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 nursing assistant reports that a patient’s blood pressure is 168/98 mmHg (it was 130/80 earlier) and the patient has a headache. What should the RN do?

  1. ADocument the value and continue with the medication round
  2. BAsk the assistant to recheck the blood pressure in an hour
  3. CAsk the assistant to give the as-needed antihypertensive medication now
  4. DAssess the patient, recheck the blood pressure and look for symptoms
2.Prioritization & delegationHard

An adult has burns over 40% of the body with no signs of airway injury. Which treatment is the priority during the first hours?

  1. AGiving a high-protein meal to support healing
  2. BApplying antibiotic cream to all the burns before anything else
  3. CLarge-volume IV fluids with close monitoring of urine output
  4. DStarting physiotherapy to prevent contractures straight away
3.Infection control & patient safetyMedium

In a hospital fire, which means of moving patients is usually avoided?

  1. AStairs
  2. BWheeling beds through fire doors
  3. CElevators (lifts)
  4. DMoving horizontally to another area on the same floor behind fire doors
4.Infection control & patient safetyHard

A patient arrives in the operating room for knee surgery, and the site has not been marked. What should happen?

  1. AMark the site after the patient is anesthetized and draped
  2. BDo not start until the site is marked and verified with the patient
  3. CStart the surgery, because the consent form shows the side
  4. DLet the circulating nurse mark the site from memory of the surgeon’s plan
5.Lab values & electrolytesMedium

On the first day after major surgery, a patient's white cell count is 12.5 × 10³/µL, with no fever or wound signs. What is the best interpretation?

  1. AA laboratory error, since surgery lowers white cells
  2. BA common stress response to surgery that is monitored
  3. CA sign of leukemia that needs bone marrow testing
  4. DDefinite wound infection that needs antibiotics now
6.Lab values & electrolytesHard

The nurse teaches a patient with chronic kidney disease about a potassium-restricted diet. Which statement shows a need for further teaching?

  1. A"Dried apricots and raisins will be a good snack for me now"
  2. B"I'll check food labels and ask my dietitian about portion sizes"
  3. C"I can leach potatoes by soaking them before cooking them"
  4. D"I'll limit bananas, oranges and potatoes in my meals"
7.Clinical nursingMedium

What should a patient starting oral iron tablets be told?

  1. AThey must take the tablets with strong tea
  2. BTheir urine will turn bright green
  3. CThe tablets will cause weight loss
  4. DTheir stools may turn dark or black
8.Clinical nursingHard

The fluid in an underwater seal chest drain has stopped swinging with breathing. What could this mean?

  1. AThe patient's breathing has become normal and the drain can be pulled out by the nurse
  2. BThe drain is working perfectly and needs no checks
  3. CThe water seal has been set up correctly for the first time
  4. DThe tube may be kinked or blocked, or the lung may have fully re-expanded
9.Med-surg: cardiovascular & respiratoryMedium

Why should a beta-blocker not be stopped suddenly in a patient with ischaemic heart disease?

  1. AThe drug stays stored in the tissues for several months afterwards
  2. BThe heart rate becomes permanently slow afterwards
  3. CRebound tachycardia and hypertension can trigger angina or MI
  4. DSudden stopping causes severe and prolonged hypoglycaemia
10.Med-surg: cardiovascular & respiratoryHard

A patient with known hypertension has a BP of 186/112 mmHg with no symptoms and no signs of organ damage. Which response is most appropriate?

  1. ARecheck it, report it and expect oral treatment over hours to days
  2. BGive an IV antihypertensive bolus to reach 120/80 mmHg within 15 minutes
  3. CTake no action, because the patient feels well and has no symptoms
  4. DCall the cardiac arrest team and prepare for intubation
11.Med-surg: neuro, endocrine & renalMedium

A stroke patient speaks fluently, but the words make little sense, and they do not follow simple instructions. Which type of aphasia is this?

  1. AExpressive (Broca's) aphasia
  2. BDysarthria from facial weakness
  3. CGlobal aphasia with no speech at all
  4. DReceptive (Wernicke's) aphasia
12.Med-surg: neuro, endocrine & renalHard

A patient with motor neurone disease reports morning headaches, poor sleep and sleepiness during the day. What do these symptoms suggest?

  1. ALow mood, which should be treated with an antidepressant first
  2. BNormal tiredness that needs no specific action
  3. CA side effect of riluzole, which should be stopped straight away by the nurse
  4. DWeak breathing at night, so a review for ventilation support
13.Med-surg: GI, perioperative & oncologyMedium

A patient received IV morphine 20 minutes ago and the surgical consent form has not been signed. What should the nurse do?

  1. ASign the form on the patient's behalf as a witness
  2. BTell the surgeon, as the patient may not be able to consent now
  3. CAsk the patient to sign quickly before they get sleepier
  4. DAsk a relative to sign instead of the patient
14.Med-surg: GI, perioperative & oncologyHard

Why is folinic acid (leucovorin) given after high-dose methotrexate?

  1. ATo increase the anticancer effect on the tumour
  2. BTo treat the patient's anaemia only
  3. CTo prevent hair loss during treatment
  4. DTo rescue normal cells from methotrexate toxicity

3Solutions

1.Prioritization & delegation

Answer: D · Assess the patient, recheck the blood pressure and look for symptoms

Why this is the answer

A sudden rise with a headache is a change that the RN must assess. Waiting an hour delays care, and assistive personnel do not give medications or decide on treatment.

