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

Using the Emergency Severity Index, which patient receives the highest acuity level?

  1. AA patient with a sore throat for three days and normal vital signs
  2. BA patient with chest pain and normal vital signs
  3. CA patient with a possible ankle fracture
  4. DAn unresponsive patient with gasping, irregular breaths
2.Prioritization & delegationHard

A patient with raised intracranial pressure is being nursed on the ward. Which position is best?

  1. AHead of the bed at about 30 degrees with the neck straight
  2. BSitting forward with the chin on the chest
  3. CFlat on the back with the head turned well over to one side
  4. DHead down with the legs raised above the heart
3.Infection control & patient safetyMedium

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

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

A nurse finds that a patient has been taking their own sleeping pills from a bedside drawer while also receiving a hypnotic from the ward. What should the nurse do?

  1. AStop giving the hospital hypnotic without telling the provider or the pharmacy
  2. BThrow the patient’s pills away in the bin
  3. CLet the patient keep them, since they are the patient’s own
  4. DSecure the home medication per policy and inform the provider
5.Lab values & electrolytesMedium

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

  1. ADiscard the report, because a mixed growth is always normal
  2. BRecord the result as a confirmed urinary tract infection
  3. CInform the provider and arrange a new, correctly collected sample
  4. DStart treatment for all three organisms with three antibiotics
6.Lab values & electrolytesHard

A patient with chronic hyponatremia (sodium 118 mEq/L) is being treated. Why must the sodium be raised slowly?

  1. AIt can cause osmotic demyelination, a serious brain injury
  2. BSlow correction is needed only to reduce hospital costs
  3. CRapid correction causes hypokalemia, which is the only risk
  4. DRapid correction makes the sodium fall again even further
7.Clinical nursingMedium

An arterial blood gas shows a low pH, a high PaCO2 and a normal bicarbonate. What does this show?

  1. AMetabolic acidosis
  2. BMetabolic alkalosis
  3. CRespiratory acidosis
  4. DRespiratory alkalosis
8.Clinical nursingHard

A patient taking regular ibuprofen suddenly develops severe upper abdominal pain, a rigid abdomen and becomes tachycardic. What is most likely?

  1. AA perforated peptic ulcer
  2. BConstipation
  3. CIrritable bowel syndrome
  4. DIndigestion that will settle with antacids
9.Med-surg: cardiovascular & respiratoryMedium

What is the main difference between CPAP and bilevel NIV (often called BiPAP)?

  1. ABilevel NIV gives oxygen only, without any positive airway pressure
  2. BBilevel NIV adds a higher inspiratory pressure, helping remove CO₂
  3. CCPAP is given only through a tracheostomy
  4. DCPAP is mainly used to lower a raised PaCO₂ in COPD exacerbations
10.Med-surg: cardiovascular & respiratoryHard

A patient with small-cell lung cancer becomes confused. Sodium is 122 mmol/L (122 mEq/L) with concentrated urine, and there are no signs of dehydration. What is the most likely cause?

  1. ASyndrome of inappropriate ADH secretion
  2. BCranial diabetes insipidus from brain metastases
  3. CExcess salt in the diet over several weeks
  4. DSevere dehydration from poor oral intake
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. BMonitor BP, fluid balance and daily weight
  3. CCheck the weight once a week
  4. DEncourage a high-salt diet to balance the fluids
12.Med-surg: neuro, endocrine & renalHard

After a total thyroidectomy, a patient becomes anxious with stridor and a tense swelling in the neck. What should the nurse do first?

  1. AGive analgesia and reassess the swelling again in an hour
  2. BCall for emergency help: a haematoma may compress the airway
  3. CApply an ice pack to the neck and lie the patient flat
  4. DAsk the patient to talk as much as possible to test the voice
13.Med-surg: GI, perioperative & oncologyMedium

Which dressing is generally suitable for a dry, sloughy wound that needs moisture?

  1. AA foam
  2. BDry gauze
  3. CAn alginate
  4. DA hydrogel
14.Med-surg: GI, perioperative & oncologyHard

A competent adult who is a Jehovah's Witness refuses blood transfusion before major surgery. What should the nurse do?

  1. APlan to transfuse secretly during the operation if it becomes needed
  2. BCancel the surgery without discussing it
  3. CAsk the family to override the decision
  4. DRespect the decision, document it and inform the team

3Solutions

1.Prioritization & delegation

Answer: D · An unresponsive patient with gasping, irregular breaths

Why this is the answer

An unresponsive patient with agonal breathing needs immediate airway and breathing support, which is ESI level 1. Chest pain with normal vital signs is high risk (level 2), and the others are lower levels.

