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 patient can the nurse safely see last?

  1. AA patient with new crackles and pink, frothy sputum
  2. BA patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences
  3. CA patient two hours after surgery with a heart rate rising from 88 to 118/min
  4. DA patient with a sudden severe headache
2.Prioritization & delegationHard

A child is admitted with a suspected Wilms tumor (nephroblastoma). Which instruction is most important for all staff?

  1. AEncourage the child to play contact sports
  2. BDo not palpate the abdomen
  3. CMeasure abdominal girth by pressing firmly
  4. DGive a warm bath with abdominal massage
3.Infection control & patient safetyMedium

Before giving a tablet, the patient says, “This pill looks different from my usual one.” What should the nurse do?

  1. AStop and recheck the order and the drug before giving it
  2. BReassure the patient and give the pill
  3. CTell the patient that all pills look different in hospital
  4. DGive half the pill and watch for any unusual effects
4.Infection control & patient safetyHard

A nurse is about to give IV morphine. The patient’s respiratory rate is 9/min and they are very drowsy. What should the nurse do?

  1. AGive half the dose
  2. BWithhold the dose, assess the patient and inform the prescriber
  3. CGive the dose and recheck the respiratory rate tomorrow
  4. DGive the dose because pain was reported earlier
5.Lab values & electrolytesMedium

A patient who is breathless during a transfusion has hypotension, fever and bilateral lung infiltrates, with no signs of fluid overload. Which complication is most likely?

  1. ATransfusion-related acute lung injury (TRALI)
  2. BTransfusion-associated circulatory overload
  3. CA simple allergic reaction with hives
  4. DA mild febrile nonhemolytic reaction
6.Lab values & electrolytesHard

A young adult has fatigue, bruising and fever. The white cell count is 85 × 10³/µL with many blasts, the hemoglobin is 7.9 g/dL (79 g/L) and the platelets are 22 × 10³/µL. What is the most likely diagnosis?

  1. APolycythemia vera
  2. BAcute leukemia
  3. CAcute viral infection
  4. DIron-deficiency anemia
7.Clinical nursingMedium

A patient's NEWS2 score has risen to 7. What is the appropriate response?

  1. ARecord the score, increase observations and wait for the morning ward round
  2. BEmergency assessment by a clinical team with critical care skills
  3. CContinue observations every 12 hours
  4. DGive a sedative and recheck later
8.Clinical nursingHard

An older patient becomes acutely confused overnight, with fluctuating attention. What is the most likely cause to investigate first?

  1. ASudden onset of Alzheimer's disease
  2. BLack of interest in the surroundings
  3. CDelirium caused by an underlying problem such as infection or medication
  4. DNormal ageing
9.Med-surg: cardiovascular & respiratoryMedium

Which set of side effects is typical of thiazide or thiazide-like diuretics such as indapamide?

  1. AHigh sodium and magnesium, with low blood glucose
  2. BLow potassium and sodium, raised uric acid and raised glucose
  3. CDry cough, taste disturbance and swelling of the lips
  4. DHigh potassium and sodium, low uric acid and low blood glucose
10.Med-surg: cardiovascular & respiratoryHard

A patient on an unfractionated heparin infusion has a nosebleed that will not stop, and the aPTT is far above the target range. What is the most appropriate action?

  1. AContinue the infusion at the same rate and pack the nose firmly
  2. BGive vitamin K and continue the infusion at a slightly lower rate
  3. CStop the infusion, inform the prescriber and anticipate protamine
  4. DIncrease the infusion, as the aPTT will settle
11.Med-surg: neuro, endocrine & renalMedium

A patient with severe vomiting and diarrhoea takes ramipril, furosemide and metformin. Which advice is correct?

  1. ADouble the furosemide to prevent fluid retention
  2. BKeep taking everything as normal and drink less
  3. CPause these medicines until eating and drinking again
  4. DAdd ibuprofen to treat the abdominal cramps
12.Med-surg: neuro, endocrine & renalHard

A patient with gastroparesis has hypos soon after their meal-time insulin, then high glucose several hours later. What is the best explanation?

  1. AThe meter gives false results for several hours after every meal
  2. BThe insulin has gone off and needs replacing
  3. CThe patient is secretly eating sweets between meals
  4. DFood is absorbed slowly, so the insulin peaks before the glucose rises
13.Med-surg: GI, perioperative & oncologyMedium

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

  1. AAn alginate
  2. BA foam
  3. CA hydrogel
  4. DDry gauze
14.Med-surg: GI, perioperative & oncologyHard

A patient with recurrent diverticulitis reports passing air and faecal matter in the urine. What is the most likely cause?

  1. AA kidney stone blocking the ureter
  2. BA fistula between the colon and the bladder
  3. CA simple lower urinary tract infection
  4. DBowel preparation that was taken too quickly

3Solutions

1.Prioritization & delegation

Answer: B · A patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences

Why this is the answer

The COPD patient is within the prescribed target and is comfortable, so this patient is stable. A rising heart rate after surgery, signs of pulmonary edema and a sudden severe headache all need prompt assessment.

