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 receives hemodialysis this morning. Which type of medication is often held before dialysis, as prescribed?

  1. AAntihypertensive drugs
  2. BTopical skin creams
  3. CEye drops for glaucoma
  4. DInhaled bronchodilators
2.Prioritization & delegationHard

A trauma patient has an open leg fracture, absent breath sounds on one side, a trachea shifted to the other side and a falling blood pressure. Which problem is the priority?

  1. AThe risk of wound infection
  2. BThe suspected tension pneumothorax
  3. CThe pain from the fracture
  4. DThe open fracture of the leg
3.Infection control & patient safetyMedium

When should a nurse use an extinguisher on a fire?

  1. ANever; only firefighters may use fire extinguishers
  2. BWhenever there is smoke, even if the exit is blocked
  3. COnly if the fire is small, the alarm is raised and the exit is clear
  4. DAlways, even before the alarm has been raised, to save time
4.Infection control & patient safetyHard

A patient sitting in a chair starts to have a generalized seizure. What should the nurse do?

  1. AHold the patient firmly in the chair until the seizure stops
  2. BLeave to get the provider, then return
  3. CEase the patient to the floor, protect the head and turn them on their side
  4. DPut a padded tongue blade between the teeth to protect the tongue and airway
5.Lab values & electrolytesMedium

A patient with joint aches has a positive antinuclear antibody (ANA) test. Which statement is correct?

  1. AA positive ANA means the patient has a viral infection
  2. BA positive ANA proves the patient has rheumatoid arthritis
  3. CA positive ANA rules out all other autoimmune diseases
  4. DA positive ANA supports lupus but does not diagnose it alone
6.Lab values & electrolytesHard

A patient has fever, confusion, a platelet count of 15 × 10³/µL, anemia with fragmented red cells (schistocytes) and a raised creatinine. Clotting times are normal. Which condition should be suspected?

  1. ADisseminated intravascular coagulation
  2. BVitamin K deficiency with bleeding
  3. CThrombotic thrombocytopenic purpura (TTP)
  4. DImmune thrombocytopenia (ITP)
7.Clinical nursingMedium

A patient with hyponatraemia should be especially monitored for:

  1. ABright red rash
  2. BIncreased hair growth
  3. CConfusion, headache and seizures
  4. DHearing loss
8.Clinical nursingHard

A nurse phones a doctor about a deteriorating patient using SBAR. Which statement belongs in the "R" section?

  1. A"Please review him within the next 15 minutes."
  2. B"His blood pressure is 85/50 and he is confused."
  3. C"He was admitted three days ago with pneumonia."
  4. D"I am calling about Mr Smith, who is breathless."
9.Med-surg: cardiovascular & respiratoryMedium

Why is a higher level of HDL cholesterol considered protective?

  1. AHDL carries cholesterol from the tissues back to the liver
  2. BHDL is converted into vitamin D in the walls of the arteries
  3. CHDL lowers the blood pressure directly
  4. DHDL thins the blood in the same way as an anticoagulant
10.Med-surg: cardiovascular & respiratoryHard

A patient with COPD on a 28% Venturi mask (SpO₂ 90%) wants to eat a meal. What is the most appropriate plan?

  1. ARemove all oxygen during the meal and replace it afterwards
  2. BChange to a non-rebreather mask at 15 L/min during the meal
  3. CKeep the Venturi mask on and give only liquids through a straw
  4. DSwitch to nasal cannula at low flow, keeping SpO₂ at 88–92%
11.Med-surg: neuro, endocrine & renalMedium

A stroke patient speaks fluently, but the words make little sense, and they do not follow simple instructions. Which type of aphasia is this?

  1. AExpressive (Broca's) aphasia
  2. BDysarthria from facial weakness
  3. CReceptive (Wernicke's) aphasia
  4. DGlobal aphasia with no speech at all
12.Med-surg: neuro, endocrine & renalHard

A patient's chronic hyponatraemia was corrected from 115 to 132 mmol/L in 24 hours. Two days later they develop slurred speech, difficulty swallowing and limb weakness. What is the most likely cause?

  1. AOsmotic demyelination syndrome
  2. BNormal recovery from hyponatraemia
  3. CA new stroke unrelated to the sodium
  4. DHypoglycaemia from poor intake
13.Med-surg: GI, perioperative & oncologyMedium

How are skin staples usually removed from a healed incision?

  1. AOnly the staples at each end, leaving the others for good
  2. BThe staples are left in permanently under the skin
  3. CAll staples at once by pulling each one straight up from the skin
  4. DAlternate staples first, then the rest if the wound holds
14.Med-surg: GI, perioperative & oncologyHard

Which medicine commonly needs enteral feeds paused before and after each dose because the feed reduces its absorption?

  1. ALactulose
  2. BOmeprazole liquid
  3. CPhenytoin
  4. DParacetamol

3Solutions

1.Prioritization & delegation

Answer: A · Antihypertensive drugs

Why this is the answer

Removing fluid during dialysis can cause hypotension, so blood pressure drugs are often held before treatment as prescribed. Some drugs are also removed by dialysis and given afterwards.

