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 reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

  1. AGive the strongest analgesic on the chart straight away
  2. BAsk the nursing assistant to reposition the patient
  3. CTell the patient to wait until the next scheduled dose is due in two hours
  4. DAssess the location, character and onset of the pain and the vital signs
2.Prioritization & delegationHard

Which patient finding after a total knee replacement needs the nurse’s action first?

  1. APain of 4/10 when the physiotherapist bends the knee during the morning session
  2. BSudden calf pain and swelling in the operated leg, with new breathlessness
  3. CA small amount of dried blood on the dressing
  4. DAsks for an ice pack to help with swelling around the knee
3.Infection control & patient safetyMedium

When should blood specimen tubes be labeled?

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

During flu season, a nurse wakes up with fever, cough and muscle aches. What is the best action?

  1. AGo to work but wear a surgical mask for the whole shift
  2. BStay home and inform the employer according to the illness policy
  3. CTake an antipyretic so the fever does not show at work
  4. DGo to work but avoid caring for patients who have weak immune systems
5.Lab values & electrolytesMedium

A patient has burning on urination and frequency. The dipstick is positive for nitrites and leukocyte esterase, and a urine culture is ordered. When should the sample be taken?

  1. ABefore the first dose of antibiotic
  2. BAfter the symptoms have fully settled
  3. CAfter 3 days of antibiotic treatment
  4. DAt any time, as antibiotics do not matter
6.Lab values & electrolytesHard

During surgery under general anesthesia, a patient develops a rising end-tidal CO2, muscle rigidity and tachycardia, then a high potassium and a rising temperature. Which condition is most likely?

  1. AAcute hemolytic transfusion reaction
  2. BHypovolemic shock
  3. CMalignant hyperthermia
  4. DHypoglycemia from fasting
7.Clinical nursingMedium

Which blood result often rises in an upper GI bleed because blood is digested in the gut?

  1. ACalcium
  2. BUrea (blood urea nitrogen)
  3. CSodium
  4. DGlucose
8.Clinical nursingHard

A patient has a single hot, swollen, very painful knee and a fever. Why is urgent joint aspiration important?

  1. ATo rule out septic arthritis, which can rapidly destroy the joint
  2. BTo check for rheumatoid arthritis antibodies in the joint fluid
  3. CTo prevent osteoporosis
  4. DTo measure the patient's cholesterol
9.Med-surg: cardiovascular & respiratoryMedium

A patient is starting long-term amiodarone. Which teaching and monitoring are most important?

  1. AProtect skin from sunlight and have thyroid, liver and lung checks
  2. BAvoid dairy products and have the INR checked once at the start
  3. CExpect orange urine and no need for blood tests
  4. DEat extra salt and stop the drug as soon as the pulse is regular
10.Med-surg: cardiovascular & respiratoryHard

After a car crash, a patient is severely breathless with absent breath sounds on the right, a deviated trachea, distended neck veins and BP 76/40 mmHg. What is the immediate management?

  1. AInsertion of a urinary catheter to monitor output
  2. BLying the patient flat with the legs raised
  3. CUrgent needle or finger decompression of the right chest
  4. DA chest X-ray to confirm the diagnosis before any treatment
11.Med-surg: neuro, endocrine & renalMedium

A patient taking a GLP-1 receptor agonist has severe, constant upper abdominal pain spreading to the back, with vomiting. What should the nurse suspect?

  1. AAcute pancreatitis
  2. BNormal nausea from the drug
  3. CA simple urinary tract infection
  4. DLow blood glucose
12.Med-surg: neuro, endocrine & renalHard

A student has fever, a severe headache, a spreading non-blanching rash and a BP of 85/50 mmHg. A lumbar puncture is planned. What is the priority?

  1. AGive paracetamol (acetaminophen) and recheck observations in an hour
  2. BGive IV antibiotics at once and start sepsis treatment
  3. CWait until after the lumbar puncture before giving antibiotics
  4. DArrange a CT scan of the head before any treatment
13.Med-surg: GI, perioperative & oncologyMedium

Why do patients with major burns lose so much fluid in the first 24–48 hours?

  1. AThe burned skin absorbs fluid from the air
  2. BThe kidneys stop making urine completely
  3. CPatients drink far too little in hospital in the first days
  4. DLeaky capillaries let plasma move into the tissues
14.Med-surg: GI, perioperative & oncologyHard

A nurse teaches a patient with GORD. Which statement shows a need for further teaching?

  1. A"I'll stop smoking because it makes reflux worse."
  2. B"I'll try to lose some weight over the next months."
  3. C"I'll keep a diary of foods that trigger my symptoms."
  4. D"Peppermint tea after dinner will settle my reflux."