Answer

D · Assess the patient, recheck the blood pressure and look for symptoms
2.Prioritization & delegation

Answer: C · Large-volume IV fluids with close monitoring of urine output

Why this is the answer

Once the airway is secure, the early priority in major burns is fluid resuscitation to prevent burn shock. Urine output is a key guide to whether enough fluid is being given.

Answer

C · Large-volume IV fluids with close monitoring of urine output
3.Infection control & patient safety

Answer: C · Elevators (lifts)

Why this is the answer

Elevators are not used during a fire unless the fire service directs it, because they can stop or fill with smoke. Patients are usually moved horizontally behind fire doors first, then downstairs if needed.

Answer

C · Elevators (lifts)
4.Infection control & patient safety

Answer: B · Do not start until the site is marked and verified with the patient

Why this is the answer

Wrong-site surgery is prevented by marking the site before the procedure, ideally with the awake patient’s involvement, and confirming it at the time-out. The procedure does not begin until this is done.

Answer

B · Do not start until the site is marked and verified with the patient
5.Lab values & electrolytes

Answer: B · A common stress response to surgery that is monitored

Why this is the answer

A mild leukocytosis is common after surgery because of tissue injury and the stress response. It is monitored along with temperature and wound assessment. A rising count after several days, or fever, suggests infection.Checked against: WBC count · MedlinePlus (NIH) (2025)

Answer

B · A common stress response to surgery that is monitored
6.Lab values & electrolytes

Answer: A · "Dried apricots and raisins will be a good snack for me now"

Why this is the answer

Dried fruits such as apricots and raisins are very high in potassium and should be limited in kidney disease with hyperkalemia. Limiting high-potassium foods, leaching vegetables and reading labels are correct strategies.Checked against: Potassium in diet · MedlinePlus (NIH) (2026); Spironolactone · MedlinePlus (NIH) (2018)

Answer

A · "Dried apricots and raisins will be a good snack for me now"
7.Clinical nursing

Answer: D · Their stools may turn dark or black

Why this is the answer

Oral iron commonly darkens the stool and can cause constipation or stomach upset. Tea and antacids reduce absorption, while vitamin C may increase it.

Answer

D · Their stools may turn dark or black
8.Clinical nursing

Answer: D · The tube may be kinked or blocked, or the lung may have fully re-expanded

Why this is the answer

Loss of swing can mean a kinked, clamped or blocked tube, or re-expansion of the lung. The nurse checks the tubing and the patient and reports the finding.

Answer

D · The tube may be kinked or blocked, or the lung may have fully re-expanded
9.Med-surg: cardiovascular & respiratory

Answer: C · Rebound tachycardia and hypertension can trigger angina or MI

Why this is the answer

Long-term beta-blockade increases the number and sensitivity of beta receptors. Abrupt withdrawal exposes them to normal adrenaline levels, which can cause rebound tachycardia, hypertension and myocardial ischaemia. Doses are tapered.

Answer

C · Rebound tachycardia and hypertension can trigger angina or MI
10.Med-surg: cardiovascular & respiratory

Answer: A · Recheck it, report it and expect oral treatment over hours to days

Why this is the answer

Severe hypertension without acute organ damage (sometimes called hypertensive urgency) is managed by confirming the reading, looking for causes such as pain or missed doses and adjusting oral therapy to lower the pressure over hours to days. Rapid lowering risks ischaemia of the brain, heart and kidneys, but ignoring it is also unsafe.

Answer

A · Recheck it, report it and expect oral treatment over hours to days
11.Med-surg: neuro, endocrine & renal

Answer: D · Receptive (Wernicke's) aphasia

Why this is the answer

Receptive aphasia comes from damage to Wernicke's area in the dominant temporal lobe. Speech is fluent but often meaningless, and comprehension is impaired. Patients are often unaware of their errors.

Answer

D · Receptive (Wernicke's) aphasia
12.Med-surg: neuro, endocrine & renal

Answer: D · Weak breathing at night, so a review for ventilation support

Why this is the answer

Weak respiratory muscles cause nocturnal hypoventilation and a rise in CO2, leading to morning headaches, disturbed sleep and daytime drowsiness. Non-invasive ventilation can improve symptoms and survival, in line with the patient's wishes.

Answer

D · Weak breathing at night, so a review for ventilation support
13.Med-surg: GI, perioperative & oncology

Answer: B · Tell the surgeon, as the patient may not be able to consent now

Why this is the answer

Opioids and sedatives can impair understanding, so consent may not be valid. The surgeon is informed; consent is obtained when the patient has capacity, or other legal processes are followed in an emergency.

Answer

B · Tell the surgeon, as the patient may not be able to consent now
14.Med-surg: GI, perioperative & oncology

Answer: D · To rescue normal cells from methotrexate toxicity

Why this is the answer

Methotrexate inhibits dihydrofolate reductase. Timed folinic acid bypasses this block in normal cells, reducing toxicity such as mucositis and myelosuppression, while methotrexate levels and kidney function are monitored.

Answer

D · To rescue normal cells from methotrexate toxicity

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