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 finding is unexpected and needs prompt follow-up?

  1. AA patient on a heparin infusion has a new black, tarry stool
  2. BA patient one day after laparoscopic gallbladder surgery has right shoulder pain
  3. CA patient with long-standing COPD has a barrel-shaped chest
  4. DA patient with known cirrhosis has yellow skin that has not changed
2.Prioritization & delegationHard

A patient is receiving IV potassium chloride through a peripheral line and complains of burning at the site, which looks red. What does the nurse do first?

  1. ATell the patient that burning is expected and continue
  2. BIncrease the infusion rate to finish the dose sooner
  3. CStop the infusion and assess the IV site
  4. DApply a warm pack and continue the infusion
3.Infection control & patient safetyMedium

A peripheral IV site is red, warm and tender along the vein. What should the nurse do?

  1. ARemove the catheter and insert a new one at another site if still needed
  2. BApply a warm pack and keep using the same site
  3. CFlush the catheter harder to clear the vein and keep using the same site
  4. DIncrease the infusion rate to finish the bag sooner
4.Infection control & patient safetyHard

A nurse teaches a patient who has had a splenectomy. Which statement shows a need for further teaching?

  1. A“Now that my spleen is out, a fever is nothing to worry about.”
  2. B“I will keep my vaccinations up to date.”
  3. C“I will tell all of my health care providers that I have no spleen.”
  4. D“I will get medical help quickly if I get a high temperature.”
5.Lab values & electrolytesMedium

Which ECG change is linked to hypocalcemia?

  1. AA prominent delta wave
  2. BA shortened QT interval
  3. CTall, peaked T waves
  4. DA prolonged QT interval
6.Lab values & electrolytesHard

A patient with acute kidney injury after severe dehydration has a rising creatinine. Which urine findings support a prerenal cause rather than acute tubular necrosis (ATN)?

  1. ARed cell casts with heavy protein loss in the urine
  2. BLow urine sodium and concentrated urine with a high specific gravity
  3. CWhite cell casts with positive nitrites on the dipstick
  4. DHigh urine sodium and dilute urine with muddy brown granular casts
7.Clinical nursingMedium

A patient with Guillain–Barré syndrome has weakness spreading upwards from the legs. Which monitoring is most important?

  1. ABreathing function, such as forced vital capacity
  2. BVisual acuity
  3. CWeekly weight
  4. DBlood glucose, measured once a day before breakfast
8.Clinical nursingHard

Why might a patient with diabetes who takes a beta-blocker not notice hypoglycaemia early?

  1. ABeta-blockers raise blood glucose, so true hypoglycaemia cannot happen at all
  2. BBeta-blockers make the patient sleep through the night
  3. CBeta-blockers can mask warning signs such as tremor and a fast heart rate
  4. DBeta-blockers stop the liver from responding to insulin
9.Med-surg: cardiovascular & respiratoryMedium

What is the main difference between CPAP and bilevel NIV (often called BiPAP)?

  1. ACPAP is mainly used to lower a raised PaCO₂ in COPD exacerbations
  2. BCPAP is given only through a tracheostomy
  3. CBilevel NIV adds a higher inspiratory pressure, helping remove CO₂
  4. DBilevel NIV gives oxygen only, without any positive airway pressure
10.Med-surg: cardiovascular & respiratoryHard

A patient with heart failure has gained 2.5 kg in three days, has new crackles at both bases and now sleeps on four pillows. BP 138/84 mmHg, SpO₂ 93% on air. What is the priority?

  1. ALay the patient flat to rest the heart and lower demand
  2. BRecord the weight and check it again at the end of the next week
  3. CSit the patient up, assess fully and report the fluid overload
  4. DEncourage extra oral fluids to protect the kidneys
11.Med-surg: neuro, endocrine & renalMedium

When a patient sticks out their tongue, it points to the right. Which nerve is affected?

  1. AThe right facial nerve (VII)
  2. BThe left hypoglossal nerve (XII)
  3. CThe right hypoglossal nerve (XII)
  4. DThe left trigeminal nerve (V)
12.Med-surg: neuro, endocrine & renalHard

A patient with cranial diabetes insipidus starts desmopressin. Which complication should the nurse monitor for?

  1. ASevere diarrhoea
  2. BHyperglycaemia
  3. CHyperkalaemia
  4. DHyponatraemia
13.Med-surg: GI, perioperative & oncologyMedium

How does sucralfate help a peptic ulcer heal?

  1. AIt speeds up emptying of the stomach
  2. BIt kills H. pylori in the stomach lining
  3. CIt blocks histamine receptors on parietal cells
  4. DIt forms a protective coating over the ulcer base
14.Med-surg: GI, perioperative & oncologyHard

After forearm fracture surgery, a patient has severe pain not eased by opioids, made worse by passively moving the fingers. What should the nurse do?

  1. AApply ice and a tighter bandage to reduce the swelling
  2. BLoosen any tight dressing, keep the arm at heart level and escalate
  3. CRaise the arm as high as possible and give a further dose of opioid
  4. DReassure the patient that this pain is expected

3Solutions

1.Prioritization & delegation

Answer: A · A patient on a heparin infusion has a new black, tarry stool

Why this is the answer

Black, tarry stool (melena) suggests bleeding from the upper gut, a dangerous complication of anticoagulation. Shoulder pain after laparoscopy from the gas used is common, and a barrel chest in COPD and stable jaundice in cirrhosis are expected.

