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 instruction to a nursing assistant is the clearest?

  1. A“Let me know if anything seems wrong with Mr Lee while you are in there.”
  2. B“Do Mr Lee’s vital signs sometime before lunch and write them on the chart for me.”
  3. C“Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”
  4. D“Keep an eye on Mr Lee this morning and let me know how he is doing.”
2.Prioritization & delegationHard

A patient is bleeding internally after a fall. Which finding is usually an early sign of hypovolemic shock?

  1. ALoss of consciousness with gasping breaths
  2. BA slow heart rate with warm, dry, flushed skin and a normal blood pressure throughout
  3. CRestlessness and a rising heart rate while the blood pressure is still normal
  4. DA very low blood pressure with fixed, dilated pupils
3.Infection control & patient safetyMedium

Why can side rails be dangerous for a confused, restless patient?

  1. ASide rails always cause pressure injuries
  2. BSide rails make the bed move by itself
  3. CThe patient may climb over them or get trapped in gaps
  4. DSide rails stop staff from reaching the patient in an emergency
4.Infection control & patient safetyHard

A patient’s cardiac monitor alarms often because of artifact, and a colleague suggests turning the alarm off. What is the best response?

  1. AKeep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
  2. BTurn the alarm off and check the monitor screen at the nurses’ station every hour instead
  3. CTurn the alarm volume down as low as it will go
  4. DDisconnect the monitor overnight so the patient can sleep
5.Lab values & electrolytesMedium

An older adult with chronic kidney disease takes glyburide (glibenclamide, a sulfonylurea) and has repeated low glucose readings. Why is this a concern?

  1. AThe drug causes high potassium that lowers the glucose
  2. BThe drug and its metabolites build up and cause long lows
  3. CThe drug stops working entirely when the kidneys fail
  4. DThe drug makes the glucose meter read falsely low
6.Lab values & electrolytesHard

A patient with heart failure takes lisinopril, spironolactone and a potassium supplement. Today the potassium is 6.0 mEq/L. What is the most likely explanation?

  1. APotassium supplements have no effect on the serum level
  2. BSeveral medicines that raise potassium are being taken together
  3. CSpironolactone causes potassium loss
  4. DLisinopril lowers potassium
7.Clinical nursingMedium

Why are patients encouraged to use an incentive spirometer after abdominal surgery?

  1. ATo encourage deep breaths that prevent atelectasis and chest infection
  2. BTo strengthen the abdominal muscles around the wound
  3. CTo measure their lung function so the result can go in the discharge letter
  4. DTo lower their heart rate before mobilising
8.Clinical nursingHard

A patient with type 1 diabetes is nil by mouth before surgery. Why must their insulin not simply be stopped?

  1. AInsulin is needed for the anaesthetic to work
  2. BInsulin prevents wound infection on its own
  3. CWithout any insulin they can develop diabetic ketoacidosis
  4. DStopping insulin causes immediate hypoglycaemia during the operation
9.Med-surg: cardiovascular & respiratoryMedium

A patient is starting warfarin for a DVT. Why is heparin or LMWH also given for the first several days?

  1. AWarfarin takes several days to reach its full effect
  2. BHeparin protects against bleeding from warfarin
  3. CBoth drugs must always be continued together for life
  4. DHeparin improves the absorption of warfarin
10.Med-surg: cardiovascular & respiratoryHard

A patient has been on continuous NIV via a full-face mask for two days. Which nursing measure helps prevent the most common complication?

  1. ATighten the straps as far as they will go to stop any leak
  2. BCheck mask fit and protect the bridge of the nose
  3. CUse the same mask size for every patient
  4. DRemove the mask for an hour each time the alarm sounds
11.Med-surg: neuro, endocrine & renalMedium

Why might a patient taking a beta-blocker not notice a hypoglycaemic episode?

  1. ABeta-blockers make the patient sleep through every hypo
  2. BBeta-blockers can mask the tremor and racing heart of a hypo
  3. CBeta-blockers raise blood glucose, so hypos cannot happen
  4. DBeta-blockers block the effect of all diabetes medicines
12.Med-surg: neuro, endocrine & renalHard

A patient with diabetic neuropathy has a hot, red, swollen foot that is barely painful. The skin is intact, and there is no fever. What should the nurse suspect?

  1. AAn acute Charcot foot, needing urgent offloading
  2. BGout, which only needs pain relief
  3. CA sprained ankle that will settle with walking
  4. DNormal swelling from standing too long
13.Med-surg: GI, perioperative & oncologyMedium

What is tumour lysis syndrome?

  1. AAn allergic reaction to a chemotherapy infusion
  2. BA skin reaction in an area recently treated with radiotherapy
  3. CA metabolic emergency from rapid breakdown of cancer cells
  4. DA slow-growing tumour that presses on the nerves
14.Med-surg: GI, perioperative & oncologyHard

At the end of an operation, the final count shows one swab missing. What should happen?

  1. AClose the wound, as the swab was probably thrown away
  2. BRecord the count as correct to avoid a delay
  3. CTell the surgeon, search, and X-ray if it is not found
  4. DLet the patient leave and search the theatre later

3Solutions

1.Prioritization & delegation

Answer: C · “Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”

Why this is the answer

The best instruction says exactly what to do, when, and which values must be reported at once. The other instructions leave the assistant to guess what matters.

