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 had a colostomy formed yesterday. Which stoma appearance should be reported straight away?

  1. ASlightly swollen
  2. BDark purple or black
  3. CMoist and pink-red
  4. DA little bleeding when cleaned
2.Prioritization & delegationHard

During a busy shift, four tasks are due. Which should the nurse do first?

  1. AHelp a stable patient fill in tomorrow’s menu card
  2. BFirst dose of IV antibiotic for a patient with suspected sepsis
  3. CGive a routine daily vitamin tablet that is due at the same time
  4. DUpdate the nursing care plan before the managers’ audit
3.Infection control & patient safetyMedium

A patient is on suicide precautions. Which room safety measure is appropriate?

  1. ALet the patient keep a personal razor for shaving, as long as staff are told
  2. BKeep the door closed at all times so the patient has privacy
  3. CRemove items that could be used for self-harm, such as belts and cords
  4. DAllow glass bottles if the patient seems calm
4.Infection control & patient safetyHard

A patient on a general ward for two days is found to have smear-positive pulmonary TB. What should the nurse do besides moving the patient to an airborne isolation room?

  1. ATell all the exposed patients to start TB drugs at once, before any testing
  2. BInform infection prevention so exposed patients and staff can be identified and followed up
  3. CClose the ward to all new admissions for a full year
  4. DNothing more, because the patient has now been isolated
5.Lab values & electrolytesMedium

In countries that screen all pregnant women (such as the US), a vaginal-rectal swab is taken at about 36–37 weeks. Which organism is it screening for?

  1. AHepatitis B virus
  2. BCandida albicans
  3. CGroup B Streptococcus
  4. DStaphylococcus aureus
6.Lab values & electrolytesHard

A patient on stable digoxin starts amiodarone. A week later, the patient has nausea and visual changes, and the digoxin level is above the range. What is the most likely explanation?

  1. AAmiodarone has lowered potassium only
  2. BAmiodarone has raised the digoxin level
  3. CDigoxin has raised the amiodarone level
  4. DThe patient has started a viral illness
7.Clinical nursingMedium

What should a nurse do during a generalised tonic-clonic seizure?

  1. AHold the limbs firmly to stop the jerking and prevent injury
  2. BGive the patient a drink of water
  3. CProtect the head, time the seizure and do not put anything in the mouth
  4. DPut a tongue depressor between the teeth so that the tongue is not bitten
8.Clinical nursingHard

Why can pulse oximetry be misleading in carbon monoxide poisoning?

  1. AThe oximeter overheats in smoke-exposed patients
  2. BCarbon monoxide only affects the heart rate reading
  3. CCarbon monoxide makes the oximeter read zero even in a well patient
  4. DStandard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
9.Med-surg: cardiovascular & respiratoryMedium

What is the main difference between CPAP and bilevel NIV (often called BiPAP)?

  1. ABilevel NIV adds a higher inspiratory pressure, helping remove CO₂
  2. BCPAP is given only through a tracheostomy
  3. CBilevel NIV gives oxygen only, without any positive airway pressure
  4. DCPAP is mainly used to lower a raised PaCO₂ in COPD exacerbations
10.Med-surg: cardiovascular & respiratoryHard

A day after a myocardial infarction, a patient has frequent ventricular ectopic beats on the monitor. Which blood results should be checked first?

  1. AFerritin and vitamin B12
  2. BAlbumin and bilirubin
  3. CAmylase and lipase
  4. DPotassium and magnesium
11.Med-surg: neuro, endocrine & renalMedium

After pressing the plunger of an insulin pen, what should the patient do?

  1. APull the needle out at once and rub the site firmly
  2. BLeave the needle on the pen for the next injection
  3. CInject a second dose straight away to be sure
  4. DKeep the needle in the skin for about 10 seconds
12.Med-surg: neuro, endocrine & renalHard

The nurse has four urology patients. Which one needs to be seen first?

  1. AA patient with stress incontinence asking about pelvic floor exercises
  2. BA patient with a suprapubic catheter due for a routine change
  3. CA patient with a nephrostomy who has rigors and a BP of 86/50 mmHg
  4. DA patient after TURP with light pink drainage and mild discomfort
13.Med-surg: GI, perioperative & oncologyMedium

Which electrolyte problem can occur in severe acute pancreatitis?

  1. AHypernatraemia
  2. BHypocalcaemia
  3. CHypercalcaemia
  4. DHyperkalaemia
14.Med-surg: GI, perioperative & oncologyHard

A patient with an epidural after abdominal surgery has BP 82/48 mmHg, a pulse of 70/min and warm feet. Bleeding has been excluded. What is the most likely cause?

  1. AAnaphylaxis to the local anaesthetic
  2. BHypovolaemic shock from blood loss
  3. CSympathetic block from the epidural
  4. DCardiogenic shock after surgery

3Solutions

1.Prioritization & delegation

Answer: B · Dark purple or black

Why this is the answer

A healthy stoma is moist and pink to red, and early swelling or slight bleeding is common. A dark purple or black stoma suggests poor blood supply (ischemia) and needs urgent review.

