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

An older patient who has been constipated for days now has small amounts of liquid stool leaking. What should the nurse suspect?

  1. AA new bowel infection that has caused the diarrhea
  2. BFecal impaction with liquid stool passing around it
  3. CA side effect of drinking too much water
  4. DThe constipation has fully resolved
2.Prioritization & delegationHard

A patient with a new tracheostomy is coughing, has noisy breathing and an SpO₂ that has fallen to 86%. What is the first action?

  1. ADocument the SpO₂ and recheck in 30 minutes
  2. BGive a nebulized bronchodilator
  3. CSuction the tracheostomy
  4. DChange the tracheostomy ties
3.Infection control & patient safetyMedium

When is a prophylactic antibiotic usually given to prevent a surgical site infection?

  1. AThe day after surgery, once the wound is closed
  2. BOne week before surgery
  3. CWithin about 60 minutes before the incision
  4. DOnly if a fever develops after surgery
4.Infection control & patient safetyHard

On admission, the medication list from home includes a blood thinner that is not on the new hospital orders. What should the nurse do?

  1. AClarify the discrepancy with the prescriber
  2. BTell the patient to take their own supply secretly
  3. CGive the home dose without an order
  4. DIgnore it, as the hospital orders replace home medicines
5.Lab values & electrolytesMedium

A patient without symptoms has a fasting plasma glucose of 132 mg/dL (7.3 mmol/L) on Monday and 138 mg/dL (7.7 mmol/L) on Thursday. What does this show?

  1. AThe results show reactive hypoglycemia
  2. BThe results are within the normal fasting range
  3. CThe results show prediabetes only
  4. DThe results meet the criteria for diabetes
6.Lab values & electrolytesHard

Why can an HbA1c result be misleading in a patient who received a large blood transfusion two weeks ago?

  1. ATransfusions always raise HbA1c to falsely high levels
  2. BHbA1c is accurate in every situation
  3. CMany red cells are donor cells, not exposed to the patient’s glucose
  4. DHbA1c measures sugar on white cells, not red cells
7.Clinical nursingMedium

Why are patients advised to rinse their mouth after using an inhaled corticosteroid?

  1. ATo reduce the risk of oral thrush
  2. BTo make the drug work faster
  3. CTo stop the drug from being absorbed in the lungs
  4. DTo prevent tooth decay from the sugar in it
8.Clinical nursingHard

A patient has a painful, punched-out ulcer on the toes, with a cold, pale foot and weak foot pulses. Which type of ulcer is most likely?

  1. AA burn
  2. BA pressure ulcer from bed rest
  3. CA venous ulcer
  4. DAn arterial ulcer
9.Med-surg: cardiovascular & respiratoryMedium

Why is a higher level of HDL cholesterol considered protective?

  1. AHDL is converted into vitamin D in the walls of the arteries
  2. BHDL carries cholesterol from the tissues back to the liver
  3. CHDL thins the blood in the same way as an anticoagulant
  4. DHDL lowers the blood pressure directly
10.Med-surg: cardiovascular & respiratoryHard

A patient with heart failure is breathless at rest, with cool peripheries, a systolic BP of 80 mmHg and falling urine output. What does this suggest?

  1. AAnxiety causing a vasovagal response
  2. BMild dehydration that oral fluids will correct
  3. CStable, well-compensated chronic heart failure
  4. DCardiogenic shock with poor tissue perfusion
11.Med-surg: neuro, endocrine & renalMedium

A patient with untreated hyperthyroidism is losing weight. Which diet is most appropriate until the condition is controlled?

  1. AA high-calorie diet with enough protein
  2. BA low-calorie diet to protect the heart
  3. CA diet very high in caffeine for energy
  4. DA strict low-protein diet
12.Med-surg: neuro, endocrine & renalHard

A patient on insulin has worsening chronic kidney disease and is having more hypos. What is the best explanation?

  1. AKidney disease makes the body resistant to insulin
  2. BKidney disease makes the meter read too low
  3. CThe patient is eating far more carbohydrate than before
  4. DThe kidneys clear less insulin, so it lasts longer
13.Med-surg: GI, perioperative & oncologyMedium

A patient takes co-codamol at home (a combination tablet sold under different names in different countries). Why should the nurse check this before giving regular paracetamol (acetaminophen)?

  1. ACo-codamol stops paracetamol from working
  2. BParacetamol and codeine cause a severe allergic reaction when combined
  3. CCo-codamol must be stopped a week before any paracetamol
  4. DIt already contains paracetamol, so overdose could occur
14.Med-surg: GI, perioperative & oncologyHard

A patient on a long-term opioid for chronic pain is admitted for surgery. Which statement is correct?

  1. AThey need lower postoperative opioid doses than opioid-naive patients
  2. BThey should receive only paracetamol after the operation is over
  3. CThe usual opioid is continued, plus extra analgesia, due to tolerance
  4. DAll opioids should be stopped on admission to prevent addiction

3Solutions

1.Prioritization & delegation

Answer: B · Fecal impaction with liquid stool passing around it

Why this is the answer

In fecal impaction, liquid stool from higher in the bowel leaks around the hard mass. Giving an antidiarrheal would make things worse; the nurse assesses and reports.

