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 stable adult has abdominal pain and normal vital signs. They will need blood tests and a CT scan. Which ESI level fits?

  1. ALevel 5
  2. BLevel 1
  3. CLevel 3
  4. DLevel 4
2.Prioritization & delegationHard

A patient is admitted with inhalational anthrax. Which precautions are needed?

  1. AAirborne precautions in a negative-pressure room for the whole of the hospital stay
  2. BDroplet precautions with a surgical mask for everyone who enters
  3. CStandard precautions, because it does not usually spread from person to person
  4. DFull contact and droplet precautions for all staff and visitors on the unit
3.Infection control & patient safetyMedium

Before a blood transfusion is started, which check is required?

  1. AThe patient’s identity is checked against the blood product and its paperwork at the bedside
  2. BOne nurse checks the blood product against the order at the nurses’ station
  3. CThe patient signs the blood bag label to confirm their name before it is hung
  4. DThe nurse checks only that the bag number matches the order
4.Infection control & patient safetyHard

A patient on an anticoagulant falls and hits their head but says they feel fine. What should the nurse do?

  1. ANotify the provider and start neurological observations, because a brain bleed may develop
  2. BWait until the next day to see if a headache develops
  3. CGive the next anticoagulant dose early to prevent clots from forming after the fall
  4. DHelp the patient back to bed and do nothing more if they feel fine
5.Lab values & electrolytesMedium

A woman who is 30 weeks pregnant has a new blood pressure of 152/98 mm Hg. Which urine finding would most support preeclampsia?

  1. AKetones in the urine
  2. BProtein in the urine
  3. CNitrites in the urine
  4. DGlucose in the urine
6.Lab values & electrolytesHard

A health care worker's hepatitis B tests show: HBsAg negative, anti-HBs positive, anti-HBc positive. What does this mean?

  1. AImmunity from vaccination only, never infected
  2. BCurrent chronic hepatitis B infection
  3. CNot immune and never exposed to the virus
  4. DPast infection that has resolved, with immunity
7.Clinical nursingMedium

A patient with neutropenia after chemotherapy has a temperature of 38.3 °C. What is the priority?

  1. AEncourage the patient to go for a walk
  2. BGive paracetamol only and recheck the temperature again tomorrow
  3. CTreat as neutropenic sepsis and give IV antibiotics urgently
  4. DWait 24 hours to see whether the fever settles
8.Clinical nursingHard

A patient with several days of vomiting and diarrhoea has low blood pressure, low urine output and a rising creatinine. Which description fits best?

  1. AIntrinsic kidney injury from glomerulonephritis, treated with high-dose steroids
  2. BPre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
  3. CPost-renal acute kidney injury from obstruction, treated with a catheter
  4. DChronic kidney disease, treated with long-term dialysis three times a week
9.Med-surg: cardiovascular & respiratoryMedium

Which investigation is usually used to confirm a deep vein thrombosis in the leg?

  1. AA plain chest X-ray and an ECG
  2. BA lung function test
  3. CCompression duplex ultrasound
  4. DAn exercise ECG
10.Med-surg: cardiovascular & respiratoryHard

A conscious adult in the dining room is suddenly unable to speak, cough or breathe after a mouthful of food. What should the nurse do first?

  1. AEncourage them to drink a glass of water to wash the food down
  2. BSweep blindly in the mouth with a finger
  3. CLie them down on the floor and start chest compressions immediately
  4. DUp to five back blows, then up to five abdominal thrusts if needed
11.Med-surg: neuro, endocrine & renalMedium

Why is IV calcium gluconate given in severe hyperkalaemia?

  1. AIt moves potassium into the cells
  2. BIt removes potassium through the kidneys
  3. CIt binds potassium in the gut
  4. DIt protects the heart from arrhythmias
12.Med-surg: neuro, endocrine & renalHard

A patient arrives five hours after the onset of a stroke. A CT angiogram shows a blockage of a large artery in the brain. What is the most appropriate next step?

  1. AUrgent referral for assessment for mechanical thrombectomy
  2. BGive aspirin and plan a review on the ward tomorrow
  3. CStart IV alteplase immediately without further imaging
  4. DNo treatment, because the time for any reperfusion has passed
13.Med-surg: GI, perioperative & oncologyMedium

Why is a gastrostomy tube with an internal bumper usually advanced and rotated regularly once the tract has healed?

  1. ATo remove any feed left in the stomach
  2. BTo stop the inner bumper becoming buried in the stomach wall
  3. CTo check that the patient is still hungry
  4. DTo make the tube longer as the patient grows or gains weight
14.Med-surg: GI, perioperative & oncologyHard

A patient with a permanent pacemaker is booked for surgery using monopolar diathermy. Why must the team know?

  1. AThe pacemaker will always be removed during surgery
  2. BPacemakers stop all bleeding during surgery
  3. CDiathermy can interfere with the pacemaker's function
  4. DThe patient cannot have any anaesthetic at all

3Solutions

1.Prioritization & delegation

Answer: C · Level 3

Why this is the answer

Blood tests (one resource) plus a CT scan (a second resource) make two resources, which is ESI level 3 when the vital signs are acceptable.

