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 nurse teaches a patient with COPD pursed-lip breathing. Which statement shows a need for further teaching?

  1. A“I will breathe out slowly through pursed lips.”
  2. B“I will breathe in slowly through my nose.”
  3. C“I will breathe in through my mouth and out quickly through my nose.”
  4. D“I will make my breath out about twice as long as my breath in.”
2.Prioritization & delegationHard

A patient rescued from a house fire has burns to the face, singed nasal hair and a hoarse voice. What is the priority?

  1. ACleaning and dressing the facial burns
  2. BProtecting the airway, preparing for early airway support
  3. CStarting IV fluid resuscitation calculated from the burn size
  4. DGiving pain relief
3.Infection control & patient safetyMedium

Why are blood cultures usually taken from two separate venipuncture sites?

  1. ABecause each site tests a different antibiotic
  2. BTo make the results come back faster from the laboratory
  3. CTo reduce the total amount of blood taken
  4. DTo help tell a true infection from skin contamination
4.Infection control & patient safetyHard

A nurse calls a provider using SBAR about a patient with falling blood pressure. Which statement is the “Recommendation”?

  1. A“He is 72 and had a bowel resection yesterday.”
  2. B“I think he needs to be assessed now. Can you come within the next 15 minutes?”
  3. C“His blood pressure has fallen from 130/80 to 88/50 over the last two hours.”
  4. D“I am calling about Mr. Jansen in room 12, who is hypotensive.”
5.Lab values & electrolytesMedium

Which laboratory value best reflects the cause of confusion in a patient with severe liver disease and a flapping tremor?

  1. AA low serum lipase
  2. BA raised serum ammonia
  3. CA low serum potassium only
  4. DA raised troponin
6.Lab values & electrolytesHard

A patient started methimazole for hyperthyroidism 6 weeks ago and now has a fever and a severe sore throat. Which action is most important?

  1. ACheck the TSH and double the dose if it is still low
  2. BGive the next dose and suggest warm salt-water gargles for comfort
  3. CHold the drug and arrange an urgent white cell and neutrophil count
  4. DAdvise the patient to continue the drug and drink more fluid
7.Clinical nursingMedium

Which mask is required for staff during an aerosol-generating procedure on a patient with a respiratory infection spread by aerosols?

  1. AA fit-tested respirator mask (such as FFP3 or N95)
  2. BA cloth face covering
  3. CNo mask, as long as gloves are worn
  4. DA standard fluid-repellent surgical mask with a visor
8.Clinical nursingHard

A patient with COPD on high-flow oxygen becomes drowsy with a bounding pulse and flushed skin. Blood gas shows a raised PaCO2 and low pH. What is the most likely cause?

  1. AOpioid allergy
  2. BHypercapnic respiratory failure, partly due to excessive oxygen
  3. CHypoglycaemia
  4. DMetabolic alkalosis from vomiting
9.Med-surg: cardiovascular & respiratoryMedium

After varicose vein surgery, which advice is usually given?

  1. AStay in bed for two weeks with the legs hanging down
  2. BWear the compression stockings as advised and walk regularly
  3. CStand still for long periods to help the veins heal
  4. DAvoid all walking until the bruising has gone
10.Med-surg: cardiovascular & respiratoryHard

A patient with heart failure has gained 2.5 kg in three days, has new crackles at both bases and now sleeps on four pillows. BP 138/84 mmHg, SpO₂ 93% on air. What is the priority?

  1. ALay the patient flat to rest the heart and lower demand
  2. BRecord the weight and check it again at the end of the next week
  3. CEncourage extra oral fluids to protect the kidneys
  4. DSit the patient up, assess fully and report the fluid overload
11.Med-surg: neuro, endocrine & renalMedium

A patient takes an SGLT2 inhibitor. Which sick-day advice is correct?

  1. AStop drinking fluids while taking the drug
  2. BDouble the dose during illness to control the glucose
  3. CKeep taking it as normal, whatever the illness
  4. DPause the drug during illness with vomiting or poor intake
12.Med-surg: neuro, endocrine & renalHard

At 03:00 a patient's glucose is 3.6 mmol/L, but before breakfast it is high. They take a long-acting insulin in the evening. What should the nurse do?

  1. ATreat the low and report the pattern so the evening dose is reviewed
  2. BIgnore the night reading and act on the morning value only
  3. CStop all insulin permanently and monitor glucose four-hourly
  4. DGive extra insulin at 03:00 because the morning value will be high
13.Med-surg: GI, perioperative & oncologyMedium

How is an uncomplicated sigmoid volvulus often first treated?

  1. ADecompression with a flexible sigmoidoscope and flatus tube
  2. BHigh-dose laxatives taken by mouth
  3. CA barium meal given by mouth to untwist the bowel slowly
  4. DEating a large high-fibre meal
14.Med-surg: GI, perioperative & oncologyHard

A patient has negative pressure wound therapy. The pump alarms and the dressing has lost its seal. What is the most appropriate action?

  1. ALeave the foam in the wound without suction for several days until review
  2. BTurn the suction up to its maximum setting to pull the seal back
  3. CPack the wound with dry gauze over the foam and tape it tightly
  4. DRestore the seal; if that fails in time, change to a moist dressing

3Solutions

1.Prioritization & delegation

Answer: C · “I will breathe in through my mouth and out quickly through my nose.”