Answer

B · Fecal impaction with liquid stool passing around it
2.Prioritization & delegation

Answer: C · Suction the tracheostomy

Why this is the answer

Noisy breathing, coughing and a falling SpO₂ in a patient with a tracheostomy suggest secretions in the tube. Suctioning clears the airway. If the airway is still blocked, follow the emergency tracheostomy algorithm and call for help.

Answer

C · Suction the tracheostomy
3.Infection control & patient safety

Answer: C · Within about 60 minutes before the incision

Why this is the answer

For most drugs, prophylaxis is given within 60 minutes before the incision so tissue levels are high during surgery. Some drugs, such as vancomycin, start earlier because they are infused over longer.

Answer

C · Within about 60 minutes before the incision
4.Infection control & patient safety

Answer: A · Clarify the discrepancy with the prescriber

Why this is the answer

An unexplained difference between home medicines and hospital orders can be an omission or an intentional change. The nurse asks the prescriber, so the decision is deliberate and documented. Unintended omission of an anticoagulant can lead to clots.

Answer

A · Clarify the discrepancy with the prescriber
5.Lab values & electrolytes

Answer: D · The results meet the criteria for diabetes

Why this is the answer

Two fasting results of 126 mg/dL (7.0 mmol/L) or more confirm diabetes in a person without symptoms. Prediabetes is 100–125 mg/dL. The nurse helps the patient understand the next steps, including education and follow-up.Checked against: Diabetes · MedlinePlus (NIH) (2025)

Answer

D · The results meet the criteria for diabetes
6.Lab values & electrolytes

Answer: C · Many red cells are donor cells, not exposed to the patient’s glucose

Why this is the answer

HbA1c forms as glucose attaches to hemoglobin over the life of a red cell. Transfused donor cells and conditions that shorten red cell life give falsely low values, so a glucose log or other markers are used instead.

Answer

C · Many red cells are donor cells, not exposed to the patient’s glucose
7.Clinical nursing

Answer: A · To reduce the risk of oral thrush

Why this is the answer

Inhaled steroid deposited in the mouth and throat can cause oral candidiasis and a hoarse voice. Rinsing and using a spacer reduce this.

Answer

A · To reduce the risk of oral thrush
8.Clinical nursing

Answer: D · An arterial ulcer

Why this is the answer

Arterial ulcers are usually on the feet or toes, painful and punched-out, with signs of poor perfusion. Venous ulcers are usually around the ankle, shallow and associated with swelling and skin staining.

Answer

D · An arterial ulcer
9.Med-surg: cardiovascular & respiratory

Answer: B · HDL carries cholesterol from the tissues back to the liver

Why this is the answer

HDL transports cholesterol from the tissues and artery walls to the liver for removal (reverse cholesterol transport), so higher levels are linked with lower cardiovascular risk. LDL carries cholesterol to tissues and drives atherosclerosis.

Answer

B · HDL carries cholesterol from the tissues back to the liver
10.Med-surg: cardiovascular & respiratory

Answer: D · Cardiogenic shock with poor tissue perfusion

Why this is the answer

Cardiogenic shock is pump failure with hypotension and hypoperfusion (cool skin, oliguria, confusion, raised lactate), often with pulmonary congestion. It needs urgent critical care review. Large fluid boluses can worsen congestion unless guided by careful assessment.

Answer

D · Cardiogenic shock with poor tissue perfusion
11.Med-surg: neuro, endocrine & renal

Answer: A · A high-calorie diet with enough protein

Why this is the answer

Excess thyroid hormone raises metabolism, so patients need more calories and protein to prevent weight loss. Caffeine is limited because it worsens palpitations, tremor and anxiety.

Answer

A · A high-calorie diet with enough protein
12.Med-surg: neuro, endocrine & renal

Answer: D · The kidneys clear less insulin, so it lasts longer

Why this is the answer

The kidneys clear a large share of insulin. As kidney function falls, insulin stays in the blood longer and some oral agents build up, so hypos increase. Insulin doses often need to be reduced.

Answer

D · The kidneys clear less insulin, so it lasts longer
13.Med-surg: GI, perioperative & oncology

Answer: D · It already contains paracetamol, so overdose could occur

Why this is the answer

Co-codamol combines codeine and paracetamol. Giving extra paracetamol can exceed the maximum daily dose and cause liver damage, so all sources of paracetamol are counted.

Answer

D · It already contains paracetamol, so overdose could occur
14.Med-surg: GI, perioperative & oncology

Answer: C · The usual opioid is continued, plus extra analgesia, due to tolerance

Why this is the answer

Patients on long-term opioids have tolerance and physical dependence. Stopping their usual opioid risks withdrawal and uncontrolled pain. Their baseline dose is continued (or converted to another route) and multimodal analgesia added; they often need more opioid than opioid-naive patients, with careful monitoring.

Answer

C · The usual opioid is continued, plus extra analgesia, due to tolerance

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