Answer

C · Level 3
2.Prioritization & delegation

Answer: C · Standard precautions, because it does not usually spread from person to person

Why this is the answer

Inhalational anthrax is not spread from person to person, so standard precautions are used. Contact precautions may be added for skin (cutaneous) anthrax with draining lesions.

Answer

C · Standard precautions, because it does not usually spread from person to person
3.Infection control & patient safety

Answer: A · The patient’s identity is checked against the blood product and its paperwork at the bedside

Why this is the answer

Wrong-patient transfusion can cause a fatal ABO reaction, so the final check is always done at the bedside, with positive patient identification against the product label, compatibility tag and order. Many US hospitals require two qualified people for this check, while UK guidance allows one trained person if positive identification is used. Local policy decides who checks.

Answer

A · The patient’s identity is checked against the blood product and its paperwork at the bedside
4.Infection control & patient safety

Answer: A · Notify the provider and start neurological observations, because a brain bleed may develop

Why this is the answer

Head injury in a patient on anticoagulants can cause bleeding inside the skull that shows signs later. The provider is told at once, imaging may be needed and neurological checks are done closely.

Answer

A · Notify the provider and start neurological observations, because a brain bleed may develop
5.Lab values & electrolytes

Answer: B · Protein in the urine

Why this is the answer

Preeclampsia is new hypertension after 20 weeks of pregnancy with proteinuria or other signs of organ involvement, such as low platelets, raised liver enzymes or rising creatinine. Proteinuria reflects damage to the glomerular filter.

Answer

B · Protein in the urine
6.Lab values & electrolytes

Answer: D · Past infection that has resolved, with immunity

Why this is the answer

The vaccine contains only surface antigen, so vaccination produces anti-HBs alone. A positive anti-HBc shows past or current infection; with HBsAg negative and anti-HBs positive, the infection has cleared and the person is immune.

Answer

D · Past infection that has resolved, with immunity
7.Clinical nursing

Answer: C · Treat as neutropenic sepsis and give IV antibiotics urgently

Why this is the answer

Neutropenic sepsis is an oncological emergency. Broad-spectrum IV antibiotics should be given within an hour, without waiting for test results.

Answer

C · Treat as neutropenic sepsis and give IV antibiotics urgently
8.Clinical nursing

Answer: B · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume

Why this is the answer

Fluid loss reduces kidney perfusion, causing pre-renal AKI. Prompt fluid replacement can restore function before the kidney tissue itself is damaged.

Answer

B · Pre-renal acute kidney injury from poor perfusion, treated by restoring fluid volume
9.Med-surg: cardiovascular & respiratory

Answer: C · Compression duplex ultrasound

Why this is the answer

Compression ultrasound shows whether a deep vein is compressible and whether flow is normal; a vein containing clot does not compress. A low clinical probability with a negative D-dimer can rule out DVT without imaging.

Answer

C · Compression duplex ultrasound
10.Med-surg: cardiovascular & respiratory

Answer: D · Up to five back blows, then up to five abdominal thrusts if needed

Why this is the answer

For a conscious adult with severe choking, current UK, European and AHA (2025) guidance teach up to five back blows, then up to five abdominal thrusts, repeated until the obstruction clears; some older courses used abdominal thrusts alone. If the person becomes unconscious, CPR is started. Blind finger sweeps can push the object further in.

Answer

D · Up to five back blows, then up to five abdominal thrusts if needed
11.Med-surg: neuro, endocrine & renal

Answer: D · It protects the heart from arrhythmias

Why this is the answer

Calcium stabilises the cardiac cell membrane and reduces the risk of arrhythmias within minutes. It does not change the potassium level, so other treatments are needed to shift and remove potassium.

Answer

D · It protects the heart from arrhythmias
12.Med-surg: neuro, endocrine & renal

Answer: A · Urgent referral for assessment for mechanical thrombectomy

Why this is the answer

IV thrombolysis is usually given within 4.5 hours of onset. Mechanical thrombectomy for a large vessel occlusion can be done later, typically up to 6 hours and in selected patients up to 24 hours, based on imaging. Time still matters, so referral is urgent.

Answer

A · Urgent referral for assessment for mechanical thrombectomy
13.Med-surg: GI, perioperative & oncology

Answer: B · To stop the inner bumper becoming buried in the stomach wall

Why this is the answer

Buried bumper syndrome occurs when the internal fixator embeds in the gastric wall. Following local guidance, the tube is gently advanced, rotated and returned once healed, and the external fixator is kept slightly loose.

Answer

B · To stop the inner bumper becoming buried in the stomach wall
14.Med-surg: GI, perioperative & oncology

Answer: C · Diathermy can interfere with the pacemaker's function

Why this is the answer

Electrical interference from monopolar diathermy can inhibit or reprogram pacemakers and defibrillators. The team plans ahead, for example using bipolar diathermy, placing the plate carefully or having the device checked.

Answer

C · Diathermy can interfere with the pacemaker's function

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