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.

New problemsBack to the course

In the print window, choose “Save as PDF” to keep a copy on your device.

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 receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?

  1. AGive a cool shower and offer extra fluids, then wait and see what happens
  2. BReport it at once, because cultures and antibiotics are needed quickly
  3. CRecheck the temperature in four hours before telling anyone
  4. DDocument the reading and mention it at the next handover
2.Prioritization & delegationHard

On a cardiac step-down unit, which patient should the nurse assess first?

  1. AAtrial fibrillation on warfarin with an INR of 2.6 this morning
  2. BDay 2 after a pacemaker insertion, asking when the wound dressing will be changed
  3. CSix hours after a coronary stent, new chest pain with ST elevation on the monitor
  4. DHeart failure, weight up 0.5 kg since yesterday, no breathlessness at rest
3.Infection control & patient safetyMedium

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

  1. APush the tube back in and restart the feed
  2. BIncrease the feed rate to make up for the lost time
  3. CTape the tube in its new position and continue
  4. DStop the feeding until the tube position is checked
4.Infection control & patient safetyHard

A competent adult patient with pneumonia wants to leave the hospital against medical advice. What should the nurse do?

  1. ALock the doors so the patient cannot leave
  2. BHide the patient’s clothes and belongings so that they cannot leave the ward
  3. CExplain the risks, notify the provider and follow the policy for leaving against advice
  4. DApply wrist restraints until the provider arrives to speak with the patient
5.Lab values & electrolytesMedium

A patient's eGFR has fallen to 24 mL/min/1.73 m². Which prescribed drug should the nurse question before giving it?

  1. AAcetaminophen (paracetamol)
  2. BLevothyroxine
  3. CInsulin glargine
  4. DMetformin
6.Lab values & electrolytesHard

A patient with a new deep vein thrombosis is on a heparin infusion, and warfarin has just been started. Why is the heparin continued for several days?

  1. AHeparin increases the absorption of warfarin from the gut
  2. BWarfarin only works when heparin is given at the same time
  3. CWarfarin takes several days to reach its full anticoagulant effect
  4. DHeparin prevents the side effects of warfarin
7.Clinical nursingMedium

What should a patient be told before using sublingual glyceryl trinitrate (GTN, nitroglycerin) spray for angina?

  1. AUse it only after the pain has lasted over an hour, with the patient lying flat
  2. BSwallow the spray rather than leaving it under the tongue
  3. CSit down before using it, as it can cause dizziness and low blood pressure
  4. DTake it with a large glass of milk to protect the stomach lining
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. ASIADH, often managed first with fluid restriction
  2. BDehydration, managed with an IV fluid bolus
  3. CCushing's syndrome, managed with potassium
  4. DDiabetes insipidus, managed with extra fluids
9.Med-surg: cardiovascular & respiratoryMedium

A patient choosing between a mechanical and a biological heart valve asks about the main difference. Which answer is accurate?

  1. ABoth types need no medicines after surgery
  2. BMechanical valves last longer but need lifelong anticoagulation
  3. CMechanical valves wear out within one year
  4. DBiological valves last longer but need lifelong warfarin
10.Med-surg: cardiovascular & respiratoryHard

After four days of antibiotics for pneumonia, a patient still has fever and pleuritic pain. There is dullness and reduced breath sounds at the right base. What complication should be suspected?

  1. AAsthma triggered by the infection
  2. BNormal recovery from pneumonia
  3. CA parapneumonic effusion or empyema
  4. DAn allergic reaction to the antibiotic
11.Med-surg: neuro, endocrine & renalMedium

A patient is due a rapid-acting insulin dose before lunch, but the meal trays are delayed. What should the nurse do?

  1. AWait to give the insulin until the meal arrives
  2. BGive the insulin now and the meal when it comes
  3. CGive the insulin with a glass of water instead
  4. DOmit the dose entirely for the rest of the day
12.Med-surg: neuro, endocrine & renalHard

A man who takes tamsulosin for BPH is listed for cataract surgery. Which statement is correct?

  1. AThe eye surgeon must be told, as it can cause floppy iris during surgery
  2. BThe dose should be doubled before surgery to prevent urinary retention
  3. CTamsulosin has no effects outside the urinary tract, so nothing changes
  4. DIt should be swapped for oxybutynin the night before to protect the eye
13.Med-surg: GI, perioperative & oncologyMedium

Which nursing care helps a new skin graft take?

  1. AEncouraging the patient to exercise the area straight away
  2. BKeeping the area still and avoiding shearing forces
  3. CRemoving the dressing every hour to look at it
  4. DMassaging the graft firmly several times a day
14.Med-surg: GI, perioperative & oncologyHard

A nurse teaches a patient after a colonoscopy with polyp removal. Which statement shows a need for further teaching?

  1. A"Some wind and bloating today is expected."
  2. B"I should report a fever or a swollen, painful abdomen."
  3. C"Severe abdominal pain is normal for a week afterwards."
  4. D"I'll report heavy bleeding from my bottom."

3Solutions

1.Prioritization & delegation

Answer: B · Report it at once, because cultures and antibiotics are needed quickly

Why this is the answer

Neutropenic fever is a medical emergency. The patient may have few other signs of infection, so the nurse reports it immediately so that cultures can be taken and IV antibiotics started.

