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 scheduled medication is the most time-critical?

  1. AA daily stool softener due with breakfast
  2. BRapid-acting insulin due with a breakfast tray that has arrived
  3. CA daily cholesterol-lowering statin tablet due with breakfast at 08:00
  4. DA daily multivitamin tablet due at 08:00
2.Prioritization & delegationHard

Two hours after a femoral cardiac catheterization, the nurse sees blood spreading from the puncture site. What is the first action?

  1. AApply firm, direct pressure just above the puncture site
  2. BRaise the head of the bed so the patient can sit up
  3. CRemove the dressing and leave the site open to the air
  4. DAsk the patient to bend the leg at the hip to stop the bleeding
3.Infection control & patient safetyMedium

Why does a nurse wear chemotherapy-tested gloves and a gown when emptying the urinal of a patient who recently had chemotherapy?

  1. AThe urine always contains infectious bacteria after chemotherapy
  2. BThe body fluids can contain active drug for a time after treatment
  3. CThe patient is on airborne precautions after treatment
  4. DChemotherapy makes the urine strongly acidic and corrosive
4.Infection control & patient safetyHard

A patient’s WBC is 4,000/mm3, with 30% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)?

  1. A1,200/mm3
  2. B140/mm3
  3. C1,400/mm3
  4. D3,500/mm3
5.Lab values & electrolytesMedium

A stool test for Clostridioides difficile is ordered. Which sample is appropriate?

  1. AA rectal swab from a patient with constipation
  2. BAn unformed (liquid or soft) stool
  3. CA formed, hard stool sample
  4. DAny stool after a laxative dose
6.Lab values & electrolytesHard

A patient with a new deep vein thrombosis is on a heparin infusion, and warfarin has just been started. Why is the heparin continued for several days?

  1. AWarfarin takes several days to reach its full anticoagulant effect
  2. BHeparin increases the absorption of warfarin from the gut
  3. CHeparin prevents the side effects of warfarin
  4. DWarfarin only works when heparin is given at the same time
7.Clinical nursingMedium

After thyroid surgery, a patient has tingling around the mouth and muscle cramps. Which electrolyte problem should be suspected?

  1. AHypernatraemia
  2. BHypermagnesaemia
  3. CHypocalcaemia
  4. DHyperkalaemia
8.Clinical nursingHard

A patient with a burn of 30% body surface area is admitted. Which early complication is of greatest concern in the first 24 hours?

  1. APressure ulcers from prolonged immobility
  2. BConstipation
  3. CScarring and contractures
  4. DHypovolaemic shock from fluid loss
9.Med-surg: cardiovascular & respiratoryMedium

Which position is usually best for the legs of a patient with chronic venous insufficiency and ankle swelling?

  1. AKept still in a standing position for long periods
  2. BRaised above the level of the heart when resting
  3. CCrossed at the knees while sitting
  4. DHanging down over the side of the bed
10.Med-surg: cardiovascular & respiratoryHard

A 25-year-old non-smoker has wheeze and cough that come and go, worse at night and after exercise. Spirometry improves markedly after a bronchodilator. Which diagnosis is most likely?

  1. AHeart failure
  2. BIdiopathic pulmonary fibrosis
  3. CCOPD
  4. DAsthma
11.Med-surg: neuro, endocrine & renalMedium

Fifteen minutes after treatment with glucose tablets, a patient's glucose has risen from 3.2 to 5.1 mmol/L. Their next meal is in two hours. What should happen next?

  1. AGive the usual dose of rapid-acting insulin straight away
  2. BGive another dose of glucose tablets to push it higher
  3. CNo further action is needed until the next meal is served later
  4. DGive a longer-acting carbohydrate snack, such as a sandwich
12.Med-surg: neuro, endocrine & renalHard

A patient with AKI has a low urine sodium and concentrated urine. What does this suggest?

  1. AAcute tubular necrosis, with damaged and leaking tubules
  2. BDiabetes insipidus, with too little ADH
  3. CA pre-renal cause, with kidneys holding salt and water
  4. DA post-renal blockage, with urine backed up
13.Med-surg: GI, perioperative & oncologyMedium

How large should the opening of a stoma appliance be cut?

  1. AAbout 2–3 mm larger than the stoma all round
  2. BAbout 2 cm larger than the stoma all round
  3. CSlightly smaller than the stoma for a tight seal
  4. DAny size, as long as the stoma is covered
14.Med-surg: GI, perioperative & oncologyHard

A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?

  1. AReport it; this is hand-foot syndrome and treatment may need changing
  2. BTell the patient to take a double dose next time
  3. CReassure that it is a sign of an unrelated allergy to washing powder
  4. DAdvise hot soaks for the hands and feet

3Solutions

1.Prioritization & delegation

Answer: B · Rapid-acting insulin due with a breakfast tray that has arrived

Why this is the answer

Rapid-acting insulin is given with a meal; giving it late or without food can cause high or low blood glucose. The other daily medicines can be given a little later without harm.

