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

Before giving a scheduled dose of metoprolol, which assessment is most important?

  1. ABowel sounds and urine color
  2. BApical pulse and blood pressure
  3. CTemperature and the latest pain score
  4. DBlood glucose and weight
2.Prioritization & delegationHard

An older adult with type 2 diabetes is confused and very dehydrated. The glucose is 900 mg/dL (50 mmol/L), and blood and urine show no significant ketones. What is the most likely problem?

  1. AHypoglycemia with rebound
  2. BStress-induced mild hyperglycemia
  3. CHyperosmolar hyperglycemic state
  4. DDiabetic ketoacidosis
3.Infection control & patient safetyMedium

A nurse pours sterile saline into a bowl on a sterile field. Which technique is correct?

  1. AReach across the field to fill the bowl at the far side
  2. BPour from below the level of the field to reduce splashing
  3. CHold the bottle with the label in the palm and pour without touching the bowl
  4. DRest the lip of the bottle on the edge of the bowl so that the saline does not splash
4.Infection control & patient safetyHard

A child with chickenpox is admitted. Which staff member is the best choice to care for the child?

  1. AA nurse who has never had chickenpox or the vaccine
  2. BA nurse with documented immunity to varicella
  3. CA nurse who is pregnant and unsure of her immunity
  4. DA student nurse with unknown immunity
5.Lab values & electrolytesMedium

When should a blood specimen tube be labeled?

  1. AAt the nurses' station, after all samples for the shift are drawn
  2. BBefore entering the room, so tubes are ready for the next patients
  3. CAt the bedside, in the patient's presence, using two identifiers
  4. DIn the laboratory, by the staff who receive the unlabeled sample
6.Lab values & electrolytesHard

A patient has a sodium of 150 mEq/L, a glucose of 180 mg/dL and a BUN of 28 mg/dL. Using the formula 2 × Na + glucose/18 + BUN/2.8, what is the calculated serum osmolality?

  1. AAbout 300 mOsm/kg, which is normal
  2. BAbout 358 mOsm/kg, which is high
  3. CAbout 285 mOsm/kg, which is normal
  4. DAbout 320 mOsm/kg, which is high
7.Clinical nursingMedium

Which of these is one of the "4 Hs", the reversible causes of cardiac arrest?

  1. AHyperventilation
  2. BHypoxia
  3. CHypertension
  4. DHyperthyroidism
8.Clinical nursingHard

A nurse notices that a wrong dose of a drug was prepared but was caught before it was given. What should be done?

  1. ASay nothing, because no harm reached the patient
  2. BTell only the patient's family
  3. CReport it as a near miss through the incident reporting system
  4. DDiscipline the nurse who prepared it on the spot in front of colleagues
9.Med-surg: cardiovascular & respiratoryMedium

After repair of an abdominal aortic aneurysm, which regular assessment helps detect a blocked graft or clots in the legs?

  1. AChecking leg pulses, colour, warmth and sensation
  2. BChecking the pupils' response to light
  3. CTesting the gag reflex every four hours after surgery
  4. DMeasuring the blood glucose every hour through the night
10.Med-surg: cardiovascular & respiratoryHard

A patient taking warfarin for AF falls and hits their head. An hour later they are drowsy and have vomited. What is the priority?

  1. AEncourage sleep and check observations at the next routine time
  2. BUrgent escalation for CT of the head and anticoagulant reversal
  3. CWithhold tonight's warfarin and review tomorrow
  4. DGive paracetamol (acetaminophen) and a light meal
11.Med-surg: neuro, endocrine & renalMedium

A patient has a nephrostomy tube. Which finding needs urgent action?

  1. ADrainage that stops suddenly with new loin pain
  2. BSteady urine drainage into the bag
  3. CLight pink urine on the first day after insertion
  4. DA dry, intact dressing at the site
12.Med-surg: neuro, endocrine & renalHard

A patient in thyroid storm has a temperature of 40 °C (104 °F). Which measure for the fever is usually avoided?

  1. AAspirin
  2. BFanning with cool air
  3. CParacetamol (acetaminophen)
  4. DCooling blankets
13.Med-surg: GI, perioperative & oncologyMedium

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

  1. AAvoid all fruit and vegetables for the rest of their life
  2. BDrink as little fluid as possible to reduce output
  3. CEat a normal, balanced diet and introduce foods gradually
  4. DEat only liquids until the stoma is removed
14.Med-surg: GI, perioperative & oncologyHard

On day 2 after upper abdominal surgery, a patient has a temperature of 37.8 °C, SpO₂ 93% on air and reduced breath sounds at both bases. They have not used their incentive spirometer because of pain. What is the most appropriate nursing plan?

  1. AKeep the patient in bed and restrict movement until the fever settles
  2. BGive oxygen at 15 L/min and leave the patient to rest quietly
  3. CBetter pain control, sitting up, deep breathing, mobilising and reporting
  4. DStop all analgesia so that the patient can cough more strongly

3Solutions

1.Prioritization & delegation

Answer: B · Apical pulse and blood pressure

Why this is the answer

Metoprolol can cause bradycardia and hypotension, so the nurse checks the apical pulse and blood pressure first. The dose is held and reported according to the prescribed parameters.

