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 taking warfarin has an INR of 5.2 and no signs of bleeding. What should the nurse do?

  1. AGive the usual dose and recheck the INR next month
  2. BGive a double dose to correct the result
  3. CEncourage the patient to take aspirin for pain
  4. DHold the warfarin dose and inform the provider
2.Prioritization & delegationHard

During START triage, an adult is not breathing. The airway is repositioned and the victim still does not breathe. What is the correct category?

  1. AYellow, and come back later
  2. BBlack (deceased or expectant)
  3. CRed, because no breathing is the most urgent finding
  4. DRed, and start CPR at once
3.Infection control & patient safetyMedium

A nurse gives part of a dose of an opioid from a vial and must discard the rest. What is correct?

  1. AReturn the rest to the patient’s medication drawer
  2. BDiscard it alone in the sink and document the amount wasted later in the shift
  3. CDiscard it in front of a second licensed (registered) nurse, who witnesses and documents it
  4. DKeep the rest for the patient’s next dose
4.Infection control & patient safetyHard

A patient’s white cell differential shows a raised number of band (immature) neutrophils, called a “shift to the left”. What does this usually suggest?

  1. AA typical viral infection
  2. BAn allergic reaction
  3. CAn acute bacterial infection
  4. DA long-standing parasitic infection
5.Lab values & electrolytesMedium

A patient with schizophrenia is starting clozapine. Which laboratory value must be monitored regularly?

  1. AAbsolute neutrophil count
  2. BInternational normalized ratio
  3. CSerum amylase
  4. DSerum lithium level
6.Lab values & electrolytesHard

A patient with severe vomiting has a potassium of 3.0 mEq/L, a chloride of 88 mEq/L and a high bicarbonate. What pattern does this show?

  1. AHigh potassium with metabolic acidosis caused by dehydration
  2. BLoss of stomach acid: low potassium and chloride, metabolic alkalosis
  3. CDiabetic ketoacidosis with a high anion gap
  4. DNormal results that need no follow-up
7.Clinical nursingMedium

A patient receiving warfarin has an INR far above the target range and bruising. Which drug may be prescribed to reverse the effect?

  1. ANaloxone
  2. BProtamine sulfate
  3. CAspirin
  4. DVitamin K
8.Clinical nursingHard

A patient's hypoglycaemia was caused by a sulfonylurea such as gliclazide or glipizide. Why might they need monitoring for longer than usual?

  1. ASulfonylureas act for a long time, so hypoglycaemia can recur
  2. BSulfonylureas only work at night
  3. CThe drug makes glucose tablets and drinks ineffective
  4. DThe drug causes rebound hyperglycaemia later the same day
9.Med-surg: cardiovascular & respiratoryMedium

A patient on furosemide has a serum potassium of 3.0 mmol/L (3.0 mEq/L). Which symptoms may this cause?

  1. ASevere headache and a stiff neck
  2. BMuscle weakness, cramps and an irregular pulse
  3. CTingling around the lips and painful spasm of the hands
  4. DFacial flushing, fever and a skin rash
10.Med-surg: cardiovascular & respiratoryHard

A patient with chest pain has ST elevation in leads II, III and aVF. BP is 86/54 mmHg, the lungs are clear and the neck veins are distended. Which prescribed medicine should the nurse question?

  1. AAn IV antiemetic
  2. BSublingual glyceryl trinitrate
  3. COxygen if SpO₂ falls below target
  4. DChewed aspirin 300 mg
11.Med-surg: neuro, endocrine & renalMedium

Which headache feature most suggests raised intracranial pressure from a brain tumour?

  1. ABetter in the morning and worse with stress
  2. BA tight band across the forehead that eases with rest
  3. COnly present after reading for a long time
  4. DWorse on waking and on coughing, with vomiting
12.Med-surg: neuro, endocrine & renalHard

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

  1. AA patient on insulin for DKA whose potassium is now 2.9 mmol/L
  2. BA patient with hypothyroidism asking when to take levothyroxine
  3. CA patient with Parkinson's disease whose next dose is due in two hours
  4. DA patient with stable CKD waiting for a renal diet review
13.Med-surg: GI, perioperative & oncologyMedium

In the SBAR communication tool, what belongs under "A"?

  1. AThe patient's admission date only
  2. BThe address and phone number of the patient's next of kin
  3. CThe nurse's assessment of what the problem is
  4. DA list of the patient's allergies only
14.Med-surg: GI, perioperative & oncologyHard

An adult weighing 70 kg has 40% total body surface area burns. Using the Parkland formula, how is the first 24 hours' crystalloid usually divided?

  1. AEqual hourly amounts over 24 hours, counted from arrival at hospital
  2. BOne quarter in the first 8 hours from arrival, the rest over 16 hours
  3. CHalf in the first 8 hours from the time of the burn, half over the next 16 hours
  4. DAll of it in the first hour, then oral fluids only for the rest of the day

3Solutions

1.Prioritization & delegation

Answer: D · Hold the warfarin dose and inform the provider

Why this is the answer

An INR well above target raises the risk of serious bleeding. The nurse holds the dose, informs the provider and watches for bleeding. Without bleeding, holding warfarin is usually enough at this level; vitamin K is mainly used for very high INRs or bleeding.

