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

Five days after starting heparin, a patient’s platelet count has fallen by more than half. What should the nurse suspect?

  1. AAn expected effect that needs no action
  2. BVitamin K deficiency
  3. CHeparin-induced thrombocytopenia
  4. DIron deficiency anemia
2.Prioritization & delegationHard

A patient in labor is receiving oxytocin, and the fetal monitor shows repeated late decelerations. What should the nurse do first?

  1. APlace the patient flat on her back
  2. BEncourage the patient to start pushing
  3. CStop the oxytocin infusion
  4. DIncrease the oxytocin rate
3.Infection control & patient safetyMedium

When should blood specimen tubes be labeled?

  1. AAt the nurses’ station before going to the patient, to save time
  2. BBack at the station after all the samples are collected
  3. CBy the laboratory staff after the tubes arrive
  4. DAt the bedside, in front of the patient, right after collection
4.Infection control & patient safetyHard

A patient with pneumonia has low blood pressure and a raised serum lactate. What does the raised lactate suggest?

  1. ARecovery from the infection is beginning
  2. BMild dehydration from poor intake, with no further concern
  3. CA normal response to having a fever
  4. DPoor tissue perfusion, a sign of sepsis-related shock
5.Lab values & electrolytesMedium

A patient has weight loss, tremor and heat intolerance. Which thyroid test pattern fits Graves disease?

  1. ALow TSH with a high free T4
  2. BHigh TSH with a low free T4
  3. CNormal TSH with a low free T4
  4. DHigh TSH with a normal free T4
6.Lab values & electrolytesHard

A patient with schizophrenia drinks very large amounts of water each day. Sodium is 121 mEq/L, and the urine is very dilute (urine osmolality 70 mOsm/kg). Which explanation fits best?

  1. APrimary (psychogenic) polydipsia
  2. BSyndrome of inappropriate ADH
  3. CCentral diabetes insipidus
  4. DHyperosmolar hyperglycemic state
7.Clinical nursingMedium

During a red cell transfusion, when are serious acute reactions most likely to start?

  1. AIn the first 15 minutes
  2. BAbout 24 hours later
  3. CAfter the third unit only
  4. DOnly after the unit has finished
8.Clinical nursingHard

A patient with small cell lung cancer has hyponatraemia, concentrated urine and no signs of dehydration. Which condition and first measure fit best?

  1. ACushing's syndrome, managed with potassium
  2. BDehydration, managed with an IV fluid bolus
  3. CDiabetes insipidus, managed with extra fluids
  4. DSIADH, often managed first with fluid restriction
9.Med-surg: cardiovascular & respiratoryMedium

A patient with chest pain asks for glyceryl trinitrate. Which information means the nurse should withhold it and contact the prescriber?

  1. AThe patient had a headache last week
  2. BThe patient took sildenafil earlier today
  3. CThe patient takes a daily statin
  4. DThe patient's blood pressure is 150/90 mmHg
10.Med-surg: cardiovascular & respiratoryHard

A patient with COPD on a 28% Venturi mask (SpO₂ 90%) wants to eat a meal. What is the most appropriate plan?

  1. ASwitch to nasal cannula at low flow, keeping SpO₂ at 88–92%
  2. BRemove all oxygen during the meal and replace it afterwards
  3. CChange to a non-rebreather mask at 15 L/min during the meal
  4. DKeep the Venturi mask on and give only liquids through a straw
11.Med-surg: neuro, endocrine & renalMedium

A patient's potassium stays low despite replacement. Which other level should be checked?

  1. ABilirubin
  2. BMagnesium
  3. CAmylase
  4. DFerritin
12.Med-surg: neuro, endocrine & renalHard

Weeks after starting insulin, a patient with newly diagnosed type 1 diabetes needs much less insulin and has frequent mild hypos. What is the most likely explanation?

  1. AThe patient actually has type 2 diabetes
  2. BThe diabetes has been cured, so insulin can stop
  3. CA honeymoon phase, but insulin is still needed
  4. DThe insulin has gone off and should be replaced
13.Med-surg: GI, perioperative & oncologyMedium

Why is the time a surgical limb tourniquet is inflated carefully recorded?

  1. AThe surgeon is paid per minute of use
  2. BLong inflation can cause nerve and muscle damage
  3. CThe tourniquet slowly loses all its air after one minute
  4. DIt shows how long the anaesthetic gas was used
14.Med-surg: GI, perioperative & oncologyHard

A patient with long-standing chronic pancreatitis now has weight loss, thirst and passing large volumes of urine. What should the nurse check first?

  1. AAbdominal girth
  2. BSerum amylase level
  3. CPeak expiratory flow
  4. DCapillary blood glucose

3Solutions

1.Prioritization & delegation

Answer: C · Heparin-induced thrombocytopenia

Why this is the answer

Heparin-induced thrombocytopenia usually appears 5–10 days after starting heparin, with a large fall in platelets and a risk of clotting. The nurse reports at once so heparin can be stopped.

