NCLEX-style Prioritization & Delegation: cram pack

Formula sheets, the key method steps for every topic and 14 practice problems, with full solutions at the back.

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1Formulas and methods

Prioritization & delegation

Method

  1. Ask what will harm the patient soonest if nothing is done.
  2. Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
  3. Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
  4. Assess before you act unless it is an emergency; then choose the step the others depend on.
  5. For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.

Infection control & patient safety

Method

  1. Start with standard precautions for every patient: hand hygiene, PPE for the expected exposure, safe sharps.
  2. Add precautions by route: contact (gown, gloves), droplet (surgical mask), airborne (N95, negative-pressure room).
  3. Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
  4. Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
  5. Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.

Lab values & electrolytes

Method

  1. Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
  2. Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
  3. Link the value to its typical signs and to the drugs and conditions that cause it.
  4. Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
  5. Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.

Med-surg: cardiovascular & respiratory

Method

  1. Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
  2. Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
  3. Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
  4. Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
  5. Choose the safe first action, then escalate and reassess.

Med-surg: neuro, endocrine & renal

Method

  1. Check the glucose in every patient with new confusion, weakness or a seizure.
  2. Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
  3. For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
  4. For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
  5. For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.

Med-surg: GI, perioperative & oncology

Method

  1. Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
  2. Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
  3. For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
  4. For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
  5. For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.

2Practice problems

1.Prioritization & delegationMedium

Using the Emergency Severity Index, which level fits a 70-year-old with chest pressure that suggests a heart attack, but normal vital signs?

  1. ALevel 5
  2. BLevel 2
  3. CLevel 1
  4. DLevel 4
2.Prioritization & delegationHard

During an infusion of a thrombolytic drug for stroke, the patient develops a severe headache and starts vomiting. What should the nurse do first?

  1. AContinue the infusion, because headache is expected
  2. BSlow the infusion and give an antiemetic as prescribed
  3. CGive a dose of aspirin for the headache
  4. DStop the infusion and inform the provider at once
3.Infection control & patient safetyMedium

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

  1. AIt means “every day at bedtime” in some hospitals
  2. BIt is a Latin abbreviation, and only plain English abbreviations may be used
  3. CIt can be misread as QID or QOD, so the drug is given too often or too rarely
  4. DIt is only allowed for intravenous medicines
4.Infection control & patient safetyHard

A patient asks for a pain tablet. The record shows none has been given, but the patient says, “The other nurse gave me one earlier.” What should the nurse do?

  1. AGive half a tablet now, to be safe, and the other half later if needed
  2. BGive the tablet, because the record shows none was given
  3. CCheck with the other nurse and the records before giving another dose
  4. DTell the patient they must be confused
5.Lab values & electrolytesMedium

A conscious patient with a blood glucose of 54 mg/dL (3.0 mmol/L) has taken 15 g of fast-acting carbohydrate. When should the glucose be rechecked?

  1. AAfter about 15 minutes
  2. BAfter about 2 hours
  3. CThe next morning
  4. DAt the next meal
6.Lab values & electrolytesHard

A patient's creatinine was 0.9 mg/dL (80 µmol/L) on admission and is 1.3 mg/dL (115 µmol/L) 36 hours later. Using the common KDIGO criteria, what does this show?

  1. AA laboratory error, because creatinine cannot change within 2 days
  2. BNo kidney injury, because the creatinine is still within the normal range
  3. CChronic kidney disease, because creatinine has risen above baseline
  4. DAcute kidney injury, because it rose by at least 0.3 mg/dL within 48 hours
7.Clinical nursingMedium

Which electrolyte disturbance is most dangerous for the heart rhythm?

  1. AHigh chloride
  2. BHigh or low potassium
  3. CLow sodium
  4. DLow phosphate
8.Clinical nursingHard

A catheterised postoperative patient has passed only 10 mL of urine in the last two hours. What should the nurse check first?

  1. AWhether the patient has eaten breakfast
  2. BThe patient's cholesterol level from the admission bloods
  3. CThat the catheter and tubing are not kinked or blocked
  4. DThe patient's weight from last year
9.Med-surg: cardiovascular & respiratoryMedium

Why must inspired air be humidified for a patient with a tracheostomy?

  1. ADry air is needed to stop secretions forming in the trachea
  2. BHumidified air contains more oxygen than dry air at the same flow
  3. CHumidification prevents the cuff from deflating
  4. DThe nose and upper airway, which warm and moisten air, are bypassed
10.Med-surg: cardiovascular & respiratoryHard

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

  1. AIt is needed only while she has palpitations
  2. BHer risk of stroke is high, and an anticoagulant lowers it
  3. CThe anticoagulant will stop the irregular heartbeat for good
  4. DIt is given to lower her blood pressure
11.Med-surg: neuro, endocrine & renalMedium

Why is a patient weighed before and after each haemodialysis session?

  1. ABecause the machine cannot start without a weight
  2. BTo calculate the dose of every medicine for the coming week
  3. CTo check for weight loss caused by malnutrition
  4. DTo see how much fluid was removed and guide the dry weight
12.Med-surg: neuro, endocrine & renalHard

Which task for a stroke patient can a registered nurse safely delegate to a healthcare assistant (nursing assistant)?

  1. ACarrying out the first bedside water swallow screen after admission
  2. BRepositioning the patient every two hours as set out in the care plan
  3. CAssessing a new weakness the patient reports in the leg
  4. DTeaching the patient how to take a new anticoagulant
13.Med-surg: GI, perioperative & oncologyMedium

What is the purpose of the lockout interval on a PCA pump?

