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

Which SBAR recommendation is the clearest?

  1. A“He seems a bit off tonight, so maybe you could come up and do something about it.”
  2. B“I would like you to see him within 15 minutes and consider a fluid bolus.”
  3. C“I just wanted to let you know about him.”
  4. D“I will keep watching him and call again tomorrow.”
2.Prioritization & delegationHard

A patient with heart failure is short of breath with crackles in both lungs. Which order of actions is correct?

  1. ALay the patient flat to rest, then start the IV maintenance fluids
  2. BWeigh the patient first, then reassess the breathing in four hours
  3. CGive the scheduled oral medicines first, then sit the patient up
  4. DSit up, give oxygen as prescribed, then call the provider
3.Infection control & patient safetyMedium

A patient with difficulty swallowing is prescribed an extended-release tablet. What should the nurse do?

  1. ADissolve the tablet in a glass of hot water
  2. BCut the tablet in half so it is easier to swallow
  3. CCrush the tablet finely and mix it into a spoonful of applesauce or yogurt
  4. DAsk the prescriber or pharmacist for another form and not crush the tablet
4.Infection control & patient safetyHard

A patient on oxygen needs an MRI scan. Which plan is safe?

  1. ARemove the oxygen for the scan without telling anyone
  2. BTake the usual steel cylinder into the room if it is tightly strapped to the trolley frame
  3. CUse only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room
  4. DLeave the steel cylinder on the patient’s bed during the scan
5.Lab values & electrolytesMedium

A patient on a heparin infusion has an aPTT of 110 seconds; the protocol target is 1.5–2.5 times the control of 30 seconds. What should the nurse do?

  1. AGive vitamin K as prescribed and continue the infusion
  2. BFollow the heparin protocol, check for bleeding and inform the provider
  3. CIncrease the infusion rate, because the result is above the target range
  4. DContinue unchanged and repeat the aPTT the next morning
6.Lab values & electrolytesHard

A patient with severe hypertriglyceridemia has a measured sodium of 128 mEq/L, but a measured serum osmolality is normal, and the patient has no symptoms. What is the most likely explanation?

  1. AHyponatremia caused by drinking far too much water
  2. BPseudohyponatremia, an artifact caused by very high lipids
  3. CTrue hyponatremia from SIADH that needs fluid restriction
  4. DHyponatremia caused by severe hyperglycemia in diabetes
7.Clinical nursingMedium

A patient has a fentanyl patch for chronic pain. Which advice is correct?

  1. ACut the patch in half if the pain improves, to lower the dose
  2. BAvoid heat sources such as hot water bottles over the patch
  3. CApply the patch to broken skin for faster effect
  4. DKeep using the old patch with the new one
8.Clinical nursingHard

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

  1. A"My output will be firm and formed like before."
  2. B"I will drink extra fluids when it is hot."
  3. C"I will empty the bag when it is about a third to half full."
  4. D"My stoma should look pink or red and moist."
9.Med-surg: cardiovascular & respiratoryMedium

A patient with angle-closure glaucoma needs nebulised ipratropium. What precaution is sensible?

  1. AGive it only with the patient lying completely flat
  2. BUse a mouthpiece or protect the eyes from the mist
  3. CRun it at the highest possible gas flow
  4. DMix it with an eye drop before putting it in the nebuliser
10.Med-surg: cardiovascular & respiratoryHard

A patient with heart failure is breathless at rest, with cool peripheries, a systolic BP of 80 mmHg and falling urine output. What does this suggest?

  1. AStable, well-compensated chronic heart failure
  2. BMild dehydration that oral fluids will correct
  3. CAnxiety causing a vasovagal response
  4. DCardiogenic shock with poor tissue perfusion
11.Med-surg: neuro, endocrine & renalMedium

An 80-year-old with angina is diagnosed with hypothyroidism. How is levothyroxine usually started?

  1. AAt a low dose, increased slowly
  2. BAt a full dose from the first day
  3. CAs a single large weekly injection
  4. DOnly after the angina has been cured
12.Med-surg: neuro, endocrine & renalHard

A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6.9 mmol/L. What is the priority?

  1. AOral potassium supplements and rest
  2. BLarge IV fluid boluses to improve the circulation
  3. CUrgent dialysis, with cardiac monitoring meanwhile
  4. DA routine dialysis session at the next planned slot
13.Med-surg: GI, perioperative & oncologyMedium

Which statement about pain relief in acute pancreatitis is correct?

  1. APain relief should be withheld until the diagnosis is certain
  2. BOpioids can be used, and good analgesia is a priority
  3. COpioids must never be used in pancreatitis
  4. DOnly paracetamol may be given
14.Med-surg: GI, perioperative & oncologyHard

Two days after surgery, a patient on regular ibuprofen has a low urine output and a rising creatinine, and intake has been poor. What should the nurse do?

  1. AChange to a higher-strength NSAID tablet
  2. BWithhold the next dose and report to the prescriber
  3. CIncrease the dose to treat the pain better and encourage fluids
  4. DGive the next dose with extra food

3Solutions

1.Prioritization & delegation

Answer: B · “I would like you to see him within 15 minutes and consider a fluid bolus.”