Why this is the answer

Pursed-lip breathing means breathing in through the nose and out slowly through pursed lips, making exhalation longer. This keeps airways open and reduces air trapping.

Answer

C · “I will breathe in through my mouth and out quickly through my nose.”
2.Prioritization & delegation

Answer: B · Protecting the airway, preparing for early airway support

Why this is the answer

Singed nasal hair and hoarseness suggest inhalation injury. The upper airway can swell and close within hours, so it is protected early. Fluids, pain relief and wound care follow.

Answer

B · Protecting the airway, preparing for early airway support
3.Infection control & patient safety

Answer: D · To help tell a true infection from skin contamination

Why this is the answer

If the same organism grows from both sets, it is more likely to be a true bloodstream infection. Growth in only one set may be contamination from the skin.

Answer

D · To help tell a true infection from skin contamination
4.Infection control & patient safety

Answer: B · “I think he needs to be assessed now. Can you come within the next 15 minutes?”

Why this is the answer

In SBAR, the situation names the problem, the background gives the history, the assessment shares the nurse’s findings and judgement, and the recommendation states a clear request with a time frame.

Answer

B · “I think he needs to be assessed now. Can you come within the next 15 minutes?”
5.Lab values & electrolytes

Answer: B · A raised serum ammonia

Why this is the answer

A failing liver cannot convert ammonia into urea, so ammonia builds up and contributes to hepatic encephalopathy. Lactulose is commonly used to lower ammonia absorption from the gut.Checked against: Ammonia Levels · MedlinePlus (NIH) (2026); Loss of brain function - liver disease · MedlinePlus (NIH) (2025)

Answer

B · A raised serum ammonia
6.Lab values & electrolytes

Answer: C · Hold the drug and arrange an urgent white cell and neutrophil count

Why this is the answer

Methimazole and propylthiouracil can cause agranulocytosis, often in the first months of therapy. Fever or sore throat must be reported at once; the drug is held and a CBC with differential is checked. Infection is treated urgently if neutrophils are low.

Answer

C · Hold the drug and arrange an urgent white cell and neutrophil count
7.Clinical nursing

Answer: A · A fit-tested respirator mask (such as FFP3 or N95)

Why this is the answer

Aerosol-generating procedures, such as intubation, release small infectious particles. Respirators that are fit-tested protect the wearer, while surgical masks mainly protect against droplets.

Answer

A · A fit-tested respirator mask (such as FFP3 or N95)
8.Clinical nursing

Answer: B · Hypercapnic respiratory failure, partly due to excessive oxygen

Why this is the answer

Uncontrolled oxygen in CO2-retaining patients can worsen hypercapnia and respiratory acidosis. Oxygen should be titrated to 88–92% and medical review sought, possibly for non-invasive ventilation.

Answer

B · Hypercapnic respiratory failure, partly due to excessive oxygen
9.Med-surg: cardiovascular & respiratory

Answer: B · Wear the compression stockings as advised and walk regularly

Why this is the answer

After varicose vein treatment, patients are encouraged to walk regularly and wear compression as instructed to reduce bruising, swelling and DVT risk. They avoid standing still or sitting for long periods and elevate the legs when resting.

Answer

B · Wear the compression stockings as advised and walk regularly
10.Med-surg: cardiovascular & respiratory

Answer: D · Sit the patient up, assess fully and report the fluid overload

Why this is the answer

Rapid weight gain with crackles and orthopnoea indicates fluid overload and worsening heart failure. Sitting upright reduces venous return and eases breathing. The nurse completes an assessment (oxygen trend, fluid balance, oedema) and escalates so the prescriber can adjust diuretics. More fluid or lying flat would worsen congestion.

Answer

D · Sit the patient up, assess fully and report the fluid overload
11.Med-surg: neuro, endocrine & renal

Answer: D · Pause the drug during illness with vomiting or poor intake

Why this is the answer

During dehydrating illness, SGLT2 inhibitors increase the risk of DKA, which can occur with only modestly raised glucose, and of acute kidney injury. Patients are taught to pause them until they are eating and drinking normally.

Answer

D · Pause the drug during illness with vomiting or poor intake
12.Med-surg: neuro, endocrine & renal

Answer: A · Treat the low and report the pattern so the evening dose is reviewed

Why this is the answer

Nocturnal hypoglycaemia must be treated. A high morning glucose after a night-time low may reflect rebound (the Somogyi effect) or a separate cause; in either case the evening insulin regimen needs review. Giving extra insulin at night would make the hypoglycaemia worse.

Answer

A · Treat the low and report the pattern so the evening dose is reviewed
13.Med-surg: GI, perioperative & oncology

Answer: A · Decompression with a flexible sigmoidoscope and flatus tube

Why this is the answer

Endoscopic decompression often untwists a sigmoid volvulus. Recurrence is common, so elective surgery may follow. Signs of ischaemia or perforation need emergency surgery.

Answer

A · Decompression with a flexible sigmoidoscope and flatus tube
14.Med-surg: GI, perioperative & oncology

Answer: D · Restore the seal; if that fails in time, change to a moist dressing

Why this is the answer

NPWT needs an airtight seal. If the seal or suction is lost and cannot be restored promptly (many guidelines say within about 2 hours), the foam is removed and replaced with a standard dressing to reduce infection risk. Manufacturer and local guidance define the safe interval.

Answer

D · Restore the seal; if that fails in time, change to a moist dressing

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