Answer

A · A patient on a heparin infusion has a new black, tarry stool
2.Prioritization & delegation

Answer: C · Stop the infusion and assess the IV site

Why this is the answer

Pain and redness suggest phlebitis or infiltration. The nurse stops the infusion, assesses the site and informs the provider. Continuing the infusion, or giving it faster, increases tissue damage.

Answer

C · Stop the infusion and assess the IV site
3.Infection control & patient safety

Answer: A · Remove the catheter and insert a new one at another site if still needed

Why this is the answer

Redness, warmth and tenderness along the vein indicate phlebitis, which can lead to infection. The catheter is removed and, if IV access is still needed, a new one is placed at a different site.

Answer

A · Remove the catheter and insert a new one at another site if still needed
4.Infection control & patient safety

Answer: A · “Now that my spleen is out, a fever is nothing to worry about.”

Why this is the answer

People without a spleen are at risk of overwhelming infection, especially from encapsulated bacteria. Fever needs prompt medical assessment, and vaccines are kept up to date.

Answer

A · “Now that my spleen is out, a fever is nothing to worry about.”
5.Lab values & electrolytes

Answer: D · A prolonged QT interval

Why this is the answer

Low calcium prolongs the QT interval, which can lead to dangerous arrhythmias. High calcium shortens the QT interval, and peaked T waves are typical of hyperkalemia.

Answer

D · A prolonged QT interval
6.Lab values & electrolytes

Answer: B · Low urine sodium and concentrated urine with a high specific gravity

Why this is the answer

In prerenal AKI the tubules are intact, so they keep sodium and water, giving a low urine sodium and concentrated urine. In ATN the damaged tubules cannot do this, so urine sodium is high, the urine is dilute and muddy brown casts appear.Checked against: Urine specific gravity test · MedlinePlus (NIH) (2025)

Answer

B · Low urine sodium and concentrated urine with a high specific gravity
7.Clinical nursing

Answer: A · Breathing function, such as forced vital capacity

Why this is the answer

Guillain–Barré syndrome can paralyse the respiratory muscles. Serial vital capacity measurements help identify patients who need ventilation before they deteriorate.

Answer

A · Breathing function, such as forced vital capacity
8.Clinical nursing

Answer: C · Beta-blockers can mask warning signs such as tremor and a fast heart rate

Why this is the answer

Tremor, palpitations and anxiety in hypoglycaemia are driven by the sympathetic system, which beta-blockers blunt. Sweating is often still present, and patients need to monitor glucose closely.

Answer

C · Beta-blockers can mask warning signs such as tremor and a fast heart rate
9.Med-surg: cardiovascular & respiratory

Answer: C · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂

Why this is the answer

CPAP gives one continuous pressure that splints the airways and alveoli open, improving oxygenation (for example in pulmonary oedema or OSA). Bilevel NIV adds a higher inspiratory pressure that supports ventilation, so it is used for hypercapnic respiratory failure such as COPD exacerbations.

Answer

C · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂
10.Med-surg: cardiovascular & respiratory

Answer: C · Sit the patient up, assess fully and report the fluid overload

Why this is the answer

Rapid weight gain with crackles and orthopnoea indicates fluid overload and worsening heart failure. Sitting upright reduces venous return and eases breathing. The nurse completes an assessment (oxygen trend, fluid balance, oedema) and escalates so the prescriber can adjust diuretics. More fluid or lying flat would worsen congestion.

Answer

C · Sit the patient up, assess fully and report the fluid overload
11.Med-surg: neuro, endocrine & renal

Answer: C · The right hypoglossal nerve (XII)

Why this is the answer

With a lower motor neuron lesion of the hypoglossal nerve, the tongue deviates towards the side of the lesion, because the healthy muscles push it across. Wasting and fasciculation of that side may also be seen.

Answer

C · The right hypoglossal nerve (XII)
12.Med-surg: neuro, endocrine & renal

Answer: D · Hyponatraemia

Why this is the answer

Desmopressin is a synthetic ADH analogue. If the patient continues drinking large amounts, water retention can cause hyponatraemia, with headache, confusion or seizures. Patients are advised to drink to thirst, and sodium, weight and fluid balance are monitored.

Answer

D · Hyponatraemia
13.Med-surg: GI, perioperative & oncology

Answer: D · It forms a protective coating over the ulcer base

Why this is the answer

Sucralfate binds to the ulcer base and forms a barrier against acid and pepsin. It works best on an empty stomach and can reduce the absorption of other drugs, so doses are separated.

Answer

D · It forms a protective coating over the ulcer base
14.Med-surg: GI, perioperative & oncology

Answer: B · Loosen any tight dressing, keep the arm at heart level and escalate

Why this is the answer

These are early signs of compartment syndrome, where raised pressure in a muscle compartment reduces blood flow. Constrictive dressings are released, the limb is kept at heart level and urgent surgical review is needed, as fasciotomy may be required.

Answer

B · Loosen any tight dressing, keep the arm at heart level and escalate

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