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 receiving chemotherapy has a temperature of 38.3 °C and a very low neutrophil count. What should the nurse do?

  1. ARecheck the temperature in four hours before telling anyone
  2. BReport it at once, because cultures and antibiotics are needed quickly
  3. CDocument the reading and mention it at the next handover
  4. DGive a cool shower and offer extra fluids, then wait and see what happens
2.Prioritization & delegationHard

A nurse must care for a patient with a radioactive implant. Which approach best limits the nurse’s exposure?

  1. ASpend longer in the room each time but visit less often during the shift
  2. BLimit time in the room, keep as far away as possible and use shielding
  3. CStand close to the patient to finish care faster
  4. DWear a surgical mask to block the radiation
3.Infection control & patient safetyMedium

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

  1. AIt is only allowed for intravenous medicines
  2. BIt is a Latin abbreviation, and only plain English abbreviations may be used
  3. CIt means “every day at bedtime” in some hospitals
  4. DIt can be misread as QID or QOD, so the drug is given too often or too rarely
4.Infection control & patient safetyHard

A bag of chemotherapy drug leaks onto the floor. What is the first step?

  1. AWipe it up quickly with paper towels and bare hands
  2. BPut on the spill kit’s protective equipment and contain the spill
  3. CAsk the cleaner to mop it up with the usual mop
  4. DLeave it to dry, then clean it up at the end of the shift
5.Lab values & electrolytesMedium

A patient taking furosemide has a potassium of 3.3 mEq/L and is told to eat more potassium-rich foods. Which snack is the best choice?

  1. APlain crackers
  2. BWhite bread
  3. CRice cakes
  4. DDried apricots
6.Lab values & electrolytesHard

A patient has a hematocrit of 60% and a raised red cell mass. Which result suggests polycythemia vera rather than secondary polycythemia from chronic hypoxia?

  1. AA low erythropoietin level
  2. BA high carboxyhemoglobin
  3. CA low oxygen saturation
  4. DA high erythropoietin level
7.Clinical nursingMedium

Why is lactulose given to a patient with hepatic encephalopathy?

  1. ATo lower the blood glucose
  2. BTo stop bleeding from varices
  3. CTo increase the liver's production of albumin
  4. DTo reduce the absorption of ammonia from the gut
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. BCheck the patient's condition and inform the doctor
  3. CAsk a colleague not to mention it
  4. DWait to see whether any side effects develop
9.Med-surg: cardiovascular & respiratoryMedium

Which ECG finding is typical of atrial flutter?

  1. ARegular sawtooth flutter waves between QRS complexes
  2. BWide, bizarre QRS complexes at 180/min
  3. CA chaotic baseline with no clear P waves and irregular QRS
  4. DP waves with no relationship to the QRS complexes
10.Med-surg: cardiovascular & respiratoryHard

A patient with both COPD and heart disease is more breathless, with bilateral basal crackles, raised JVP, ankle swelling and a markedly raised NT-proBNP. Which problem is most likely driving this episode?

  1. AA primary spontaneous pneumothorax
  2. BHyperventilation from anxiety
  3. CAn asthma attack
  4. DDecompensated heart failure
11.Med-surg: neuro, endocrine & renalMedium

A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?

  1. AGive large amounts of IV fluid
  2. BEncourage a high-salt diet to balance the fluids
  3. CCheck the weight once a week
  4. DMonitor BP, fluid balance and daily weight
12.Med-surg: neuro, endocrine & renalHard

A 66-year-old smoker has had two episodes of painless red urine. Urine cultures are negative. Which plan is most appropriate?

  1. AReassure him, because the blood has stopped
  2. BUrgent referral for cystoscopy and imaging
  3. CAnother course of antibiotics for a UTI
  4. DAdvise more fluids and review in a year
13.Med-surg: GI, perioperative & oncologyMedium

Which finding suggests a deep tissue pressure injury?

  1. AA small scratch on the skin with a little fresh red blood
  2. BIntact skin that is purple or maroon over a bony area
  3. CDry, flaky skin on both shins
  4. DPale pink skin that blanches quickly when pressed
14.Med-surg: GI, perioperative & oncologyHard

A patient with suspected appendicitis says the pain suddenly eased, but an hour later has a temperature of 38.9 °C, a rigid abdomen and a pulse of 118/min. What does this suggest?