3Solutions

1.Prioritization & delegation

Answer: D · Assess the location, character and onset of the pain and the vital signs

Why this is the answer

Assessment comes first, because severe pain may be a sign of a new complication such as bleeding or a heart attack. The assessment also guides which analgesic is appropriate.

Answer

D · Assess the location, character and onset of the pain and the vital signs
2.Prioritization & delegation

Answer: B · Sudden calf pain and swelling in the operated leg, with new breathlessness

Why this is the answer

Calf pain and swelling suggest deep vein thrombosis, and new breathlessness raises concern for a pulmonary embolism. This needs immediate assessment and escalation; the other findings are expected.

Answer

B · Sudden calf pain and swelling in the operated leg, with new breathlessness
3.Infection control & patient safety

Answer: A · 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

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

Answer: B · Stay home and inform the employer according to the illness policy

Why this is the answer

Health care workers with signs of influenza should not work, because they can infect patients and colleagues. They follow the employer’s policy on when they may return.

Answer

B · Stay home and inform the employer according to the illness policy
5.Lab values & electrolytes

Answer: A · Before the first dose of antibiotic

Why this is the answer

The culture sample is taken before antibiotics, so the organism can be grown and its sensitivities tested. A sample taken after antibiotics may give a false negative culture.

Answer

A · Before the first dose of antibiotic
6.Lab values & electrolytes

Answer: C · Malignant hyperthermia

Why this is the answer

Malignant hyperthermia is a genetic hypermetabolic reaction to volatile anesthetics or succinylcholine. Muscle cells release calcium, producing CO2, heat, rigidity, hyperkalemia and very high CK. It is treated with dantrolene and stopping the trigger.

Answer

C · Malignant hyperthermia
7.Clinical nursing

Answer: B · Urea (blood urea nitrogen)

Why this is the answer

Blood proteins digested in the upper GI tract are absorbed and converted to urea, so urea rises out of proportion to creatinine. Urea is part of the Glasgow-Blatchford bleeding score.

Answer

B · Urea (blood urea nitrogen)
8.Clinical nursing

Answer: A · To rule out septic arthritis, which can rapidly destroy the joint

Why this is the answer

Septic arthritis can destroy cartilage within days. Aspiration allows microscopy and culture, and helps distinguish infection from crystal arthritis such as gout.

Answer

A · To rule out septic arthritis, which can rapidly destroy the joint
9.Med-surg: cardiovascular & respiratory

Answer: A · Protect skin from sunlight and have thyroid, liver and lung checks

Why this is the answer

Amiodarone causes photosensitivity, thyroid dysfunction (it contains iodine), liver toxicity, pulmonary fibrosis and corneal deposits. Patients use high-factor sunscreen and have regular thyroid and liver tests and reviews for cough or breathlessness. It also interacts with warfarin and digoxin.

Answer

A · Protect skin from sunlight and have thyroid, liver and lung checks
10.Med-surg: cardiovascular & respiratory

Answer: C · Urgent needle or finger decompression of the right chest

Why this is the answer

These signs indicate a tension pneumothorax, which causes obstructive shock. It is decompressed immediately (needle or finger thoracostomy) without waiting for an X-ray, followed by a chest drain. The nurse gives high-flow oxygen and calls for senior help.

Answer

C · Urgent needle or finger decompression of the right chest
11.Med-surg: neuro, endocrine & renal

Answer: A · Acute pancreatitis

Why this is the answer

GLP-1 receptor agonists have been linked to acute pancreatitis. Severe persistent abdominal pain radiating to the back needs urgent assessment, and the drug is stopped if pancreatitis is suspected.

Answer

A · Acute pancreatitis
12.Med-surg: neuro, endocrine & renal

Answer: B · Give IV antibiotics at once and start sepsis treatment

Why this is the answer

Meningococcal septicaemia can kill within hours. Antibiotics must not be delayed for a lumbar puncture or scan. Fluids and other sepsis care are started, and a lumbar puncture is often unsafe in a shocked patient.

Answer

B · Give IV antibiotics at once and start sepsis treatment
13.Med-surg: GI, perioperative & oncology

Answer: D · Leaky capillaries let plasma move into the tissues

Why this is the answer

Inflammatory mediators make capillaries leaky, so plasma moves into the tissues and from the burn surface. Without fluids this causes burn shock; oedema is greatest in the first day or two.

Answer

D · Leaky capillaries let plasma move into the tissues
14.Med-surg: GI, perioperative & oncology

Answer: D · "Peppermint tea after dinner will settle my reflux."

Why this is the answer

Peppermint can relax the lower oesophageal sphincter and may worsen reflux. Weight loss, stopping smoking and avoiding personal triggers are standard lifestyle measures.

Answer

D · "Peppermint tea after dinner will settle my reflux."

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