Why this is the answer

A good recommendation is specific about the request and the time frame. Vague statements leave the provider unsure how urgent the problem is.

Answer

B · “I would like you to see him within 15 minutes and consider a fluid bolus.”
2.Prioritization & delegation

Answer: D · Sit up, give oxygen as prescribed, then call the provider

Why this is the answer

Sitting upright reduces the return of blood to the heart and eases breathing, and oxygen treats hypoxia. Then the provider is called and diuretics are prepared. Lying flat or giving IV fluids makes pulmonary congestion worse.

Answer

D · Sit up, give oxygen as prescribed, then call the provider
3.Infection control & patient safety

Answer: D · Ask the prescriber or pharmacist for another form and not crush the tablet

Why this is the answer

Crushing or splitting an extended-release product can release the whole dose at once and cause toxicity. The nurse asks for a suitable alternative, such as a liquid or immediate-release form.

Answer

D · Ask the prescriber or pharmacist for another form and not crush the tablet
4.Infection control & patient safety

Answer: C · Use only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room

Why this is the answer

Steel oxygen cylinders can become projectiles in an MRI room and cause fatal injuries. Only equipment labeled MRI-safe is used, and the patient’s oxygen needs are planned with the MRI team.

Answer

C · Use only MRI-safe equipment, and never take a standard steel oxygen cylinder into the scanner room
5.Lab values & electrolytes

Answer: B · Follow the heparin protocol, check for bleeding and inform the provider

Why this is the answer

110 s is well above the target of about 45–75 s, so the bleeding risk is high. The nurse follows the heparin protocol, assesses for bleeding and informs the provider. Protamine is the reversal agent for heparin; vitamin K reverses warfarin.Checked against: Partial Thromboplastin Time (PTT) Test · MedlinePlus (NIH) (2026)

Answer

B · Follow the heparin protocol, check for bleeding and inform the provider
6.Lab values & electrolytes

Answer: B · Pseudohyponatremia, an artifact caused by very high lipids

Why this is the answer

Very high lipids or proteins take up part of the plasma volume, so some laboratory methods report a falsely low sodium. The osmolality and the sodium measured by direct methods are normal. Treating this "hyponatremia" would be harmful.

Answer

B · Pseudohyponatremia, an artifact caused by very high lipids
7.Clinical nursing

Answer: B · Avoid heat sources such as hot water bottles over the patch

Why this is the answer

Heat increases absorption of fentanyl through the skin and can cause overdose. Old patches are removed and folded before disposal, and patches should not be cut unless the product allows it.

Answer

B · Avoid heat sources such as hot water bottles over the patch
8.Clinical nursing

Answer: A · "My output will be firm and formed like before."

Why this is the answer

Ileostomy output is liquid to porridge-like because it bypasses the colon. The other statements describe correct care: good hydration, emptying the bag before it is too heavy and recognising a healthy stoma.

Answer

A · "My output will be firm and formed like before."
9.Med-surg: cardiovascular & respiratory

Answer: B · Use a mouthpiece or protect the eyes from the mist

Why this is the answer

Ipratropium is an antimuscarinic bronchodilator. Mist escaping from a face mask can reach the eyes, dilate the pupil and trigger acute angle-closure glaucoma in susceptible patients. A mouthpiece or eye protection reduces the risk.

Answer

B · Use a mouthpiece or protect the eyes from the mist
10.Med-surg: cardiovascular & respiratory

Answer: D · Cardiogenic shock with poor tissue perfusion

Why this is the answer

Cardiogenic shock is pump failure with hypotension and hypoperfusion (cool skin, oliguria, confusion, raised lactate), often with pulmonary congestion. It needs urgent critical care review. Large fluid boluses can worsen congestion unless guided by careful assessment.

Answer

D · Cardiogenic shock with poor tissue perfusion
11.Med-surg: neuro, endocrine & renal

Answer: A · At a low dose, increased slowly

Why this is the answer

Levothyroxine raises metabolic rate and myocardial oxygen demand. In older people and those with heart disease, a low starting dose that is increased gradually reduces the risk of angina and arrhythmias.

Answer

A · At a low dose, increased slowly
12.Med-surg: neuro, endocrine & renal

Answer: C · Urgent dialysis, with cardiac monitoring meanwhile

Why this is the answer

Missing dialysis causes fluid overload and hyperkalaemia, both of which can be fatal. The patient needs cardiac monitoring, emergency treatment of the potassium and urgent dialysis to remove fluid and potassium.

Answer

C · Urgent dialysis, with cardiac monitoring meanwhile
13.Med-surg: GI, perioperative & oncology

Answer: B · Opioids can be used, and good analgesia is a priority

Why this is the answer

Acute pancreatitis is very painful, and opioids are used as part of multimodal analgesia. There is no good evidence that they worsen the condition. Sedation and breathing are monitored.

Answer

B · Opioids can be used, and good analgesia is a priority
14.Med-surg: GI, perioperative & oncology

Answer: B · Withhold the next dose and report to the prescriber

Why this is the answer

NSAIDs can cause acute kidney injury, particularly with hypovolaemia, older age or other nephrotoxic drugs. The nurse withholds and reports, and fluid status and other analgesia are reviewed.

Answer

B · Withhold the next dose and report to the prescriber

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