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. ACheck the pump rate and leave the infusion running
  2. BOffer an iron-rich meal to replace the lost blood
  3. CStop the heparin infusion and inform the provider
  4. DGive a dose of vitamin K by mouth
2.Prioritization & delegationHard

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4.3 kPa) on arrival. An hour later it is 46 mmHg (6.1 kPa), and the patient seems tired. What does this suggest?

  1. AA laboratory error that should be ignored
  2. BRespiratory muscle fatigue with possible impending respiratory failure
  3. CThe patient is hyperventilating even more than before and needs calming
  4. DThe asthma is improving, because the PaCO₂ is now near normal
3.Infection control & patient safetyMedium

A patient with a fever and a cough arrives in a crowded clinic waiting room. What should the nurse do?

  1. AAsk the patient to wait outside in the car park
  2. BDo nothing until the patient is seen by the provider
  3. CGive the patient a mask and seat them apart from others
  4. DGive everyone else in the waiting room a mask instead
4.Infection control & patient safetyHard

A nurse teaches a patient about care of a surgical incision at home. Which statement shows a need for further teaching?

  1. A“If the wound gets red and drains pus, I will wait for my appointment next month.”
  2. B“I will call the clinic if I get a fever or more pain around the wound.”
  3. C“I will wash my hands with soap before I touch or change the dressing.”
  4. D“I will keep the dressing clean and dry as I was shown.”
5.Lab values & electrolytesMedium

A patient takes high-dose furosemide. Besides potassium, which electrolyte is most commonly lowered?

  1. AUric acid
  2. BPhosphate
  3. CSodium bicarbonate
  4. DMagnesium
6.Lab values & electrolytesHard

A patient with a long-standing lung condition has a serum bicarbonate of 32 mEq/L, an arterial PaCO₂ that is always high and a pH of 7.36. Which condition fits best?

  1. AAcute severe diarrhea with large bicarbonate losses
  2. BCOPD with chronic CO₂ retention and metabolic compensation
  3. CAcute diabetic ketoacidosis with severe dehydration and vomiting
  4. DAcute aspirin overdose with rapid breathing
7.Clinical nursingMedium

Which group of symptoms suggests hypothyroidism?

  1. AWeight loss, heat intolerance and tremor
  2. BExcessive thirst and passing large volumes of urine
  3. CFever, neck stiffness and photophobia
  4. DTiredness, weight gain and feeling cold
8.Clinical nursingHard

Which feature suggests moisture-associated skin damage rather than a pressure ulcer?

  1. ADiffuse, superficial redness in a skin fold, not over a bony prominence
  2. BA round area of necrosis over the heel
  3. CNon-blanching redness directly over the hip bone after lying on one side
  4. DA deep wound over the sacrum with exposed bone and a dark base
9.Med-surg: cardiovascular & respiratoryMedium

What is pulmonary rehabilitation in COPD?

  1. AA course of oral steroids and antibiotics given at home each winter
  2. BSupervised exercise and education that ease breathlessness
  3. CSurgery to remove the most damaged areas of lung
  4. DA lung function test repeated every six months
10.Med-surg: cardiovascular & respiratoryHard

A 74-year-old with atrial fibrillation, hypertension and diabetes asks why she needs an anticoagulant when she feels well. Which reply is best?

  1. AThe anticoagulant will stop the irregular heartbeat for good
  2. BIt is given to lower her blood pressure
  3. CIt is needed only while she has palpitations
  4. DHer risk of stroke is high, and an anticoagulant lowers it
11.Med-surg: neuro, endocrine & renalMedium

After a change in the levothyroxine dose, when is the TSH usually rechecked?

  1. AAfter about 2 years of treatment
  2. BAfter 3 days
  3. CAfter about 6–8 weeks
  4. DAfter 24 hours
12.Med-surg: neuro, endocrine & renalHard

A patient with raised intracranial pressure needs endotracheal suctioning. Which approach is most appropriate?

  1. ASuction every 15 minutes as a routine, even without secretions
  2. BPre-oxygenate, keep each pass short and limit the number of passes
  3. CLie the patient flat with the head turned during suctioning
  4. DSuction for at least 30 seconds to clear all secretions at once
13.Med-surg: GI, perioperative & oncologyMedium

A patient with cirrhosis takes lactulose for hepatic encephalopathy. What is the usual aim?

  1. AOne firm stool every week
  2. BTwo to three soft stools a day
  3. CNo bowel movement for several days
  4. DTen or more watery stools a day
14.Med-surg: GI, perioperative & oncologyHard

During burn resuscitation, an 80 kg adult's urine output is 15 mL/h for 2 hours. What does this indicate?

  1. AUnder-resuscitation; the fluid rate usually needs increasing
  2. BA normal urine output for a patient with burns
  3. CFluid overload; all IV fluids should be stopped now
  4. DA blocked catheter that should simply be removed

3Solutions

1.Prioritization & delegation

Answer: C · 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

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

Answer: B · Respiratory muscle fatigue with possible impending respiratory failure

Why this is the answer

Early in an asthma attack, fast breathing lowers the PaCO₂. A rising, “normal” value in a tiring patient means they can no longer move enough air, which is a warning sign of respiratory failure.

