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 on a continuous IV heparin infusion has new black, tarry stools and an aPTT well above the target range. What should the nurse do first?

  1. AGive a dose of vitamin K by mouth
  2. BCheck the pump rate and leave the infusion running
  3. COffer an iron-rich meal to replace the lost blood
  4. DStop the heparin infusion and inform the provider
2.Prioritization & delegationHard

Which assignment to an LPN/LVN is most appropriate?

  1. AA patient who needs discharge teaching for newly started warfarin
  2. BA patient with new atrial fibrillation who has just started an IV diltiazem infusion
  3. CA patient transferred from intensive care one hour ago
  4. DA patient with stable COPD who needs scheduled nebulized bronchodilators and oral medications
3.Infection control & patient safetyMedium

Why must an insulin pen never be used for more than one patient, even with a new needle?

  1. AThe insulin in the pen would expire faster once it is shared
  2. BSharing a pen changes the dose that is delivered
  3. CBlood can flow back into the cartridge and spread infection
  4. DEach pen holds only one dose of insulin
4.Infection control & patient safetyHard

A patient was harmed by a medication error and asks the nurse what happened. Which approach is best?

  1. ATell the patient to make a formal complaint to find out
  2. BBlame the pharmacy for the error so that the nurse and the ward are not at fault
  3. CTell the patient nothing happened to avoid worry
  4. DBe honest that an error occurred and involve the provider and team in disclosure per policy
5.Lab values & electrolytesMedium

A patient has had severe watery diarrhea for 4 days. Which laboratory pattern would the nurse expect?

  1. AHigh potassium and high bicarbonate
  2. BLow glucose and high magnesium
  3. CHigh sodium and high calcium
  4. DLow potassium and low bicarbonate
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 severe hyperglycemia in diabetes
  2. BHyponatremia caused by drinking far too much water
  3. CPseudohyponatremia, an artifact caused by very high lipids
  4. DTrue hyponatremia from SIADH that needs fluid restriction
7.Clinical nursingMedium

Why is an urgent brain scan needed before thrombolysis for a suspected stroke?

  1. ATo confirm the patient's age
  2. BTo rule out bleeding in the brain
  3. CTo check for brain tumours only
  4. DTo measure the size of the ventricles
8.Clinical nursingHard

Which route and site are recommended for the first dose of adrenaline (epinephrine) in anaphylaxis on a ward?

  1. AIntramuscular injection into the anterolateral thigh
  2. BSubcutaneous injection into the upper arm
  3. CIntravenous bolus given by the nurse without monitoring
  4. DOral tablet dissolved under the tongue
9.Med-surg: cardiovascular & respiratoryMedium

A patient arrives with suspected cardiac chest pain. How soon should a 12-lead ECG be recorded?

  1. AThe following morning
  2. BWithin about 10 minutes of arrival
  3. COnly after the troponin result is available
  4. DWithin 2 hours of arrival
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. BContinue the same support and recheck in four hours
  3. CLay the patient flat so they can rest the breathing muscles
  4. DChange to a nasal cannula at 4 L/min to reduce nasal dryness
11.Med-surg: neuro, endocrine & renalMedium

A patient with Alzheimer's disease starts donepezil. Which side effects should the nurse look for?

  1. ANausea, diarrhoea and a slow heart rate
  2. BWeight gain, high glucose and swollen ankles
  3. CDry mouth, constipation and a fast heart rate
  4. DA persistent dry cough and a raised potassium
12.Med-surg: neuro, endocrine & renalHard

A patient has episodes of severe headache, sweating, palpitations and very high blood pressure. Which condition should be considered?

  1. AHypothyroidism
  2. BDiabetes insipidus
  3. CPhaeochromocytoma
  4. DAddison's disease
13.Med-surg: GI, perioperative & oncologyMedium

A patient with a new ileostomy has a very high output. What is the main risk?

  1. AConstipation and faecal impaction in the bowel above the stoma
  2. BFluid overload and swelling of the ankles
  3. CDehydration and loss of sodium, potassium and magnesium
  4. DHigh calcium and kidney stones within days
14.Med-surg: GI, perioperative & oncologyHard

A patient arrives in the anaesthetic room without an identity band. What should the nurse do?

  1. AProceed because the patient can say their name
  2. BProceed and add a band once in recovery
  3. CStop and confirm identity, then apply a band
  4. DUse the spare identity band from the front of the patient's notes folder

3Solutions

1.Prioritization & delegation

Answer: D · Stop the heparin infusion and inform the provider

Why this is the answer

Black, tarry stools suggest upper GI bleeding, and a high aPTT shows too much anticoagulation. The nurse stops the heparin, checks vital signs and informs the provider, who may prescribe protamine sulfate. Vitamin K reverses warfarin, not heparin.

