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 has a blood pressure of 210/120 mmHg. Which finding would make this a hypertensive emergency?

  1. AA history of high blood pressure for ten years
  2. BMild anxiety about the high reading on the monitor
  3. CNew chest pain or confusion suggesting organ damage
  4. DForgetting to take the blood pressure tablet this morning
2.Prioritization & delegationHard

A nurse thinks a prescribed dose is unsafe. The prescriber says to give it anyway. What should the nurse do?

  1. AGive the dose, because the prescriber is now responsible for it
  2. BSkip the dose quietly and say nothing to avoid conflict
  3. CHold the dose and escalate through the chain of command
  4. DGive half the dose as a compromise and document the reason
3.Infection control & patient safetyMedium

A patient with suspected tuberculosis is in a negative-pressure room. Which practice is correct?

  1. AKeep the door closed except when entering or leaving
  2. BLet visitors enter without any protection
  3. CKeep the door open so staff can see the patient at all times
  4. DTurn off the room ventilation at night
4.Infection control & patient safetyHard

A confused patient in wrist restraints has cool, pale fingers on one hand and a weak radial pulse on that side. What should the nurse do first?

  1. ARaise the hand on a pillow, leaving the restraint as it is
  2. BTighten the other restraint to stop the patient pulling
  3. CDocument the findings carefully and recheck in two hours
  4. DLoosen that restraint and assess the hand’s circulation
5.Lab values & electrolytesMedium

Why do patients with chronic kidney disease often have anemia?

  1. AUremic toxins make the bone marrow produce white cells instead of red cells
  2. BThe damaged kidneys filter out and destroy red blood cells
  3. CHigh potassium in kidney disease breaks down red cells
  4. DThe kidneys make less erythropoietin, which drives red cell production
6.Lab values & electrolytesHard

A patient taking isoniazid for latent TB reports nausea, loss of appetite and dark urine. The ALT is five times the upper limit of normal. What is the best action?

  1. AHold the isoniazid and report the findings to the prescriber at once
  2. BContinue the isoniazid and give it with food to settle the stomach
  3. CDouble the dose to finish the treatment course more quickly
  4. DReassure the patient that dark urine is a harmless drug effect
7.Clinical nursingMedium

Why is it important to prevent hypothermia during and after surgery?

  1. AIt increases the risk of wound infection, bleeding and cardiac complications
  2. BIt causes high blood glucose only
  3. CIt makes the patient wake up too quickly and become agitated in recovery
  4. DIt makes the patient's pain disappear
8.Clinical nursingHard

A patient with severe asthma becomes quiet, with a "silent chest", exhaustion and a falling respiratory rate. What does this indicate?

  1. AAnxiety only
  2. BNormal recovery after a nebuliser
  3. CLife-threatening asthma with impending respiratory arrest
  4. DImprovement of the attack as the bronchospasm settles and the airways relax
9.Med-surg: cardiovascular & respiratoryMedium

Where is the V1 electrode placed for a 12-lead ECG?

  1. AThe fifth intercostal space in the mid-axillary line
  2. BThe fourth intercostal space just right of the sternum
  3. COver the left nipple
  4. DJust below the left collarbone
10.Med-surg: cardiovascular & respiratoryHard

A ventilated patient suddenly desaturates to 82%. The cause is not obvious and the ventilator alarms are sounding. What should the nurse do first?

  1. ADisconnect and hand-ventilate with 100% oxygen while calling for help
  2. BChange the ventilator settings to a higher rate
  3. CSilence the alarm and wait for the result of the next routine blood gas
  4. DIncrease the sedation and watch the monitor for the next half hour
11.Med-surg: neuro, endocrine & renalMedium

What is the dexamethasone suppression test used for?

  1. ATo help diagnose Cushing's syndrome
  2. BTo measure kidney function
  3. CTo diagnose diabetes insipidus
  4. DTo check thyroid function
12.Med-surg: neuro, endocrine & renalHard

A patient with a severe head injury does not open the eyes, and in response to pain the arms extend and rotate inwards with the legs extended. What does this indicate?

  1. AExtensor (decerebrate) posturing: severe brainstem injury
  2. BA normal withdrawal response to a painful stimulus
  3. CFlexor (decorticate) posturing, a sign of mild cortical injury
  4. DA focal seizure that will stop without any treatment
13.Med-surg: GI, perioperative & oncologyMedium

How does sucralfate help a peptic ulcer heal?

  1. AIt blocks histamine receptors on parietal cells
  2. BIt forms a protective coating over the ulcer base
  3. CIt speeds up emptying of the stomach
  4. DIt kills H. pylori in the stomach lining
14.Med-surg: GI, perioperative & oncologyHard

After a coughing fit, the external mark on a patient's nasogastric tube has moved 10 cm. Feed is due. What should the nurse do?

  1. AGive the medicines only and save the feed for later
  2. BPush the tube back to the original mark and start the feed
  3. CStart the feed at a slow rate and watch for coughing
  4. DDo not use the tube until its position is confirmed by policy

3Solutions

1.Prioritization & delegation

Answer: C · New chest pain or confusion suggesting organ damage

Why this is the answer

Severe hypertension becomes an emergency when there is acute organ damage, such as chest pain, neurological changes or kidney injury. It needs urgent, controlled lowering of the blood pressure.