Answer

C · “Measure Mr Lee’s blood pressure at 10:00 and tell me at once if the systolic is below 100.”
2.Prioritization & delegation

Answer: C · Restlessness and a rising heart rate while the blood pressure is still normal

Why this is the answer

In early shock, the body keeps the blood pressure up by raising the heart rate and narrowing vessels, so restlessness and tachycardia appear first. A falling blood pressure is a later sign.

Answer

C · Restlessness and a rising heart rate while the blood pressure is still normal
3.Infection control & patient safety

Answer: C · The patient may climb over them or get trapped in gaps

Why this is the answer

Confused patients may climb over rails and fall from a greater height or become trapped between the rail and mattress. Alternatives such as low beds and close observation are often safer.

Answer

C · The patient may climb over them or get trapped in gaps
4.Infection control & patient safety

Answer: A · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy

Why this is the answer

Disabling alarms is a known cause of missed deterioration. Alarm fatigue is reduced by fixing causes such as poor skin preparation or old electrodes and by setting individual limits according to orders and policy.

Answer

A · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
5.Lab values & electrolytes

Answer: B · The drug and its metabolites build up and cause long lows

Why this is the answer

Glyburide and its active metabolites are cleared by the kidneys, so they accumulate in CKD and can cause severe, prolonged hypoglycemia. Older adults are at greater risk. The prescriber is informed, and a different drug is usually chosen.

Answer

B · The drug and its metabolites build up and cause long lows
6.Lab values & electrolytes

Answer: B · Several medicines that raise potassium are being taken together

Why this is the answer

ACE inhibitors and spironolactone both make the kidneys retain potassium, and a supplement adds more. The nurse holds the supplement, informs the prescriber and checks kidney function and the ECG.Checked against: High potassium level · MedlinePlus (NIH) (2025); Spironolactone · MedlinePlus (NIH) (2018)

Answer

B · Several medicines that raise potassium are being taken together
7.Clinical nursing

Answer: A · To encourage deep breaths that prevent atelectasis and chest infection

Why this is the answer

Shallow breathing after surgery lets alveoli collapse, causing atelectasis and pneumonia. Deep-breathing exercises with an incentive spirometer help keep the lungs expanded.

Answer

A · To encourage deep breaths that prevent atelectasis and chest infection
8.Clinical nursing

Answer: C · Without any insulin they can develop diabetic ketoacidosis

Why this is the answer

People with type 1 diabetes make no insulin, so stopping it causes ketosis and DKA. Basal insulin is usually continued, often with a variable-rate insulin infusion and glucose monitoring.

Answer

C · Without any insulin they can develop diabetic ketoacidosis
9.Med-surg: cardiovascular & respiratory

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

Why this is the answer

Warfarin reduces synthesis of vitamin K-dependent clotting factors, but existing factors take days to clear, and early on it can briefly increase clotting tendency. Heparin or LMWH is overlapped for at least five days and until the INR has been in range (usually ≥2) for at least 24 hours.

Answer

A · Warfarin takes several days to reach its full effect
10.Med-surg: cardiovascular & respiratory

Answer: B · Check mask fit and protect the bridge of the nose

Why this is the answer

Pressure injury over the bridge of the nose is common with NIV masks. Correctly sized masks, avoiding overtightening (allowing a small gap under the straps), protective dressings and regular skin checks reduce it. Other problems include eye irritation, dryness and gastric distension.

Answer

B · Check mask fit and protect the bridge of the nose
11.Med-surg: neuro, endocrine & renal

Answer: B · Beta-blockers can mask the tremor and racing heart of a hypo

Why this is the answer

Beta-blockers blunt adrenergic warning symptoms such as palpitations and tremor. Sweating is often preserved. Patients should check their glucose when they feel unwell, rather than relying on symptoms alone.

Answer

B · Beta-blockers can mask the tremor and racing heart of a hypo
12.Med-surg: neuro, endocrine & renal

Answer: A · An acute Charcot foot, needing urgent offloading

Why this is the answer

Acute Charcot neuroarthropathy causes inflammation and destruction of bones and joints in a foot without protective sensation. It can look like cellulitis. Early immobilisation and offloading prevent permanent deformity.

Answer

A · An acute Charcot foot, needing urgent offloading
13.Med-surg: GI, perioperative & oncology

Answer: C · A metabolic emergency from rapid breakdown of cancer cells

Why this is the answer

Rapid tumour cell death, usually after starting treatment for fast-growing cancers such as acute leukaemia or high-grade lymphoma, releases potassium, phosphate and nucleic acids (converted to uric acid). This can cause AKI and arrhythmias.

Answer

C · A metabolic emergency from rapid breakdown of cancer cells
14.Med-surg: GI, perioperative & oncology

Answer: C · Tell the surgeon, search, and X-ray if it is not found

Why this is the answer

Any discrepancy is reported immediately, the wound is checked before closure, the area and waste are searched, and an X-ray is taken if the item is not found. The event is documented and reported.

Answer

C · Tell the surgeon, search, and X-ray if it is not found

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