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 patient is most appropriate to assign to an LPN/LVN?

  1. AA patient arriving from the recovery room who needs an initial assessment
  2. BA patient admitted 30 minutes ago with new chest pain
  3. CA patient with stable chronic heart failure who needs oral medications
  4. DA patient about to receive a first unit of red blood cells
2.Prioritization & delegationHard

After a head injury, a patient passes large amounts of very dilute urine, is thirsty and has a rising serum sodium. Which condition is most likely?

  1. ADiabetic ketoacidosis
  2. BSIADH
  3. CDiabetes insipidus
  4. DAcute kidney injury with oliguria
3.Infection control & patient safetyMedium

Two patients infected with the same organism are admitted, and no single room is available. What is an accepted option?

  1. APlacing each with a patient who has a weakened immune system
  2. BPlacing them in the corridor
  3. CCohorting them in the same room, according to infection control advice
  4. DStopping contact precautions
4.Infection control & patient safetyHard

A competent adult patient with pneumonia wants to leave the hospital against medical advice. What should the nurse do?

  1. AHide the patient’s clothes and belongings so that they cannot leave the ward
  2. BLock the doors so the patient cannot leave
  3. CApply wrist restraints until the provider arrives to speak with the patient
  4. DExplain the risks, notify the provider and follow the policy for leaving against advice
5.Lab values & electrolytesMedium

A patient's eGFR has fallen to 24 mL/min/1.73 m². Which prescribed drug should the nurse question before giving it?

  1. ALevothyroxine
  2. BAcetaminophen (paracetamol)
  3. CInsulin glargine
  4. DMetformin
6.Lab values & electrolytesHard

A patient on IV gentamicin has a trough level above the target, and the creatinine has risen since yesterday. The next dose is due. What is the best action?

  1. AGive half of the dose and document the reason for it
  2. BHold the dose and report the results to the prescriber
  3. CGive the dose now and recheck the levels next week
  4. DGive the dose with extra oral fluids to protect the kidneys
7.Clinical nursingMedium

Which statement about storing insulin is correct?

  1. AInsulin never expires once opened
  2. BUnopened insulin is kept in the fridge and must not be frozen
  3. CAll insulin should be stored in the freezer to keep it fresh
  4. DInsulin should be kept in direct sunlight
8.Clinical nursingHard

A nurse realises she has given a patient a medicine prescribed for another patient. What should she do first?

  1. AGive the patient's own medicine as well to balance it
  2. BAsk a colleague not to mention it
  3. CCheck the patient's condition and inform the doctor
  4. DWait to see whether any side effects develop
9.Med-surg: cardiovascular & respiratoryMedium

How should a patient breathe in when using a pressurised metered-dose inhaler without a spacer?

  1. AAs hard and fast as possible, then press the canister afterwards
  2. BSlowly and deeply while pressing the canister, then hold the breath
  3. CIn short gasps through the nose while pressing the canister
  4. DNormally, while breathing out through the mouthpiece
10.Med-surg: cardiovascular & respiratoryHard

A patient with pneumonia on high-flow nasal oxygen at 50 L/min with FiO₂ 0.6 has SpO₂ 90%, RR 34/min and is using accessory muscles. What is the most appropriate action?

  1. AEscalate urgently to critical care for review of respiratory support
  2. BChange to a nasal cannula at 4 L/min to reduce nasal dryness
  3. CContinue the same support and recheck in four hours
  4. DLay the patient flat so they can rest the breathing muscles
11.Med-surg: neuro, endocrine & renalMedium

A patient on ciclosporin or tacrolimus asks about grapefruit juice. Which advice is correct?

  1. ADrink it daily to protect the kidney
  2. BAvoid it, because it can raise the drug levels
  3. CIt has no effect on these drugs
  4. DDrink it with each dose to improve the absorption
12.Med-surg: neuro, endocrine & renalHard

After surgery, a patient with Graves' disease has a temperature of 39.8 °C, a heart rate of 160/min, agitation and vomiting. Which treatment set is most appropriate?

  1. AAspirin for the fever and a review by the GP within a week
  2. BCooling, a beta-blocker, an antithyroid drug, then iodine and steroids
  3. CFluid restriction and a loop diuretic to treat the tachycardia
  4. DLevothyroxine and warm blankets to settle the shivering
13.Med-surg: GI, perioperative & oncologyMedium

Which description fits a category (stage) 4 pressure ulcer?

  1. AIntact skin with redness that does not blanch
  2. BA blister filled with clear fluid over the heel or sacrum
  3. CA shallow wound into the dermis only
  4. DFull-thickness loss with exposed bone, tendon or muscle
14.Med-surg: GI, perioperative & oncologyHard

A patient has negative pressure wound therapy. The pump alarms and the dressing has lost its seal. What is the most appropriate action?

  1. ATurn the suction up to its maximum setting to pull the seal back
  2. BPack the wound with dry gauze over the foam and tape it tightly
  3. CLeave the foam in the wound without suction for several days until review
  4. DRestore the seal; if that fails in time, change to a moist dressing

3Solutions

1.Prioritization & delegation

Answer: C · A patient with stable chronic heart failure who needs oral medications

Why this is the answer

Stable chronic heart failure with routine oral medicines is predictable care. New chest pain, the start of a transfusion and the first assessment after surgery need RN assessment.