Answer

C · New chest pain or confusion suggesting organ damage
2.Prioritization & delegation

Answer: C · Hold the dose and escalate through the chain of command

Why this is the answer

A nurse who believes an order is unsafe does not give it, documents the concern, and escalates through the chain of command until it is resolved. Changing the dose alone or silently omitting it is unsafe and outside nursing scope.

Answer

C · Hold the dose and escalate through the chain of command
3.Infection control & patient safety

Answer: A · Keep the door closed except when entering or leaving

Why this is the answer

The door is kept closed so that the airflow into the room is maintained. Visitors are limited and instructed about respiratory protection according to policy.

Answer

A · Keep the door closed except when entering or leaving
4.Infection control & patient safety

Answer: D · Loosen that restraint and assess the hand’s circulation

Why this is the answer

Signs of poor circulation distal to a restraint require immediate release and assessment. The restraint is then reapplied correctly only if still needed, with the two-finger check, and the findings are reported and documented.

Answer

D · Loosen that restraint and assess the hand’s circulation
5.Lab values & electrolytes

Answer: D · The kidneys make less erythropoietin, which drives red cell production

Why this is the answer

Diseased kidneys produce less erythropoietin, so the marrow makes fewer red cells. Treatment can include erythropoiesis-stimulating agents and iron.Checked against: Anemia · MedlinePlus (NIH) (2026); Erythropoietin test · MedlinePlus (NIH) (2025)

Answer

D · The kidneys make less erythropoietin, which drives red cell production
6.Lab values & electrolytes

Answer: A · Hold the isoniazid and report the findings to the prescriber at once

Why this is the answer

Isoniazid can cause hepatitis, which may be severe. Symptoms such as nausea, loss of appetite and dark urine with a markedly raised ALT mean the drug should be held and the prescriber informed. Patients are taught to avoid alcohol and report these symptoms early.

Answer

A · Hold the isoniazid and report the findings to the prescriber at once
7.Clinical nursing

Answer: A · It increases the risk of wound infection, bleeding and cardiac complications

Why this is the answer

Inadvertent perioperative hypothermia impairs clotting and immune function and increases cardiac events and wound infection. Patients are warmed actively and their temperature monitored.

Answer

A · It increases the risk of wound infection, bleeding and cardiac complications
8.Clinical nursing

Answer: C · Life-threatening asthma with impending respiratory arrest

Why this is the answer

A silent chest, exhaustion, cyanosis and confusion are life-threatening signs. The patient needs immediate senior and critical care input.

Answer

C · Life-threatening asthma with impending respiratory arrest
9.Med-surg: cardiovascular & respiratory

Answer: B · The fourth intercostal space just right of the sternum

Why this is the answer

V1 is placed in the fourth intercostal space at the right sternal edge, and V2 at the left sternal edge. V4 is in the fifth intercostal space in the mid-clavicular line, and V6 in the mid-axillary line at the same level. Wrong placement can mimic or hide changes.

Answer

B · The fourth intercostal space just right of the sternum
10.Med-surg: cardiovascular & respiratory

Answer: A · Disconnect and hand-ventilate with 100% oxygen while calling for help

Why this is the answer

When a ventilated patient deteriorates suddenly, bag-valve ventilation with 100% oxygen takes the ventilator out of the picture. The nurse then checks for displacement, obstruction, pneumothorax and equipment failure (often remembered as DOPE) and calls for senior help.

Answer

A · Disconnect and hand-ventilate with 100% oxygen while calling for help
11.Med-surg: neuro, endocrine & renal

Answer: A · To help diagnose Cushing's syndrome

Why this is the answer

A dose of dexamethasone normally suppresses ACTH and cortisol. In Cushing's syndrome, cortisol stays high. The test is part of the work-up for cortisol excess.

Answer

A · To help diagnose Cushing's syndrome
12.Med-surg: neuro, endocrine & renal

Answer: A · Extensor (decerebrate) posturing: severe brainstem injury

Why this is the answer

Abnormal extension to pain (GCS motor score 2) indicates severe injury at or near the brainstem and carries a worse prognosis than abnormal flexion (decorticate posturing, motor score 3). Any new abnormal posturing needs immediate escalation.

Answer

A · Extensor (decerebrate) posturing: severe brainstem injury
13.Med-surg: GI, perioperative & oncology

Answer: B · It forms a protective coating over the ulcer base

Why this is the answer

Sucralfate binds to the ulcer base and forms a barrier against acid and pepsin. It works best on an empty stomach and can reduce the absorption of other drugs, so doses are separated.

Answer

B · It forms a protective coating over the ulcer base
14.Med-surg: GI, perioperative & oncology

Answer: D · Do not use the tube until its position is confirmed by policy

Why this is the answer

A change in external length means the tube may have moved. Pushing it back blindly is unsafe. It is not used until placement is confirmed by pH or X-ray, or it is replaced.

Answer

D · Do not use the tube until its position is confirmed by policy

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