Answer

B · Dark purple or black
2.Prioritization & delegation

Answer: B · First dose of IV antibiotic for a patient with suspected sepsis

Why this is the answer

Early antibiotics improve survival in sepsis and are ideally given within an hour of recognition. The other tasks are routine and can wait.

Answer

B · First dose of IV antibiotic for a patient with suspected sepsis
3.Infection control & patient safety

Answer: C · Remove items that could be used for self-harm, such as belts and cords

Why this is the answer

Patients at risk of suicide need a safe environment, with belts, cords, sharp objects and glass removed, and observation at the level ordered. Privacy is secondary to safety in this situation.

Answer

C · Remove items that could be used for self-harm, such as belts and cords
4.Infection control & patient safety

Answer: B · Inform infection prevention so exposed patients and staff can be identified and followed up

Why this is the answer

Infection prevention and public health carry out a contact investigation to identify and screen people exposed while the patient was not isolated. Treatment of contacts depends on their test results.

Answer

B · Inform infection prevention so exposed patients and staff can be identified and followed up
5.Lab values & electrolytes

Answer: C · Group B Streptococcus

Why this is the answer

Group B streptococci can colonize the vagina and rectum and can cause severe infection in newborns. Women who test positive receive IV antibiotics during labor to reduce transmission to the baby. The UK does not screen all women routinely; it uses a risk-based approach instead.Checked against: Group B streptococcal septicemia of the newborn · MedlinePlus (NIH) (2024)

Answer

C · Group B Streptococcus
6.Lab values & electrolytes

Answer: B · Amiodarone has raised the digoxin level

Why this is the answer

Amiodarone reduces digoxin clearance, so the level can rise significantly, and the digoxin dose is often reduced when amiodarone is started. Nausea and visual changes are classic signs of digoxin toxicity.

Answer

B · Amiodarone has raised the digoxin level
7.Clinical nursing

Answer: C · Protect the head, time the seizure and do not put anything in the mouth

Why this is the answer

Remove nearby hazards, cushion the head, note the time and do not restrain or put objects in the mouth. Once jerking stops, place the patient in the recovery position and check the airway.

Answer

C · Protect the head, time the seizure and do not put anything in the mouth
8.Clinical nursing

Answer: D · Standard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin

Why this is the answer

Standard SpO2 can appear normal despite severe tissue hypoxia. Carboxyhaemoglobin is measured on a blood gas, and high-concentration oxygen is given.

Answer

D · Standard oximeters cannot tell carboxyhaemoglobin from oxyhaemoglobin
9.Med-surg: cardiovascular & respiratory

Answer: A · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂

Why this is the answer

CPAP gives one continuous pressure that splints the airways and alveoli open, improving oxygenation (for example in pulmonary oedema or OSA). Bilevel NIV adds a higher inspiratory pressure that supports ventilation, so it is used for hypercapnic respiratory failure such as COPD exacerbations.

Answer

A · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂
10.Med-surg: cardiovascular & respiratory

Answer: D · Potassium and magnesium

Why this is the answer

Low potassium and low magnesium both increase ventricular irritability and the risk of VT and VF after an MI. They are checked and corrected, usually keeping potassium in the upper part of the normal range. The patient is also assessed for ischaemia and haemodynamic change.

Answer

D · Potassium and magnesium
11.Med-surg: neuro, endocrine & renal

Answer: D · Keep the needle in the skin for about 10 seconds

Why this is the answer

Holding the needle in place for around 10 seconds (or as the manufacturer advises) lets the full dose be delivered. A new needle is used for each injection, and the site should not be massaged.

Answer

D · Keep the needle in the skin for about 10 seconds
12.Med-surg: neuro, endocrine & renal

Answer: C · A patient with a nephrostomy who has rigors and a BP of 86/50 mmHg

Why this is the answer

Rigors and hypotension in a patient with a nephrostomy suggest urosepsis, which needs immediate assessment and treatment. Light pink drainage after TURP is expected. The other patients are stable.

Answer

C · A patient with a nephrostomy who has rigors and a BP of 86/50 mmHg
13.Med-surg: GI, perioperative & oncology

Answer: B · Hypocalcaemia

Why this is the answer

Fat necrosis releases fatty acids that bind calcium (saponification), lowering serum calcium. Hypocalcaemia is a marker of severity and can cause tetany and arrhythmias. Hypercalcaemia, on the other hand, can be a cause of pancreatitis.

Answer

B · Hypocalcaemia
14.Med-surg: GI, perioperative & oncology

Answer: C · Sympathetic block from the epidural

Why this is the answer

Epidural local anaesthetic can block sympathetic outflow, causing vasodilation and hypotension. Management follows the epidural protocol: assess, lie the patient flat, give fluid or vasopressors as prescribed and inform the anaesthetist. Bleeding must always be considered too.

Answer

C · Sympathetic block from the epidural

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