Answer

B · Rapid-acting insulin due with a breakfast tray that has arrived
2.Prioritization & delegation

Answer: A · Apply firm, direct pressure just above the puncture site

Why this is the answer

Direct manual pressure just above the puncture site compresses the femoral artery and stops bleeding. The patient keeps the leg straight, and the nurse checks vital signs and distal pulses and informs the provider.

Answer

A · Apply firm, direct pressure just above the puncture site
3.Infection control & patient safety

Answer: B · The body fluids can contain active drug for a time after treatment

Why this is the answer

Many hazardous drugs are excreted in urine, stool and vomit for a period after treatment. Staff wear protective gloves and gowns when handling these fluids, according to policy.

Answer

B · The body fluids can contain active drug for a time after treatment
4.Infection control & patient safety

Answer: C · 1,400/mm3

Why this is the answer

ANC = 4,000 × (0.30 + 0.05) = 1,400/mm3. This is below normal (neutropenia), so the patient has a raised risk of infection.

Answer

C · 1,400/mm3
5.Lab values & electrolytes

Answer: B · An unformed (liquid or soft) stool

Why this is the answer

C. difficile testing is done on unformed stool from patients with diarrhea, because many people carry the organism without disease. Testing formed stool, or stool after laxatives, can lead to misdiagnosis.

Answer

B · An unformed (liquid or soft) stool
6.Lab values & electrolytes

Answer: A · Warfarin takes several days to reach its full anticoagulant effect

Why this is the answer

Warfarin blocks the making of new vitamin K–dependent clotting factors, but existing factors last for days. Heparin is therefore overlapped until the INR has been in the target range, typically for at least 24 hours and after a minimum of about 5 days.

Answer

A · Warfarin takes several days to reach its full anticoagulant effect
7.Clinical nursing

Answer: C · Hypocalcaemia

Why this is the answer

Damage to the parathyroid glands lowers calcium, causing perioral tingling, tetany and positive Chvostek or Trousseau signs.

Answer

C · Hypocalcaemia
8.Clinical nursing

Answer: D · Hypovolaemic shock from fluid loss

Why this is the answer

Major burns cause fluid to shift out of the circulation, so formula-guided IV fluid resuscitation and urine output monitoring are key. Airway burns are another early danger.

Answer

D · Hypovolaemic shock from fluid loss
9.Med-surg: cardiovascular & respiratory

Answer: B · Raised above the level of the heart when resting

Why this is the answer

Elevating the legs above heart level reduces venous pressure and oedema. Compression therapy, walking and avoiding long periods of standing also help. By contrast, patients with arterial disease often find that lowering the legs eases pain.

Answer

B · Raised above the level of the heart when resting
10.Med-surg: cardiovascular & respiratory

Answer: D · Asthma

Why this is the answer

Asthma typically causes variable symptoms with reversible airflow obstruction. COPD usually affects older people with a smoking history and causes persistent, poorly reversible obstruction. Fibrosis gives a restrictive pattern.

Answer

D · Asthma
11.Med-surg: neuro, endocrine & renal

Answer: D · Give a longer-acting carbohydrate snack, such as a sandwich

Why this is the answer

Once glucose is above 4 mmol/L, a longer-acting carbohydrate (or the next meal if it is due) prevents a recurrence. The cause of the hypoglycaemia should be identified and documented, and the treatment plan reviewed if episodes recur.

Answer

D · Give a longer-acting carbohydrate snack, such as a sandwich
12.Med-surg: neuro, endocrine & renal

Answer: C · A pre-renal cause, with kidneys holding salt and water

Why this is the answer

In pre-renal AKI, the tubules work normally and conserve sodium and water, so urine sodium is low and urine is concentrated. In acute tubular necrosis, damaged tubules cannot conserve sodium, so urine sodium is higher.

Answer

C · A pre-renal cause, with kidneys holding salt and water
13.Med-surg: GI, perioperative & oncology

Answer: A · About 2–3 mm larger than the stoma all round

Why this is the answer

The aperture is cut to fit closely around the stoma, leaving a small margin of about 2–3 mm (about 1/8 inch). Too large exposes skin to output; too small can cut into the stoma. Stomas shrink during the first weeks, so measurement is repeated.

Answer

A · About 2–3 mm larger than the stoma all round
14.Med-surg: GI, perioperative & oncology

Answer: A · Report it; this is hand-foot syndrome and treatment may need changing

Why this is the answer

Palmar-plantar erythrodysaesthesia (hand-foot syndrome) is common with capecitabine and fluorouracil. It is graded and may need a treatment break or dose reduction; emollients and avoiding heat and friction help.

Answer

A · Report it; this is hand-foot syndrome and treatment may need changing

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