Answer

C · Heparin-induced thrombocytopenia
2.Prioritization & delegation

Answer: C · Stop the oxytocin infusion

Why this is the answer

Late decelerations point to reduced blood flow through the placenta. Stopping oxytocin reduces contractions; the nurse then turns the patient onto her side, gives IV fluids as prescribed and informs the provider.

Answer

C · Stop the oxytocin infusion
3.Infection control & patient safety

Answer: D · At the bedside, in front of the patient, right after collection

Why this is the answer

Labeling tubes at the bedside, using two patient identifiers and in the patient’s presence, prevents wrong-patient specimens. Pre-labeled or later-labeled tubes are easily mixed up.

Answer

D · At the bedside, in front of the patient, right after collection
4.Infection control & patient safety

Answer: D · Poor tissue perfusion, a sign of sepsis-related shock

Why this is the answer

When tissues are poorly perfused, cells switch to anaerobic metabolism and lactate rises. In a patient with infection and hypotension, this points to septic shock and needs urgent treatment.

Answer

D · Poor tissue perfusion, a sign of sepsis-related shock
5.Lab values & electrolytes

Answer: A · Low TSH with a high free T4

Why this is the answer

In Graves disease, antibodies stimulate the thyroid to make too much hormone. The high free T4 suppresses TSH from the pituitary through negative feedback, so TSH is low. A high TSH with a low T4 fits primary hypothyroidism.Checked against: TSH test · MedlinePlus (NIH) (2026); Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Graves disease · MedlinePlus (NIH) (2026)

Answer

A · Low TSH with a high free T4
6.Lab values & electrolytes

Answer: A · Primary (psychogenic) polydipsia

Why this is the answer

In primary polydipsia, ADH is appropriately suppressed, so the kidneys make very dilute urine, but the intake exceeds what they can excrete. In SIADH the urine is inappropriately concentrated. Fluid restriction and close sodium monitoring are needed.Checked against: Osmolality urine test · MedlinePlus (NIH) (2025); Syndrome of inappropriate antidiuretic hormone secretion · MedlinePlus (NIH) (2025)

Answer

A · Primary (psychogenic) polydipsia
7.Clinical nursing

Answer: A · In the first 15 minutes

Why this is the answer

Severe reactions such as ABO incompatibility and anaphylaxis usually begin early. The patient should be watched closely in the first 15 minutes, with observations repeated as per local policy.

Answer

A · In the first 15 minutes
8.Clinical nursing

Answer: D · SIADH, often managed first with fluid restriction

Why this is the answer

In SIADH, excess ADH makes the kidneys retain water, so blood sodium is diluted while urine is concentrated. Small cell lung cancer is a classic cause; fluid restriction is a common first step.

Answer

D · SIADH, often managed first with fluid restriction
9.Med-surg: cardiovascular & respiratory

Answer: B · The patient took sildenafil earlier today

Why this is the answer

Phosphodiesterase-5 inhibitors such as sildenafil (within about 24 hours) or tadalafil (within about 48 hours) combined with nitrates can cause severe, life-threatening hypotension. Nitrates are also avoided with a systolic pressure below about 90 mmHg.

Answer

B · The patient took sildenafil earlier today
10.Med-surg: cardiovascular & respiratory

Answer: A · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%

Why this is the answer

Oxygen is prescribed to a target range and should not be stopped for meals in a patient who needs it. Nasal cannulae allow eating and talking; the flow (for example 1–2 L/min) is titrated to keep the saturation in the target range. High-concentration oxygen risks hypercapnia.

Answer

A · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%
11.Med-surg: neuro, endocrine & renal

Answer: B · Magnesium

Why this is the answer

Hypomagnesaemia increases potassium loss in the urine and makes hypokalaemia hard to correct. Magnesium is checked and replaced as well.

Answer

B · Magnesium
12.Med-surg: neuro, endocrine & renal

Answer: C · A honeymoon phase, but insulin is still needed

Why this is the answer

After diagnosis and correction of high glucose, remaining beta cells may work better for a while, so insulin needs fall. This honeymoon phase is temporary. The doses are reduced, but insulin is not stopped.

Answer

C · A honeymoon phase, but insulin is still needed
13.Med-surg: GI, perioperative & oncology

Answer: B · Long inflation can cause nerve and muscle damage

Why this is the answer

A tourniquet creates a bloodless field but causes limb ischaemia. Inflation time and pressure are recorded and the surgeon is told at set intervals, as long inflation can damage nerves and muscle.

Answer

B · Long inflation can cause nerve and muscle damage
14.Med-surg: GI, perioperative & oncology

Answer: D · Capillary blood glucose

Why this is the answer

Destruction of islet cells in chronic pancreatitis can cause diabetes (type 3c). Thirst, polyuria and weight loss suggest hyperglycaemia, which is checked straight away.

Answer

D · Capillary blood glucose

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