Answer

D · Stop the heparin infusion and inform the provider
2.Prioritization & delegation

Answer: D · A patient with stable COPD who needs scheduled nebulized bronchodilators and oral medications

Why this is the answer

A stable COPD patient with routine treatments has predictable care. A recent ICU transfer and a newly started IV rate-control infusion need RN assessment, and initial teaching about a new high-alert drug belongs to the RN.

Answer

D · A patient with stable COPD who needs scheduled nebulized bronchodilators and oral medications
3.Infection control & patient safety

Answer: C · Blood can flow back into the cartridge and spread infection

Why this is the answer

Blood and skin cells can be drawn back into the cartridge, so sharing a pen can transmit bloodborne infections. Each pen is labeled for a single patient.

Answer

C · Blood can flow back into the cartridge and spread infection
4.Infection control & patient safety

Answer: D · Be honest that an error occurred and involve the provider and team in disclosure per policy

Why this is the answer

Open, honest disclosure of errors is an ethical duty and part of a safety culture. The nurse follows policy, which usually involves the provider and risk team, and does not hide or blame.

Answer

D · Be honest that an error occurred and involve the provider and team in disclosure per policy
5.Lab values & electrolytes

Answer: D · Low potassium and low bicarbonate

Why this is the answer

Lower gut fluid contains potassium and bicarbonate, so severe diarrhea causes hypokalemia and a normal anion gap (hyperchloremic) metabolic acidosis, plus dehydration. Vomiting, in contrast, causes metabolic alkalosis.Checked against: Potassium Blood Test · MedlinePlus (NIH) (2024); Metabolic acidosis · MedlinePlus (NIH) (2025)

Answer

D · Low potassium and low bicarbonate
6.Lab values & electrolytes

Answer: C · 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

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

Answer: B · To rule out bleeding in the brain

Why this is the answer

A CT scan distinguishes haemorrhagic from ischaemic stroke. Clot-busting drugs are only given when bleeding has been excluded and other criteria are met.

Answer

B · To rule out bleeding in the brain
8.Clinical nursing

Answer: A · Intramuscular injection into the anterolateral thigh

Why this is the answer

IM adrenaline into the outer thigh is absorbed quickly and is the first-line route. IV adrenaline is reserved for experienced specialists with full monitoring because of the risk of arrhythmias.

Answer

A · Intramuscular injection into the anterolateral thigh
9.Med-surg: cardiovascular & respiratory

Answer: B · Within about 10 minutes of arrival

Why this is the answer

A 12-lead ECG should be recorded and interpreted within about 10 minutes of first contact, because STEMI needs immediate reperfusion. Repeat ECGs are taken if the pain changes or continues. Troponin results take longer and should not delay the ECG.

Answer

B · Within about 10 minutes of arrival
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: A · Nausea, diarrhoea and a slow heart rate

Why this is the answer

Donepezil is a cholinesterase inhibitor. Raised acetylcholine can cause nausea, vomiting, diarrhoea, vivid dreams and bradycardia, which can lead to dizziness or fainting.

Answer

A · Nausea, diarrhoea and a slow heart rate
12.Med-surg: neuro, endocrine & renal

Answer: C · Phaeochromocytoma

Why this is the answer

Phaeochromocytoma is a catecholamine-secreting tumour, usually of the adrenal medulla. It causes episodic hypertension, headache, sweating and tachycardia. Before surgery, alpha-blockade is started before any beta-blocker, because beta-blockade alone can cause a hypertensive crisis.

Answer

C · Phaeochromocytoma
13.Med-surg: GI, perioperative & oncology

Answer: C · Dehydration and loss of sodium, potassium and magnesium

Why this is the answer

High-output ileostomies (often defined as over about 1.5–2 L a day) can cause dehydration, acute kidney injury and electrolyte loss. Fluid balance, weight, urine output and electrolytes are monitored. Patients may need oral rehydration solution and drugs to slow output.

Answer

C · Dehydration and loss of sodium, potassium and magnesium
14.Med-surg: GI, perioperative & oncology

Answer: C · Stop and confirm identity, then apply a band

Why this is the answer

Correct identification before anaesthesia prevents wrong-patient surgery. The process stops until identity is confirmed with the patient and records and a band is applied, following the checklist.

Answer

C · Stop and confirm identity, then apply a band

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