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

A patient with a valid do-not-resuscitate order (DNR; called DNACPR in the UK) stops breathing and has no pulse. What should the nurse do?

  1. AStart CPR and stop when the family arrives
  2. BCall the cardiac arrest team and let them decide
  3. CFollow the DNR order and do not start CPR
  4. DStart chest compressions but not rescue breaths
2.Prioritization & delegationHard

A patient with a new tracheostomy is coughing, has noisy breathing and an SpO₂ that has fallen to 86%. What is the first action?

  1. ASuction the tracheostomy
  2. BDocument the SpO₂ and recheck in 30 minutes
  3. CGive a nebulized bronchodilator
  4. DChange the tracheostomy ties
3.Infection control & patient safetyMedium

Two patients infected with the same organism are admitted, and no single room is available. What is an accepted option?

  1. APlacing each with a patient who has a weakened immune system
  2. BStopping contact precautions
  3. CPlacing them in the corridor
  4. DCohorting them in the same room, according to infection control advice
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. AMild dehydration from poor intake, with no further concern
  2. BRecovery from the infection is beginning
  3. CA normal response to having a fever
  4. DPoor tissue perfusion, a sign of sepsis-related shock
5.Lab values & electrolytesMedium

Which instruction is correct for a patient starting oral iron tablets?

  1. ATake each tablet with milk to protect the stomach
  2. BYour stools may turn dark green or black
  3. CYour urine will turn bright orange while you take it
  4. DTake the tablet with an antacid to improve absorption
6.Lab values & electrolytesHard

An older adult with type 2 diabetes is drowsy and very dehydrated. Glucose 920 mg/dL (51 mmol/L), serum osmolality 350 mOsm/kg, pH 7.36, urine ketones negative or trace. Which condition fits best?

  1. ADiabetic ketoacidosis (DKA)
  2. BHyperosmolar hyperglycemic state (HHS)
  3. CSyndrome of inappropriate ADH (SIADH)
  4. DMetformin-related lactic acidosis
7.Clinical nursingMedium

A postoperative patient has a heart rate of 125/min, blood pressure 88/50 mmHg and a blood-soaked dressing. What is happening?

  1. ANormal pain response
  2. BSeptic shock from a urinary infection
  3. CAnxiety only
  4. DHypovolaemic shock from bleeding
8.Clinical nursingHard

A patient with acute pancreatitis is in severe epigastric pain radiating to the back. Which nursing care is most important?

  1. AStrict bed rest without observations
  2. BAdequate pain relief, IV fluids and close fluid balance monitoring
  3. CRestricting all fluids
  4. DA large fatty meal to stimulate the pancreas
9.Med-surg: cardiovascular & respiratoryMedium

Which investigation is usually used to confirm a deep vein thrombosis in the leg?

  1. ACompression duplex ultrasound
  2. BA lung function test
  3. CAn exercise ECG
  4. DA plain chest X-ray and an ECG
10.Med-surg: cardiovascular & respiratoryHard

A nurse receives handover on four patients. Which patient should be seen first?

  1. AA patient with pneumonia on IV antibiotics who now has a temperature of 38.2 °C
  2. BA patient with COPD on 1 L/min whose SpO₂ has been 89% and stable throughout the night
  3. CA patient with asthma who wants a reliever inhaler before a walk
  4. DA patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min
11.Med-surg: neuro, endocrine & renalMedium

A patient with AKI has a urinary catheter that drains nothing. Which quick bedside check helps rule out a post-renal cause?

  1. AEncourage the patient to drink two litres of water
  2. BGive a large bolus of IV fluid straight away
  3. CSend a urine sample for culture and wait for the laboratory result
  4. DCheck the catheter for kinks or blockage and do a bladder scan
12.Med-surg: neuro, endocrine & renalHard

After a total thyroidectomy, a patient becomes anxious with stridor and a tense swelling in the neck. What should the nurse do first?

  1. ACall for emergency help: a haematoma may compress the airway
  2. BAsk the patient to talk as much as possible to test the voice
  3. CGive analgesia and reassess the swelling again in an hour
  4. DApply an ice pack to the neck and lie the patient flat
13.Med-surg: GI, perioperative & oncologyMedium

Which intervention most reduces pressure ulcer risk in an immobile patient?

  1. AKeeping the head of the bed raised at 90° all day
  2. BUsing a doughnut-shaped ring cushion
  3. CMassaging red areas firmly at each turn to bring back the circulation
  4. DRegular repositioning and a pressure-redistributing mattress
14.Med-surg: GI, perioperative & oncologyHard

A surgical patient's MUST score is 3 and the wound is healing slowly. What is the most appropriate action?

  1. AEncourage fasting to reduce wound exudate and the size of the dressing
  2. BRepeat the score in three months' time
  3. CRefer to the dietitian, start a nutrition plan and monitor intake
  4. DRestrict protein to help the kidneys

3Solutions

1.Prioritization & delegation

Answer: C · Follow the DNR order and do not start CPR

Why this is the answer

A valid DNR order means CPR is not started. The nurse keeps the patient comfortable, informs the provider and supports the family.