Answer

D · Hold the warfarin dose and inform the provider
2.Prioritization & delegation

Answer: B · Black (deceased or expectant)

Why this is the answer

In START, a victim who does not breathe after the airway is repositioned is tagged black. CPR for one person would take rescuers away from many others who could survive. If breathing starts after repositioning, the victim is red.

Answer

B · Black (deceased or expectant)
3.Infection control & patient safety

Answer: C · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it

Why this is the answer

Wasting controlled substances requires a witness, usually another licensed nurse, and both document the waste. This prevents and detects drug diversion.

Answer

C · Discard it in front of a second licensed (registered) nurse, who witnesses and documents it
4.Infection control & patient safety

Answer: C · An acute bacterial infection

Why this is the answer

In acute bacterial infection, the bone marrow releases neutrophils before they mature, raising the proportion of bands. Allergies and parasites raise eosinophils, and viral infections more often raise lymphocytes.

Answer

C · An acute bacterial infection
5.Lab values & electrolytes

Answer: A · Absolute neutrophil count

Why this is the answer

Clozapine can cause severe neutropenia (agranulocytosis), so the ANC is checked before starting and regularly during treatment. A sore throat, fever or other sign of infection must be reported at once.

Answer

A · Absolute neutrophil count
6.Lab values & electrolytes

Answer: B · Loss of stomach acid: low potassium and chloride, metabolic alkalosis

Why this is the answer

Vomiting removes hydrochloric acid, so chloride falls and bicarbonate rises (metabolic alkalosis). The kidneys then lose potassium. Replacement usually includes 0.9% sodium chloride with potassium as prescribed.

Answer

B · Loss of stomach acid: low potassium and chloride, metabolic alkalosis
7.Clinical nursing

Answer: D · Vitamin K

Why this is the answer

Warfarin inhibits vitamin K-dependent clotting factors. Vitamin K, and for major bleeding prothrombin complex concentrate, reverse it. Protamine reverses heparin.

Answer

D · Vitamin K
8.Clinical nursing

Answer: A · Sulfonylureas act for a long time, so hypoglycaemia can recur

Why this is the answer

Sulfonylureas stimulate insulin release and have a long duration of action. Hypoglycaemia can be prolonged or recur, so glucose is monitored closely after treatment.

Answer

A · Sulfonylureas act for a long time, so hypoglycaemia can recur
9.Med-surg: cardiovascular & respiratory

Answer: B · Muscle weakness, cramps and an irregular pulse

Why this is the answer

The adult reference range is about 3.5–5.0 mmol/L, so 3.0 mmol/L is low. Hypokalaemia causes weakness, cramps, constipation and arrhythmias, with flattened T waves and U waves on the ECG. Tingling lips and hand spasm suggest low calcium.

Answer

B · Muscle weakness, cramps and an irregular pulse
10.Med-surg: cardiovascular & respiratory

Answer: B · Sublingual glyceryl trinitrate

Why this is the answer

Inferior STEMI with hypotension, raised JVP and clear lungs suggests right ventricular infarction. These patients depend on preload, and nitrates can cause profound hypotension; a systolic pressure below 90 mmHg is itself a reason to withhold them. Aspirin is still indicated, and urgent reperfusion is the definitive treatment.

Answer

B · Sublingual glyceryl trinitrate
11.Med-surg: neuro, endocrine & renal

Answer: D · Worse on waking and on coughing, with vomiting

Why this is the answer

Headaches from raised ICP are often worse on waking, when coughing, sneezing or bending, and may come with vomiting or visual changes. A new headache with these features needs prompt assessment.

Answer

D · Worse on waking and on coughing, with vomiting
12.Med-surg: neuro, endocrine & renal

Answer: A · A patient on insulin for DKA whose potassium is now 2.9 mmol/L

Why this is the answer

Insulin drives potassium into cells, and a potassium of 2.9 mmol/L during DKA treatment can cause life-threatening arrhythmias. The insulin rate and potassium replacement need urgent review under the protocol. The other patients are stable.

Answer

A · A patient on insulin for DKA whose potassium is now 2.9 mmol/L
13.Med-surg: GI, perioperative & oncology

Answer: C · The nurse's assessment of what the problem is

Why this is the answer

SBAR is Situation, Background, Assessment and Recommendation. Under Assessment, the nurse gives the findings and their interpretation, for example "I think the patient may be bleeding".

Answer

C · The nurse's assessment of what the problem is
14.Med-surg: GI, perioperative & oncology

Answer: C · Half in the first 8 hours from the time of the burn, half over the next 16 hours

Why this is the answer

Parkland gives 4 × 70 × 40 = 11 200 mL in 24 hours. Half (5600 mL) is given in the first 8 hours counted from the time of the burn, not from arrival, and the rest over 16 hours. The rate is then adjusted to urine output.

Answer

C · Half in the first 8 hours from the time of the burn, half over the next 16 hours

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