Answer

B · A patient with COPD on 1 L/min oxygen, SpO₂ 90% (target 88–92%), talking in full sentences
2.Prioritization & delegation

Answer: B · Do not palpate the abdomen

Why this is the answer

Palpating a Wilms tumor can rupture the capsule and spread cancer cells. A sign is often put on the bed to warn staff not to palpate the abdomen.

Answer

B · Do not palpate the abdomen
3.Infection control & patient safety

Answer: A · Stop and recheck the order and the drug before giving it

Why this is the answer

A patient’s concern is a safety check. The nurse stops and checks the order, the drug, the dose and the patient, and contacts the pharmacy if needed. Sometimes the reason is a different brand, but this must be confirmed first.

Answer

A · Stop and recheck the order and the drug before giving it
4.Infection control & patient safety

Answer: B · Withhold the dose, assess the patient and inform the prescriber

Why this is the answer

Slow breathing and sedation suggest opioid excess, so another dose could cause respiratory arrest. The nurse holds the dose, stimulates and assesses the patient, prepares naloxone per order and escalates.

Answer

B · Withhold the dose, assess the patient and inform the prescriber
5.Lab values & electrolytes

Answer: A · Transfusion-related acute lung injury (TRALI)

Why this is the answer

TRALI is acute lung injury within 6 hours of transfusion, caused by donor antibodies activating neutrophils in the lungs. It causes hypoxia, bilateral infiltrates and often hypotension and fever. TACO, in contrast, causes hypertension and signs of fluid overload.

Answer

A · Transfusion-related acute lung injury (TRALI)
6.Lab values & electrolytes

Answer: B · Acute leukemia

Why this is the answer

Many circulating blasts with anemia and thrombocytopenia suggest acute leukemia: malignant cells crowd out normal production in the marrow. Despite the high white count, the patient has few working white cells and is at high risk of infection and bleeding.Checked against: Laboratory Evaluation of Acute Leukemia · StatPearls (NCBI Bookshelf) (2025)

Answer

B · Acute leukemia
7.Clinical nursing

Answer: B · Emergency assessment by a clinical team with critical care skills

Why this is the answer

In NEWS2, a score of 7 or more triggers an emergency response, usually continuous monitoring and urgent review by a team competent in managing critically ill patients.

Answer

B · Emergency assessment by a clinical team with critical care skills
8.Clinical nursing

Answer: C · Delirium caused by an underlying problem such as infection or medication

Why this is the answer

Delirium develops over hours or days and fluctuates. Common causes are infection, drugs, dehydration, pain, constipation and urinary retention. Dementia develops slowly.

Answer

C · Delirium caused by an underlying problem such as infection or medication
9.Med-surg: cardiovascular & respiratory

Answer: B · Low potassium and sodium, raised uric acid and raised glucose

Why this is the answer

Thiazides cause hypokalaemia, hyponatraemia, hypomagnesaemia, hyperuricaemia (gout), hyperglycaemia and hypercalcaemia (they reduce calcium excretion). Dry cough and angioedema are ACE inhibitor effects.

Answer

B · Low potassium and sodium, raised uric acid and raised glucose
10.Med-surg: cardiovascular & respiratory

Answer: C · Stop the infusion, inform the prescriber and anticipate protamine

Why this is the answer

With bleeding and a high aPTT, the heparin infusion is stopped at once and the prescriber informed. Because heparin's effect wears off within hours, stopping is often enough, but protamine sulfate can reverse it. Vitamin K reverses warfarin, not heparin.

Answer

C · Stop the infusion, inform the prescriber and anticipate protamine
11.Med-surg: neuro, endocrine & renal

Answer: C · Pause these medicines until eating and drinking again

Why this is the answer

During dehydrating illness, ACE inhibitors, diuretics and metformin can worsen AKI or its complications. Sick-day guidance usually advises pausing them until the person is eating and drinking normally, and NSAIDs are avoided.

Answer

C · Pause these medicines until eating and drinking again
12.Med-surg: neuro, endocrine & renal

Answer: D · Food is absorbed slowly, so the insulin peaks before the glucose rises

Why this is the answer

Delayed gastric emptying means carbohydrate reaches the blood later than expected. The insulin acts too early, causing a hypo, and glucose rises later. The prescriber may change the timing, for example giving the insulin after the meal.

Answer

D · Food is absorbed slowly, so the insulin peaks before the glucose rises
13.Med-surg: GI, perioperative & oncology

Answer: C · 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

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

Answer: B · A fistula between the colon and the bladder

Why this is the answer

Pneumaturia and faecaluria suggest a colovesical fistula, a recognised complication of diverticulitis (and Crohn's disease or cancer). Recurrent urinary infections are common, and surgery is usually needed.

Answer

B · A fistula between the colon and the bladder

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