Answer

B · Apical pulse and blood pressure
2.Prioritization & delegation

Answer: C · Hyperosmolar hyperglycemic state

Why this is the answer

Hyperosmolar hyperglycemic state occurs mainly in type 2 diabetes, with extreme glucose, severe dehydration and little or no ketosis. Treatment starts with IV fluids, as in DKA.

Answer

C · Hyperosmolar hyperglycemic state
3.Infection control & patient safety

Answer: C · Hold the bottle with the label in the palm and pour without touching the bowl

Why this is the answer

The nurse pours from a little height without touching the sterile bowl, avoiding splashes that would wet the field. Holding the label in the palm keeps it readable and free of drips.

Answer

C · Hold the bottle with the label in the palm and pour without touching the bowl
4.Infection control & patient safety

Answer: B · A nurse with documented immunity to varicella

Why this is the answer

Staff with proven immunity, from vaccination or past infection, should care for patients with varicella. Non-immune staff, especially pregnant staff, risk infection and can spread the virus to other patients.

Answer

B · A nurse with documented immunity to varicella
5.Lab values & electrolytes

Answer: C · At the bedside, in the patient's presence, using two identifiers

Why this is the answer

Specimens are labeled immediately after collection, at the bedside, after checking two patient identifiers such as name and date of birth. Pre-labeling or labeling away from the patient can put the wrong patient's name on the sample, which can lead to harmful decisions.

Answer

C · At the bedside, in the patient's presence, using two identifiers
6.Lab values & electrolytes

Answer: D · About 320 mOsm/kg, which is high

Why this is the answer

Osmolality = 300 + 10 + 10 = 320 mOsm/kg, above the typical range of about 275–295 mOsm/kg. The high sodium is the main cause, which points to water loss or too little water intake.Checked against: Osmolality blood test · MedlinePlus (NIH) (2025)

Answer

D · About 320 mOsm/kg, which is high
7.Clinical nursing

Answer: B · Hypoxia

Why this is the answer

The 4 Hs are hypoxia, hypovolaemia, hypo- or hyperkalaemia and other metabolic causes, and hypothermia. The 4 Ts are thrombosis, tension pneumothorax, tamponade and toxins.

Answer

B · Hypoxia
8.Clinical nursing

Answer: C · Report it as a near miss through the incident reporting system

Why this is the answer

Near misses are reported so that causes can be studied and systems improved. A just, open culture encourages reporting without blame.

Answer

C · Report it as a near miss through the incident reporting system
9.Med-surg: cardiovascular & respiratory

Answer: A · Checking leg pulses, colour, warmth and sensation

Why this is the answer

After aortic surgery, distal pulses, skin colour, temperature, capillary refill, movement and sensation are checked often and compared with baseline. Loss of pulses, pallor or pain suggests graft occlusion or emboli and must be reported at once. Urine output is also monitored for renal perfusion.

Answer

A · Checking leg pulses, colour, warmth and sensation
10.Med-surg: cardiovascular & respiratory

Answer: B · Urgent escalation for CT of the head and anticoagulant reversal

Why this is the answer

Head injury in an anticoagulated patient with drowsiness or vomiting suggests intracranial haemorrhage. Urgent CT, neurological observations, an INR and rapid reversal (for warfarin, prothrombin complex concentrate and IV vitamin K) are needed.

Answer

B · Urgent escalation for CT of the head and anticoagulant reversal
11.Med-surg: neuro, endocrine & renal

Answer: A · Drainage that stops suddenly with new loin pain

Why this is the answer

A sudden stop in drainage with pain suggests the tube is blocked or dislodged, so the kidney is obstructed again. The nurse checks for kinks and escalates urgently. Fever or rigors may signal infection.

Answer

A · Drainage that stops suddenly with new loin pain
12.Med-surg: neuro, endocrine & renal

Answer: A · Aspirin

Why this is the answer

Aspirin (salicylates) displaces thyroid hormone from binding proteins, raising free hormone levels. Paracetamol (acetaminophen) and external cooling are used instead, together with treatment for the storm itself.

Answer

A · Aspirin
13.Med-surg: GI, perioperative & oncology

Answer: C · Eat a normal, balanced diet and introduce foods gradually

Why this is the answer

People with a colostomy can usually eat a normal diet. Foods are reintroduced gradually to see how each one affects gas, odour and output, and regular meals and fluids help.

Answer

C · Eat a normal, balanced diet and introduce foods gradually
14.Med-surg: GI, perioperative & oncology

Answer: C · Better pain control, sitting up, deep breathing, mobilising and reporting

Why this is the answer

Basal atelectasis is common after upper abdominal surgery when pain limits deep breathing. Good analgesia, upright positioning, deep breathing exercises, incentive spirometry, supported coughing and early mobilisation re-expand the lungs. The findings are reported, because they may progress to pneumonia; oxygen is given to target if needed.

Answer

C · Better pain control, sitting up, deep breathing, mobilising and reporting

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