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 nurse delegates the measurement of blood glucose to a trained assistant but never asks for the result. Which right of delegation is missing?

  1. ARight circumstance
  2. BRight supervision and evaluation
  3. CRight person for the task
  4. DRight task for the setting
2.Prioritization & delegationHard

Which patient is the most appropriate to assign to an LPN/LVN?

  1. AA patient with a long-standing tracheostomy who needs routine suctioning and care
  2. BA patient on a new IV medication that needs frequent titration
  3. CA patient with a tracheostomy placed this morning who is coughing up blood
  4. DA patient who has just arrived from the emergency department with pneumonia and confusion
3.Infection control & patient safetyMedium

Which dressing waste should be disposed of in clinical (biohazard) waste?

  1. AThe outer paper wrapping of a sterile dressing pack
  2. BA dressing soaked with fluid from an infected wound
  3. CA clean paper towel used to dry hands
  4. DAn unused, still-sealed dressing past its date
4.Infection control & patient safetyHard

A patient is receiving a high-alert drug by continuous infusion. At handover, which practice is safest?

  1. AThe incoming nurse checks it at the end of the shift
  2. BOnly the rate is checked, not the drug or concentration
  3. CThe outgoing nurse says that “the pump is fine” at the desk
  4. DBoth nurses check the pump and bag against the prescription
5.Lab values & electrolytesMedium

When do the blood counts usually reach their lowest point (nadir) after many standard chemotherapy regimens?

  1. AAbout 7–14 days after treatment
  2. BAbout 6 months after treatment
  3. COn the same day as treatment
  4. DWithin 1–2 hours of treatment
6.Lab values & electrolytesHard

Two weeks after a sore throat, a child develops dark (cola-colored) urine, puffy eyes and high blood pressure. Urinalysis shows red cell casts and protein. Which condition is most likely?

  1. APrerenal acute kidney injury
  2. BKidney stone in the ureter
  3. CPost-streptococcal glomerulonephritis
  4. DLower urinary tract infection (cystitis)
7.Clinical nursingMedium

Which instruction is correct for taking weekly alendronic acid (alendronate)?

  1. ATake it with an antacid to protect the stomach
  2. BTake it with a glass of milk at bedtime and then lie down straight away
  3. CTake it with plain water on an empty stomach and stay upright for 30 minutes
  4. DChew the tablet with breakfast and a cup of milky tea
8.Clinical nursingHard

A patient is admitted with suspected meningococcal disease. Which infection control measure is usually needed?

  1. ADroplet precautions until 24 hours of effective antibiotics have been given
  2. BAirborne precautions with a negative-pressure room for the whole hospital stay
  3. CIsolation only after the patient has gone home
  4. DNo precautions, because it is not contagious
9.Med-surg: cardiovascular & respiratoryMedium

A patient with heart failure is comfortable at rest but becomes breathless walking across a room. Which NYHA class fits best?

  1. AClass I
  2. BClass IV
  3. CClass III
  4. DClass II
10.Med-surg: cardiovascular & respiratoryHard

A patient has sudden severe chest pain spreading to the back between the shoulder blades. Which finding most supports aortic dissection rather than myocardial infarction?

  1. APain that started at rest
  2. BSweating, nausea and pallor that started with the pain
  3. CA large difference in blood pressure between the arms
  4. DA heart rate of 104/min and a respiratory rate of 22/min
11.Med-surg: neuro, endocrine & renalMedium

A patient with advanced CKD asks how to manage indigestion. Which option should they avoid?

  1. AMagnesium-containing antacids
  2. BAvoiding large meals late in the evening
  3. CEating smaller, more frequent meals
  4. DRaising the head of the bed at night
12.Med-surg: neuro, endocrine & renalHard

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

  1. ASkin, for a drug rash
  2. BCapillary glucose, for hypoglycaemia
  3. CUrine colour, for blood in the urine
  4. DPupils, for raised intracranial pressure
13.Med-surg: GI, perioperative & oncologyMedium

Which finding suggests a deep tissue pressure injury?

  1. APale pink skin that blanches quickly when pressed
  2. BA small scratch on the skin with a little fresh red blood
  3. CDry, flaky skin on both shins
  4. DIntact skin that is purple or maroon over a bony area
14.Med-surg: GI, perioperative & oncologyHard

Ten days after chemotherapy, a patient has a temperature of 37.6 °C but feels shivery and unwell, with a pulse of 112/min and BP 95/60 mmHg. What is the correct action?

  1. AReassure the patient, because the temperature is still below 38 °C
  2. BTreat as possible neutropenic sepsis: IV antibiotics within an hour
  3. CGive paracetamol and recheck the temperature again in four hours
  4. DWait for the neutrophil count before deciding on any treatment

3Solutions

1.Prioritization & delegation

Answer: B · Right supervision and evaluation

Why this is the answer

The nurse must follow up, check the result and act on it. Delegating without checking the outcome breaks the right of supervision and evaluation.