Answer

C · Follow the DNR order and do not start CPR
2.Prioritization & delegation

Answer: A · Suction the tracheostomy

Why this is the answer

Noisy breathing, coughing and a falling SpO₂ in a patient with a tracheostomy suggest secretions in the tube. Suctioning clears the airway. If the airway is still blocked, follow the emergency tracheostomy algorithm and call for help.

Answer

A · Suction the tracheostomy
3.Infection control & patient safety

Answer: D · Cohorting them in the same room, according to infection control advice

Why this is the answer

When single rooms are short, patients with the same organism (and no other infections) can share a room (cohorting), with precautions continued. Infection control staff advise on this.

Answer

D · Cohorting them in the same room, according to infection control advice
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: B · Your stools may turn dark green or black

Why this is the answer

Oral iron commonly darkens the stools, which is harmless, but black tarry stools with abdominal pain should be reported. Milk, antacids and tea reduce absorption; vitamin C or orange juice can improve it.Checked against: Ferrograd C patient information leaflet (ferrous sulfate + vitamin C) · electronic medicines compendium (eMC), UK (2018)

Answer

B · Your stools may turn dark green or black
6.Lab values & electrolytes

Answer: B · Hyperosmolar hyperglycemic state (HHS)

Why this is the answer

HHS causes extreme hyperglycemia and high osmolality with severe dehydration, but enough insulin is present to prevent significant ketosis, so the pH is near normal. DKA has ketones and acidosis; SIADH has low osmolality.Checked against: Ketoacidosis · StatPearls (NCBI Bookshelf) (2023); Osmolality blood test · MedlinePlus (NIH) (2025)

Answer

B · Hyperosmolar hyperglycemic state (HHS)
7.Clinical nursing

Answer: D · Hypovolaemic shock from bleeding

Why this is the answer

Tachycardia, hypotension and visible blood loss suggest haemorrhagic (hypovolaemic) shock. Apply pressure, call for urgent help and prepare for fluids or blood.

Answer

D · Hypovolaemic shock from bleeding
8.Clinical nursing

Answer: B · Adequate pain relief, IV fluids and close fluid balance monitoring

Why this is the answer

Acute pancreatitis can cause large fluid losses and organ failure. Care focuses on fluid resuscitation, analgesia, monitoring urine output, glucose and early nutrition when possible.

Answer

B · Adequate pain relief, IV fluids and close fluid balance monitoring
9.Med-surg: cardiovascular & respiratory

Answer: A · Compression duplex ultrasound

Why this is the answer

Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.

Answer

A · Compression duplex ultrasound
10.Med-surg: cardiovascular & respiratory

Answer: D · A patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min

Why this is the answer

New restlessness, tachypnoea and hypoxaemia despite oxygen suggest acute deterioration such as a PE, pneumonia or bleeding, so this patient is seen first. SpO₂ 89% is within target for a stable COPD patient, a mild fever on antibiotics is expected, and the asthma patient is well.

Answer

D · A patient on day 1 after surgery who is newly restless, RR 30/min, SpO₂ 88% on 4 L/min
11.Med-surg: neuro, endocrine & renal

Answer: D · Check the catheter for kinks or blockage and do a bladder scan

Why this is the answer

A blocked or kinked catheter or a distended bladder can cause or mimic anuria. Checking the tubing, flushing or changing the catheter as permitted and performing a bladder scan quickly identify obstruction. Ultrasound of the kidneys looks for higher obstruction such as hydronephrosis.

Answer

D · Check the catheter for kinks or blockage and do a bladder scan
12.Med-surg: neuro, endocrine & renal

Answer: A · Call for emergency help: a haematoma may compress the airway

Why this is the answer

A rapidly enlarging neck haematoma with stridor is an airway emergency. Urgent help is called; in many units the clips or sutures are removed at the bedside to release the haematoma (following local emergency procedures) before definitive airway management and surgery.

Answer

A · Call for emergency help: a haematoma may compress the airway
13.Med-surg: GI, perioperative & oncology

Answer: D · Regular repositioning and a pressure-redistributing mattress

Why this is the answer

Regular repositioning according to risk and suitable support surfaces reduce pressure. Massaging red areas and ring cushions can damage tissue and are not recommended.

Answer

D · Regular repositioning and a pressure-redistributing mattress
14.Med-surg: GI, perioperative & oncology

Answer: C · Refer to the dietitian, start a nutrition plan and monitor intake

Why this is the answer

A MUST score of 2 or more indicates high risk of malnutrition. Poor nutrition delays healing, so the nurse refers to the dietitian, starts a care plan with food charts and supplements as advised, and rescreens regularly.

Answer

C · Refer to the dietitian, start a nutrition plan and monitor intake

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