  1. AThe appendicitis has settled by itself
  2. BSimple constipation that needs a laxative
  3. CPerforation with peritonitis
  4. DA side effect of the analgesia given

3Solutions

1.Prioritization & delegation

Answer: B · Report it at once, because cultures and antibiotics are needed quickly

Why this is the answer

Neutropenic fever is a medical emergency. The patient may have few other signs of infection, so the nurse reports it immediately so that cultures can be taken and IV antibiotics started.

Answer

B · Report it at once, because cultures and antibiotics are needed quickly
2.Prioritization & delegation

Answer: B · Limit time in the room, keep as far away as possible and use shielding

Why this is the answer

Radiation exposure falls with less time, more distance and shielding. Care is planned to be efficient, and a surgical mask does not protect against radiation.

Answer

B · Limit time in the room, keep as far away as possible and use shielding
3.Infection control & patient safety

Answer: D · It can be misread as QID or QOD, so the drug is given too often or too rarely

Why this is the answer

“QD” and “QOD” can be confused with each other and with “QID”, leading to serious dosing errors. The word “daily” or “every other day” is written in full instead.

Answer

D · It can be misread as QID or QOD, so the drug is given too often or too rarely
4.Infection control & patient safety

Answer: B · Put on the spill kit’s protective equipment and contain the spill

Why this is the answer

Hazardous drug spills are handled with a spill kit, including chemotherapy-tested gloves, a gown and eye protection. The area is secured and the spill is contained, cleaned and disposed of as hazardous waste, then reported.

Answer

B · Put on the spill kit’s protective equipment and contain the spill
5.Lab values & electrolytes

Answer: D · Dried apricots

Why this is the answer

Dried fruits such as apricots, raisins and prunes are rich in potassium, as are bananas, oranges, potatoes, beans and tomatoes. Refined grain products such as white bread and crackers are low in potassium.

Answer

D · Dried apricots
6.Lab values & electrolytes

Answer: A · A low erythropoietin level

Why this is the answer

In polycythemia vera, a marrow mutation (usually JAK2) drives red cell production, so erythropoietin is low. In secondary polycythemia from hypoxia (COPD, high altitude, smoking), erythropoietin is high. Often white cells and platelets are also raised in polycythemia vera.

Answer

A · A low erythropoietin level
7.Clinical nursing

Answer: D · To reduce the absorption of ammonia from the gut

Why this is the answer

Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.

Answer

D · To reduce the absorption of ammonia from the gut
8.Clinical nursing

Answer: B · 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

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

Answer: A · Regular sawtooth flutter waves between QRS complexes

Why this is the answer

Atrial flutter is caused by a re-entry circuit in the right atrium, giving regular sawtooth flutter waves, often at about 300/min with 2:1 block (ventricular rate about 150/min). A chaotic baseline with irregular QRS is atrial fibrillation. Like AF, it carries a stroke risk.

Answer

A · Regular sawtooth flutter waves between QRS complexes
10.Med-surg: cardiovascular & respiratory

Answer: D · Decompensated heart failure

Why this is the answer

Basal crackles, raised JVP, oedema and a high natriuretic peptide point to heart failure rather than a COPD exacerbation alone. Distinguishing them matters, because treatment (diuretics and HF drugs versus bronchodilators and steroids) is different. Both may occur together.

Answer

D · Decompensated heart failure
11.Med-surg: neuro, endocrine & renal

Answer: D · Monitor BP, fluid balance and daily weight

Why this is the answer

In acute glomerulonephritis, salt and water retention cause oedema and hypertension. Close monitoring of BP, input and output and daily weights is needed, often with salt and fluid restriction and antihypertensives.

Answer

D · Monitor BP, fluid balance and daily weight
12.Med-surg: neuro, endocrine & renal

Answer: B · Urgent referral for cystoscopy and imaging

Why this is the answer

Painless visible haematuria in an older smoker, with no infection, must be investigated urgently for bladder or kidney cancer. Intermittent bleeding does not mean the cause has gone.

Answer

B · Urgent referral for cystoscopy and imaging
13.Med-surg: GI, perioperative & oncology

Answer: B · Intact skin that is purple or maroon over a bony area

Why this is the answer

A deep tissue injury appears as persistent purple, maroon or dark discolouration, or a blood-filled blister, from pressure and shear on underlying tissue. It may quickly turn into a deep wound.

Answer

B · Intact skin that is purple or maroon over a bony area
14.Med-surg: GI, perioperative & oncology

Answer: C · Perforation with peritonitis

Why this is the answer

Brief relief can occur when an inflamed appendix ruptures, followed by spreading peritonitis with fever, rigidity and tachycardia. This is a surgical emergency needing urgent review, IV fluids and antibiotics.

Answer

C · Perforation with peritonitis

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