Answer

B · Report it at once, because cultures and antibiotics are needed quickly
2.Prioritization & delegation

Answer: C · Six hours after a coronary stent, new chest pain with ST elevation on the monitor

Why this is the answer

New chest pain with ST elevation after a stent suggests the stent may have blocked, causing an acute myocardial infarction. This is an emergency; the other findings are within target or routine.

Answer

C · Six hours after a coronary stent, new chest pain with ST elevation on the monitor
3.Infection control & patient safety

Answer: D · Stop the feeding until the tube position is checked

Why this is the answer

A displaced tube may now sit in the esophagus or airway. The feeding is stopped and the tube is not pushed back blindly. Its position is checked according to policy, or it is replaced.

Answer

D · Stop the feeding until the tube position is checked
4.Infection control & patient safety

Answer: C · Explain the risks, notify the provider and follow the policy for leaving against advice

Why this is the answer

Holding a competent adult against their will can be false imprisonment. The nurse explains the risks, informs the provider, asks the patient to sign the against-advice form if they agree and documents the discussion.

Answer

C · Explain the risks, notify the provider and follow the policy for leaving against advice
5.Lab values & electrolytes

Answer: D · Metformin

Why this is the answer

Metformin is cleared by the kidneys, and it is contraindicated when the eGFR is below 30 mL/min/1.73 m² because of the risk of lactic acidosis. Insulin doses may also need adjustment, but insulin is not contraindicated.

Answer

D · Metformin
6.Lab values & electrolytes

Answer: C · Warfarin takes several days to reach its full anticoagulant effect

Why this is the answer

Warfarin blocks the making of new vitamin K–dependent clotting factors, but existing factors last for days. Heparin is therefore overlapped until the INR has been in the target range, typically for at least 24 hours and after a minimum of about 5 days.

Answer

C · Warfarin takes several days to reach its full anticoagulant effect
7.Clinical nursing

Answer: C · Sit down before using it, as it can cause dizziness and low blood pressure

Why this is the answer

GTN causes vasodilation, which can lead to headache, flushing, dizziness and hypotension. Patients should sit, and seek emergency help if the pain does not settle after the advised doses.

Answer

C · Sit down before using it, as it can cause dizziness and low blood pressure
8.Clinical nursing

Answer: A · 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

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

Answer: B · Mechanical valves last longer but need lifelong anticoagulation

Why this is the answer

Mechanical valves are very durable but are thrombogenic, so lifelong warfarin is needed. Biological (tissue) valves usually do not need long-term anticoagulation but wear out over time and may need replacement. Age, lifestyle and bleeding risk guide the choice.

Answer

B · Mechanical valves last longer but need lifelong anticoagulation
10.Med-surg: cardiovascular & respiratory

Answer: C · A parapneumonic effusion or empyema

Why this is the answer

Persistent fever and signs of pleural fluid suggest a parapneumonic effusion, which may become infected (empyema). Ultrasound and diagnostic pleural aspiration are needed, and an infected collection usually needs a chest drain in addition to antibiotics.

Answer

C · A parapneumonic effusion or empyema
11.Med-surg: neuro, endocrine & renal

Answer: A · Wait to give the insulin until the meal arrives

Why this is the answer

Rapid-acting insulin begins to work within about 15 minutes, so giving it without food risks hypoglycaemia. It is given just before or with the meal. Basal insulin is not affected by meal delays.

Answer

A · Wait to give the insulin until the meal arrives
12.Med-surg: neuro, endocrine & renal

Answer: A · The eye surgeon must be told, as it can cause floppy iris during surgery

Why this is the answer

Tamsulosin blocks alpha-1A receptors in the iris dilator muscle as well as in the prostate, which can cause intraoperative floppy iris syndrome during cataract surgery. The effect can persist after the drug is stopped, so the surgeon must know in advance to plan the operation. Whether to pause it is a decision for the team.

Answer

A · The eye surgeon must be told, as it can cause floppy iris during surgery
13.Med-surg: GI, perioperative & oncology

Answer: B · Keeping the area still and avoiding shearing forces

Why this is the answer

Grafts need close contact with the wound bed to gain a new blood supply. Immobilisation, careful dressings and avoiding friction, shearing and collections under the graft help it take.

Answer

B · Keeping the area still and avoiding shearing forces
14.Med-surg: GI, perioperative & oncology

Answer: C · "Severe abdominal pain is normal for a week afterwards."

Why this is the answer

Mild bloating and cramps from the air used are expected. Severe or worsening pain, fever, a distended abdomen or heavy rectal bleeding can mean perforation or haemorrhage and must be reported straight away.

Answer

C · "Severe abdominal pain is normal for a week afterwards."

This is independent practice material. ExamProblems is not affiliated with or endorsed by the organisation that runs this exam, and the exam name is used only to describe the content. NCLEX®, NCLEX-RN® and NCLEX-PN® are trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN), which is not affiliated with ExamProblems and does not endorse it or vouch for its accuracy.

ExamProblems · examproblems.com/courses/nclex-style-prioritization-and-delegation