Answer

C · A patient with stable chronic heart failure who needs oral medications
2.Prioritization & delegation

Answer: C · Diabetes insipidus

Why this is the answer

Damage to the pituitary or hypothalamus can stop the release of antidiuretic hormone, causing diabetes insipidus. The patient loses water, so urine is dilute and sodium rises; SIADH causes the opposite.

Answer

C · Diabetes insipidus
3.Infection control & patient safety

Answer: C · Cohorting them in the same room, according to infection control advice

Why this is the answer

When single rooms are short, patients with the same organism (and no other infections) can share a room (cohorting), with precautions continued. Infection control staff advise on this.

Answer

C · Cohorting them in the same room, according to infection control advice
4.Infection control & patient safety

Answer: D · Explain the risks, notify the provider and follow the policy for leaving against advice

Why this is the answer

Holding a competent adult against their will can be false imprisonment. The nurse explains the risks, informs the provider, asks the patient to sign the against-advice form if they agree and documents the discussion.

Answer

D · Explain the risks, notify the provider and follow the policy for leaving against advice
5.Lab values & electrolytes

Answer: D · Metformin

Why this is the answer

Metformin is cleared by the kidneys, and it is contraindicated when the eGFR is below 30 mL/min/1.73 m² because of the risk of lactic acidosis. Insulin doses may also need adjustment, but insulin is not contraindicated.

Answer

D · Metformin
6.Lab values & electrolytes

Answer: B · Hold the dose and report the results to the prescriber

Why this is the answer

A high aminoglycoside trough with rising creatinine means the drug is accumulating, which increases the risk of kidney damage and hearing loss. The nurse holds the dose, reports to the prescriber and asks about hearing changes and tinnitus. Only the prescriber or pharmacist changes the regimen.Checked against: Gentamicin sulfate injection - Boxed Warning (US prescribing information) · Pfizer Medical Information (FDA label)

Answer

B · Hold the dose and report the results to the prescriber
7.Clinical nursing

Answer: B · Unopened insulin is kept in the fridge and must not be frozen

Why this is the answer

Unopened insulin is refrigerated; in-use pens or vials are usually kept at room temperature for a limited time stated by the manufacturer. Frozen or overheated insulin must be discarded.

Answer

B · Unopened insulin is kept in the fridge and must not be frozen
8.Clinical nursing

Answer: C · Check the patient's condition and inform the doctor

Why this is the answer

The first priority is the patient: assess them and inform the prescriber so that any treatment can be given. The error must then be documented, reported and discussed openly with the patient (open disclosure; in the UK, the statutory duty of candour).

Answer

C · Check the patient's condition and inform the doctor
9.Med-surg: cardiovascular & respiratory

Answer: B · Slowly and deeply while pressing the canister, then hold the breath

Why this is the answer

With a metered-dose inhaler, the patient breathes out, starts a slow deep breath, presses the canister at the start of it and then holds the breath for about 10 seconds. Coordination is difficult, which is why spacers are often used.

Answer

B · Slowly and deeply while pressing the canister, then hold the breath
10.Med-surg: cardiovascular & respiratory

Answer: A · Escalate urgently to critical care for review of respiratory support

Why this is the answer

High oxygen requirements with tachypnoea and increased work of breathing despite high-flow oxygen indicate worsening respiratory failure. Early critical care review is needed for escalation such as CPAP, NIV or intubation. Reducing support or waiting risks a respiratory arrest.

Answer

A · Escalate urgently to critical care for review of respiratory support
11.Med-surg: neuro, endocrine & renal

Answer: B · Avoid it, because it can raise the drug levels

Why this is the answer

Grapefruit inhibits the CYP3A4 enzyme and can raise ciclosporin and tacrolimus levels, leading to toxicity. Patients are advised to avoid it, and to check before starting any new medicine or supplement.

Answer

B · Avoid it, because it can raise the drug levels
12.Med-surg: neuro, endocrine & renal

Answer: B · Cooling, a beta-blocker, an antithyroid drug, then iodine and steroids

Why this is the answer

Thyroid storm is life-threatening. Treatment includes supportive care and cooling, beta-blockade for adrenergic symptoms, a thionamide (often propylthiouracil) to block synthesis, iodine given after the thionamide to block hormone release, and corticosteroids. Aspirin is avoided because it can increase free thyroid hormone.

Answer

B · Cooling, a beta-blocker, an antithyroid drug, then iodine and steroids
13.Med-surg: GI, perioperative & oncology

Answer: D · Full-thickness loss with exposed bone, tendon or muscle

Why this is the answer

Category 4 has full-thickness loss with exposed bone, tendon or muscle and often undermining or tunnelling. Category 3 reaches the fat but does not expose bone, tendon or muscle.

Answer

D · Full-thickness loss with exposed bone, tendon or muscle
14.Med-surg: GI, perioperative & oncology

Answer: D · Restore the seal; if that fails in time, change to a moist dressing

Why this is the answer

NPWT needs an airtight seal. If the seal or suction is lost and cannot be restored promptly (many guidelines say within about 2 hours), the foam is removed and replaced with a standard dressing to reduce infection risk. Manufacturer and local guidance define the safe interval.

Answer

D · Restore the seal; if that fails in time, change to a moist dressing

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