  1. AIt makes the patient wait a day between large doses
  2. BIt stops the patient from getting any doses at night
  3. CIt stops a new dose before the last one has worked
  4. DIt locks the pump so the syringe cannot be changed
14.Med-surg: GI, perioperative & oncologyHard

A patient with bone metastases is starting regular zoledronic acid. Which advice is important?

  1. AStop drinking all fluids on the day of each infusion
  2. BHave a dental check and report jaw pain or loose teeth
  3. CTake extra calcium only on the day of infusion
  4. DAvoid all physical activity for six months

3Solutions

1.Prioritization & delegation

Answer: B · Level 2

Why this is the answer

Possible acute coronary syndrome is a high-risk situation, so the patient is ESI level 2 and should be seen very soon. Level 1 is kept for patients who need an immediate life-saving intervention.

Answer

B · Level 2
2.Prioritization & delegation

Answer: D · Stop the infusion and inform the provider at once

Why this is the answer

A new severe headache, vomiting or neurological decline during thrombolysis can mean intracranial bleeding. The infusion is stopped, the provider informed and an urgent scan arranged.

Answer

D · Stop the infusion and inform the provider at once
3.Infection control & patient safety

Answer: C · It can be misread as QID or QOD, so the drug is given too often or too rarely

Why this is the answer

“QD” and “QOD” can be confused with each other and with “QID”, leading to serious dosing errors. The word “daily” or “every other day” is written in full instead.

Answer

C · It can be misread as QID or QOD, so the drug is given too often or too rarely
4.Infection control & patient safety

Answer: C · Check with the other nurse and the records before giving another dose

Why this is the answer

Undocumented doses can lead to double dosing. The nurse checks with colleagues and the dispensing records, then gives the drug only once it is clear whether a dose was given.

Answer

C · Check with the other nurse and the records before giving another dose
5.Lab values & electrolytes

Answer: A · After about 15 minutes

Why this is the answer

The rule of 15 is 15 g of fast-acting carbohydrate, a recheck after 15 minutes, and a repeat if the glucose is still below 70 mg/dL (3.9 mmol/L). A snack or meal then helps prevent a recurrence.

Answer

A · After about 15 minutes
6.Lab values & electrolytes

Answer: D · Acute kidney injury, because it rose by at least 0.3 mg/dL within 48 hours

Why this is the answer

KDIGO defines AKI as a creatinine rise of at least 0.3 mg/dL (26.5 µmol/L) within 48 hours, a rise to 1.5 times baseline within 7 days, or urine output below 0.5 mL/kg/h for 6 hours. A result inside the reference range can still be a significant rise.

Answer

D · Acute kidney injury, because it rose by at least 0.3 mg/dL within 48 hours
7.Clinical nursing

Answer: B · High or low potassium

Why this is the answer

Both hyperkalaemia and hypokalaemia can cause life-threatening arrhythmias. Potassium must never be given as an undiluted rapid IV bolus.

Answer

B · High or low potassium
8.Clinical nursing

Answer: C · That the catheter and tubing are not kinked or blocked

Why this is the answer

A sudden fall in catheter output may be due to a kinked, clamped or blocked catheter. If it is draining freely, the nurse assesses fluid status and vital signs and escalates possible hypovolaemia or AKI.

Answer

C · That the catheter and tubing are not kinked or blocked
9.Med-surg: cardiovascular & respiratory

Answer: D · The nose and upper airway, which warm and moisten air, are bypassed

Why this is the answer

The tracheostomy bypasses the nose, mouth and pharynx, which warm, filter and humidify air. Without humidification, secretions become thick and can block the tube. Heat and moisture exchangers, humidified oxygen and nebulised saline are used.

Answer

D · The nose and upper airway, which warm and moisten air, are bypassed
10.Med-surg: cardiovascular & respiratory

Answer: B · Her risk of stroke is high, and an anticoagulant lowers it

Why this is the answer

In AF, blood stasis in the left atrium causes clots that can travel to the brain. Scores such as CHA₂DS₂-VASc (age, hypertension, diabetes, female sex and others) estimate stroke risk; her score is high. Anticoagulation reduces stroke risk but does not change the rhythm.

Answer

B · Her risk of stroke is high, and an anticoagulant lowers it
11.Med-surg: neuro, endocrine & renal

Answer: D · To see how much fluid was removed and guide the dry weight

Why this is the answer

The difference between pre- and post-dialysis weight shows how much fluid was removed. Large weight gains between sessions indicate excessive fluid intake and increase the risk of hypertension, breathlessness and cramps during dialysis.

Answer

D · To see how much fluid was removed and guide the dry weight
12.Med-surg: neuro, endocrine & renal

Answer: B · Repositioning the patient every two hours as set out in the care plan

Why this is the answer

Repositioning to a set plan is a routine task that trained assistants can carry out. Swallow screening, assessing new symptoms and medication teaching need the nurse's clinical judgement and stay with the registered nurse.

Answer

B · Repositioning the patient every two hours as set out in the care plan
13.Med-surg: GI, perioperative & oncology

Answer: C · It stops a new dose before the last one has worked

Why this is the answer

After each bolus, the pump ignores further presses for a set time (often 5–10 minutes) so the dose can take effect. This, together with dose limits, reduces the risk of overdose.

Answer

C · It stops a new dose before the last one has worked
14.Med-surg: GI, perioperative & oncology

Answer: B · Have a dental check and report jaw pain or loose teeth

Why this is the answer

Bisphosphonates can cause osteonecrosis of the jaw, especially after dental extractions. A dental check before starting, good oral hygiene and reporting jaw symptoms are advised. Kidney function and calcium are also monitored.

Answer

B · Have a dental check and report jaw pain or loose teeth

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