Answer

B · Respiratory muscle fatigue with possible impending respiratory failure
3.Infection control & patient safety

Answer: C · Give the patient a mask and seat them apart from others

Why this is the answer

Offering a mask to people with respiratory symptoms and separating them from others reduces the spread of droplets. Tissues, hand hygiene products and waste bins are also provided.

Answer

C · Give the patient a mask and seat them apart from others
4.Infection control & patient safety

Answer: A · “If the wound gets red and drains pus, I will wait for my appointment next month.”

Why this is the answer

Increasing redness, purulent drainage, fever and worsening pain are signs of surgical site infection and should be reported promptly. Waiting a month could allow the infection to spread.

Answer

A · “If the wound gets red and drains pus, I will wait for my appointment next month.”
5.Lab values & electrolytes

Answer: D · Magnesium

Why this is the answer

Loop diuretics block the Na-K-2Cl transporter in the loop of Henle, where much magnesium and calcium are also reabsorbed. They therefore commonly cause hypokalemia and hypomagnesemia, and they can raise uric acid and bicarbonate.Checked against: Magnesium Blood Test · MedlinePlus (NIH) (2023)

Answer

D · Magnesium
6.Lab values & electrolytes

Answer: B · COPD with chronic CO₂ retention and metabolic compensation

Why this is the answer

In chronic CO₂ retention, as in severe COPD, the kidneys retain bicarbonate over days and bring the pH back towards normal, often to the low end of the range. DKA and diarrhea lower bicarbonate, and aspirin overdose causes rapid breathing that lowers the PaCO₂.Checked against: Respiratory Acidosis · StatPearls (NCBI Bookshelf)

Answer

B · COPD with chronic CO₂ retention and metabolic compensation
7.Clinical nursing

Answer: D · Tiredness, weight gain and feeling cold

Why this is the answer

Low thyroid hormone slows metabolism, causing fatigue, weight gain, cold intolerance, constipation, dry skin and bradycardia. Weight loss, heat intolerance and tremor suggest hyperthyroidism.

Answer

D · Tiredness, weight gain and feeling cold
8.Clinical nursing

Answer: A · Diffuse, superficial redness in a skin fold, not over a bony prominence

Why this is the answer

Moisture lesions are superficial, irregular and often in skin folds or areas exposed to incontinence. Pressure ulcers usually occur over bony prominences or under devices and may be deeper.

Answer

A · Diffuse, superficial redness in a skin fold, not over a bony prominence
9.Med-surg: cardiovascular & respiratory

Answer: B · Supervised exercise and education that ease breathlessness

Why this is the answer

Pulmonary rehabilitation combines individually tailored exercise training, education and breathing techniques. It improves exercise capacity, breathlessness and quality of life and reduces hospital admissions. It is recommended for people with COPD who are limited by breathlessness and after an exacerbation.

Answer

B · Supervised exercise and education that ease breathlessness
10.Med-surg: cardiovascular & respiratory

Answer: D · Her risk of stroke is high, and an anticoagulant lowers it

Why this is the answer

In AF, blood stasis in the left atrium causes clots that can travel to the brain. Scores such as CHA₂DS₂-VASc (age, hypertension, diabetes, female sex and others) estimate stroke risk; her score is high. Anticoagulation reduces stroke risk but does not change the rhythm.

Answer

D · Her risk of stroke is high, and an anticoagulant lowers it
11.Med-surg: neuro, endocrine & renal

Answer: C · After about 6–8 weeks

Why this is the answer

Levothyroxine has a half-life of about a week, so it takes several weeks to reach a new steady state. TSH is usually rechecked about 6–8 weeks after a dose change.

Answer

C · After about 6–8 weeks
12.Med-surg: neuro, endocrine & renal

Answer: B · Pre-oxygenate, keep each pass short and limit the number of passes

Why this is the answer

Suctioning raises ICP through coughing, hypoxia and hypercapnia. It is done only when needed, with pre-oxygenation, passes of no more than about 10–15 seconds, few passes and the head kept elevated and midline. Sedation or lidocaine may be used in some units.

Answer

B · Pre-oxygenate, keep each pass short and limit the number of passes
13.Med-surg: GI, perioperative & oncology

Answer: B · Two to three soft stools a day

Why this is the answer

Lactulose acidifies the colon and traps ammonia, and it speeds transit. The dose is titrated to 2–3 soft stools a day. Excessive diarrhoea can cause dehydration and electrolyte disturbance that worsen encephalopathy.

Answer

B · Two to three soft stools a day
14.Med-surg: GI, perioperative & oncology

Answer: A · Under-resuscitation; the fluid rate usually needs increasing

Why this is the answer

The usual adult target is about 0.5 mL/kg/h (here 40 mL/h). An output of 15 mL/h suggests inadequate kidney perfusion, and the fluid rate is increased as prescribed after checking the catheter. Excessive fluid is also harmful, causing oedema and compartment syndromes, so the formula is only a starting point.

Answer

A · Under-resuscitation; the fluid rate usually needs increasing

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