Answer

B · Right supervision and evaluation
2.Prioritization & delegation

Answer: A · A patient with a long-standing tracheostomy who needs routine suctioning and care

Why this is the answer

Routine tracheostomy care for a stable, long-term patient fits the LPN/LVN role in most settings. Fresh or bleeding tracheostomies, new admissions and titrated IV drugs need RN assessment.

Answer

A · A patient with a long-standing tracheostomy who needs routine suctioning and care
3.Infection control & patient safety

Answer: B · A dressing soaked with fluid from an infected wound

Why this is the answer

Items contaminated with blood or infectious body fluids go into clinical waste according to local rules. Clean packaging goes into general or recycling waste, so the volume of clinical waste stays as small as possible.

Answer

B · A dressing soaked with fluid from an infected wound
4.Infection control & patient safety

Answer: D · Both nurses check the pump and bag against the prescription

Why this is the answer

A bedside check at handover, tracing the line from bag to patient and comparing the drug, concentration, dose and rate with the prescription, catches programming errors early.

Answer

D · Both nurses check the pump and bag against the prescription
5.Lab values & electrolytes

Answer: A · About 7–14 days after treatment

Why this is the answer

Chemotherapy damages dividing marrow cells, but mature neutrophils and platelets already in the blood survive for a while, so counts usually fall to a nadir about 7–14 days later, depending on the drug. Infection and bleeding risks are highest then.

Answer

A · About 7–14 days after treatment
6.Lab values & electrolytes

Answer: C · Post-streptococcal glomerulonephritis

Why this is the answer

Red cell casts show bleeding from the glomeruli, which is typical of glomerulonephritis. After a streptococcal infection, immune complexes inflame the glomeruli, causing hematuria, proteinuria, edema and hypertension. Cystitis and stones do not cause red cell casts.Checked against: Strep A Test · MedlinePlus (NIH) (2024)

Answer

C · Post-streptococcal glomerulonephritis
7.Clinical nursing

Answer: C · Take it with plain water on an empty stomach and stay upright for 30 minutes

Why this is the answer

Alendronic acid must be taken with plain water before food, and the patient must stay upright to reduce oesophageal irritation. Food, milk and antacids reduce absorption.

Answer

C · Take it with plain water on an empty stomach and stay upright for 30 minutes
8.Clinical nursing

Answer: A · Droplet precautions until 24 hours of effective antibiotics have been given

Why this is the answer

Neisseria meningitidis spreads through droplets and close contact. Droplet precautions are used until 24 hours of effective antibiotics, and public health arranges prophylaxis for close contacts.

Answer

A · Droplet precautions until 24 hours of effective antibiotics have been given
9.Med-surg: cardiovascular & respiratory

Answer: C · Class III

Why this is the answer

NYHA class I has no limitation, class II slight limitation with ordinary activity, class III marked limitation with less than ordinary activity but comfortable at rest, and class IV symptoms at rest. The class guides treatment and prognosis.

Answer

C · Class III
10.Med-surg: cardiovascular & respiratory

Answer: C · A large difference in blood pressure between the arms

Why this is the answer

A difference of more than about 20 mmHg in systolic pressure between the arms, a pulse deficit or a new aortic regurgitation murmur suggests dissection. Sweating, tachycardia and rest pain also occur in MI. Thrombolysis and anticoagulants could be disastrous in dissection, so the distinction matters.

Answer

C · A large difference in blood pressure between the arms
11.Med-surg: neuro, endocrine & renal

Answer: A · Magnesium-containing antacids

Why this is the answer

Magnesium and aluminium are excreted by the kidneys and can accumulate in kidney failure. Patients with CKD should check with a pharmacist before using over-the-counter remedies, including laxatives and NSAIDs.

Answer

A · Magnesium-containing antacids
12.Med-surg: neuro, endocrine & renal

Answer: B · Capillary glucose, for hypoglycaemia

Why this is the answer

Hypoglycaemia is a common complication of insulin–glucose treatment and can occur several hours later, especially in kidney failure. Glucose is checked regularly according to protocol, and potassium is rechecked.

Answer

B · Capillary glucose, for hypoglycaemia
13.Med-surg: GI, perioperative & oncology

Answer: D · Intact skin that is purple or maroon over a bony area

Why this is the answer

A deep tissue injury appears as persistent purple, maroon or dark discolouration, or a blood-filled blister, from pressure and shear on underlying tissue. It may quickly turn into a deep wound.

Answer

D · Intact skin that is purple or maroon over a bony area
14.Med-surg: GI, perioperative & oncology

Answer: B · Treat as possible neutropenic sepsis: IV antibiotics within an hour

Why this is the answer

A patient who is unwell during the expected nadir is treated as having neutropenic sepsis even without a high fever; rigors, tachycardia and hypotension are warning signs. Blood cultures are taken and empirical IV antibiotics started within 1 hour, without waiting for the blood count. Antipyretics can mask fever and should not delay assessment.

Answer

B · Treat as possible neutropenic sepsis: IV antibiotics within an hour

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