Answer

A · Antihypertensive drugs
2.Prioritization & delegation

Answer: B · The suspected tension pneumothorax

Why this is the answer

A shifted trachea, absent breath sounds and hypotension suggest tension pneumothorax, which threatens breathing and circulation within minutes. The fracture is important, but it comes after the immediate life threat.

Answer

B · The suspected tension pneumothorax
3.Infection control & patient safety

Answer: C · Only if the fire is small, the alarm is raised and the exit is clear

Why this is the answer

Staff may attempt to put out a small, contained fire once people are safe and the alarm has been raised, keeping an exit behind them. Otherwise, they close doors and evacuate.

Answer

C · Only if the fire is small, the alarm is raised and the exit is clear
4.Infection control & patient safety

Answer: C · Ease the patient to the floor, protect the head and turn them on their side

Why this is the answer

The nurse guides the patient gently to the floor, cushions the head, moves objects away and turns the patient on their side to protect the airway. The nurse stays, times the seizure and calls for help.

Answer

C · Ease the patient to the floor, protect the head and turn them on their side
5.Lab values & electrolytes

Answer: D · A positive ANA supports lupus but does not diagnose it alone

Why this is the answer

Almost all patients with SLE have a positive ANA, so a negative test makes lupus unlikely. However, many healthy people and patients with other conditions also have a positive ANA, so diagnosis needs the clinical picture and more specific antibodies such as anti-dsDNA.Checked against: ANA (Antinuclear Antibody) Test · MedlinePlus (NIH) (2025)

Answer

D · A positive ANA supports lupus but does not diagnose it alone
6.Lab values & electrolytes

Answer: C · Thrombotic thrombocytopenic purpura (TTP)

Why this is the answer

TTP causes small clots that consume platelets, break red cells (microangiopathic hemolysis) and damage the brain and kidneys, while clotting times usually stay normal. It is an emergency treated with plasma exchange; platelet transfusion is generally avoided.Checked against: Thrombotic thrombocytopenic purpura · MedlinePlus (NIH) (2025)

Answer

C · Thrombotic thrombocytopenic purpura (TTP)
7.Clinical nursing

Answer: C · Confusion, headache and seizures

Why this is the answer

Low sodium causes water to move into brain cells, leading to nausea, headache, confusion and in severe cases seizures. It must be corrected slowly to avoid osmotic demyelination.

Answer

C · Confusion, headache and seizures
8.Clinical nursing

Answer: A · "Please review him within the next 15 minutes."

Why this is the answer

In SBAR, R is the recommendation or request, such as a review within a time frame. The other statements belong to Assessment, Background and Situation.

Answer

A · "Please review him within the next 15 minutes."
9.Med-surg: cardiovascular & respiratory

Answer: A · HDL carries cholesterol from the tissues back to the liver

Why this is the answer

HDL transports cholesterol from the tissues and artery walls to the liver for removal (reverse cholesterol transport), so higher levels are linked with lower cardiovascular risk. LDL carries cholesterol to tissues and drives atherosclerosis.

Answer

A · HDL carries cholesterol from the tissues back to the liver
10.Med-surg: cardiovascular & respiratory

Answer: D · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%

Why this is the answer

Oxygen is prescribed to a target range and should not be stopped for meals in a patient who needs it. Nasal cannulae allow eating and talking; the flow (for example 1–2 L/min) is titrated to keep the saturation in the target range. High-concentration oxygen risks hypercapnia.

Answer

D · Switch to nasal cannula at low flow, keeping SpO₂ at 88–92%
11.Med-surg: neuro, endocrine & renal

Answer: C · Receptive (Wernicke's) aphasia

Why this is the answer

Receptive aphasia comes from damage to Wernicke's area in the dominant temporal lobe. Speech is fluent but often meaningless, and comprehension is impaired. Patients are often unaware of their errors.

Answer

C · Receptive (Wernicke's) aphasia
12.Med-surg: neuro, endocrine & renal

Answer: A · Osmotic demyelination syndrome

Why this is the answer

Rapid correction of chronic hyponatraemia shrinks brain cells and can damage the myelin of the pons and other areas. Symptoms (dysarthria, dysphagia, quadriparesis, "locked-in" state) appear days later. This is why correction rates are limited and sodium is monitored closely.

Answer

A · Osmotic demyelination syndrome
13.Med-surg: GI, perioperative & oncology

Answer: D · Alternate staples first, then the rest if the wound holds

Why this is the answer

Removing alternate staples first allows the nurse to check that the wound edges stay together. If the wound is secure, the rest are removed, and adhesive strips can be applied for support.

Answer

D · Alternate staples first, then the rest if the wound holds
14.Med-surg: GI, perioperative & oncology

Answer: C · Phenytoin

Why this is the answer

Enteral feeds bind phenytoin and lower its levels, risking seizures. Feeds are usually paused around doses, as advised by the pharmacist, and drug levels are monitored.

Answer

C · Phenytoin

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