Answer

D · An unresponsive patient with gasping, irregular breaths
2.Prioritization & delegation

Answer: A · Head of the bed at about 30 degrees with the neck straight

Why this is the answer

Raising the head to about 30 degrees and keeping the neck in line helps venous drainage and lowers intracranial pressure. Head-down positions and neck bending or turning can raise it.

Answer

A · Head of the bed at about 30 degrees with the neck straight
3.Infection control & patient safety

Answer: B · 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

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

Answer: D · Secure the home medication per policy and inform the provider

Why this is the answer

Unrecorded home medicines can lead to duplicate doses, interactions and falls. They are stored or sent home according to policy, and the provider is told so the treatment plan can be reviewed.

Answer

D · Secure the home medication per policy and inform the provider
5.Lab values & electrolytes

Answer: C · Inform the provider and arrange a new, correctly collected sample

Why this is the answer

Several organisms in one urine sample usually mean contamination from the skin or perineum during collection. The provider is informed, and a new clean-catch or catheter-port sample is usually needed before an infection can be confirmed.

Answer

C · Inform the provider and arrange a new, correctly collected sample
6.Lab values & electrolytes

Answer: A · It can cause osmotic demyelination, a serious brain injury

Why this is the answer

When hyponatremia develops slowly, brain cells adapt. Raising the sodium too fast shrinks them and can damage the myelin of nerve cells (osmotic demyelination). Many guidelines limit the rise to about 8–10 mEq/L in 24 hours.Checked against: Osmotic demyelination syndrome · MedlinePlus (NIH) (2026)

Answer

A · It can cause osmotic demyelination, a serious brain injury
7.Clinical nursing

Answer: C · Respiratory acidosis

Why this is the answer

A raised PaCO2 with a low pH means the lungs are not removing enough CO2, for example from hypoventilation. A normal bicarbonate suggests it is acute.

Answer

C · Respiratory acidosis
8.Clinical nursing

Answer: A · A perforated peptic ulcer

Why this is the answer

Sudden severe pain with a board-like abdomen suggests perforation and peritonitis. The patient needs nil by mouth, IV access, analgesia and urgent surgical review.

Answer

A · A perforated peptic ulcer
9.Med-surg: cardiovascular & respiratory

Answer: B · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂

Why this is the answer

CPAP gives one continuous pressure that splints the airways and alveoli open, improving oxygenation (for example in pulmonary oedema or OSA). Bilevel NIV adds a higher inspiratory pressure that supports ventilation, so it is used for hypercapnic respiratory failure such as COPD exacerbations.

Answer

B · Bilevel NIV adds a higher inspiratory pressure, helping remove CO₂
10.Med-surg: cardiovascular & respiratory

Answer: A · Syndrome of inappropriate ADH secretion

Why this is the answer

Small-cell lung cancer can secrete ADH, causing water retention and dilutional hyponatraemia (normal sodium about 135–145 mmol/L). Urine is inappropriately concentrated and the patient is not dry. Fluid restriction and treating the cancer are the main measures; sodium is corrected slowly to avoid osmotic demyelination.

Answer

A · Syndrome of inappropriate ADH secretion
11.Med-surg: neuro, endocrine & renal

Answer: B · 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

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

Answer: B · Call for emergency help: a haematoma may compress the airway

Why this is the answer

A rapidly enlarging neck haematoma with stridor is an airway emergency. Urgent help is called; in many units the clips or sutures are removed at the bedside to release the haematoma (following local emergency procedures) before definitive airway management and surgery.

Answer

B · Call for emergency help: a haematoma may compress the airway
13.Med-surg: GI, perioperative & oncology

Answer: D · A hydrogel

Why this is the answer

Hydrogels donate moisture and promote autolytic debridement of dry slough or necrotic tissue. Alginates and foams absorb exudate and suit wet wounds; dry gauze sticks to the wound bed and damages new tissue when removed.

Answer

D · A hydrogel
14.Med-surg: GI, perioperative & oncology

Answer: D · Respect the decision, document it and inform the team

Why this is the answer

An informed refusal by a competent adult must be respected. The team discusses which products and alternatives (such as cell salvage or iron) the patient accepts, documents the decision and plans to reduce blood loss.

Answer

D · Respect the decision, document it and inform the team

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