (Bathing, toileting, feeding, ambulating), Vitals (on stable patients only), I&O (Measuring urine, emptying drains).
- Cannot Do: Administer ANY meds (even creams), Assess, Teach.
4. Special Situations: “The Floating RN”
Often, the NCLEX asks about an RN “floating” from another unit (e.g., a Pediatric RN floated to an Adult Med-Surg unit).
The Rule: Treat the floating RN like an LPN for the new unit.
- Assign them patients that are similar to their own specialty (if possible).
- If not, assign them the most stable, routine patients.
- Example: A Labor & Delivery RN floated to Med-Surg should NOT take the patient with active CHF exacerbation. Give them the post-op hysterectomy (creates similarities to OB) or the stable discharge.
5. Summary Strategy for Answering Questions
- Identify the Question: Is it “Who to see first?” (Prioritization) or “Who to assign?” (Delegation).
- Apply Unstable vs. Stable: Eliminate the stable patients.
- Apply ABCs: Among the unstable, who has the airway problem?
- The Tie-Breaker: Ask yourself: “If I do nothing, which patient will suffer the most serious harm or die right now?”
Remember: On the NCLEX, you only have two hands. You can only be in one room at a time. Choose the patient who cannot wait.
Frequently Asked Questions
What is the difference between delegation and assignment?
Assignment is distributing work to a staff member within their scope of employment (e.g., assigning a patient to another RN). Delegation is transferring authority to a person who usually isn’t authorized to perform that task, but is qualified to do so (e.g., RN delegating a blood sugar check to a UAP).
Can LPNs give IV medications?
On the NCLEX, assume NO for IV push and blood products. Some states allow IV piggybacks if certified, but generally, IV therapy is the RN’s domain. Stick to the strictest rule for safety.
Is pain a priority?
Pain is usually “psychosocial” or lower physiological priority unless it is: 1) Cardiac pain (Chest pain = Oxygen/Circulation issue), 2) Severe/Intractable (Kidney stones can cause shock), or 3) A sign of a complication (Compartment syndrome). Simple post-op pain or chronic pain is rarely the priority over a breathing problem.
How do I handle UAP delegation in the Philippines vs US?
In the US, UAPs are employees with a specific scope. In the PH, “watchers” (family) often do feeding, bathing, etc. On the NCLEX, ignore the “watcher.” Assume you have a UAP/CNA and follow the US scope of practice strictly.
Master Prioritization & Delegation with RAGRS
The frameworks in this guide have helped thousands of Filipino nurses conquer the toughest questions on the NCLEX. At Ray A. Gapuz Review System, we teach these strategies systematically, ensuring you don’t just memorize rules—you understand the logic behind them.
Ready to master NCLEX? Contact RAGRS today to learn how our proven review program can accelerate your preparation.
Contact Ray A. Gapuz Review System:
- Website: raygapuzreviewsystem.com
- Location: United Nations Avenue, Manila
- Programs: In-person and online NCLEX review options