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 on hemodialysis has an arteriovenous fistula in the left arm. Which instruction should the nurse give the nursing assistant?

  1. AHelp the patient carry shopping bags on the left arm
  2. BMeasure blood pressure on the left arm only, every 4 hours
  3. CDo not measure blood pressure on the left arm
  4. DKeep the left arm wrapped tightly in a bandage at night
2.Prioritization & delegationHard

A patient with a head injury and a leg fracture is being monitored. Which finding is the priority?

  1. AA small graze on the elbow
  2. BThe Glasgow Coma Scale score falls from 15 to 12
  3. CLeg pain of 6/10 despite the last dose of analgesia
  4. DThe patient asks for something to eat
3.Infection control & patient safetyMedium

Why is “QD” (once daily) on The Joint Commission’s “Do Not Use” list?

  1. AIt can be misread as QID or QOD, so the drug is given too often or too rarely
  2. BIt is a Latin abbreviation, and only plain English abbreviations may be used
  3. CIt means “every day at bedtime” in some hospitals
  4. DIt is only allowed for intravenous medicines
4.Infection control & patient safetyHard

A patient is prescribed hydralazine, but the pharmacy has sent hydroxyzine. What should the nurse do?

  1. AGive it now and tell the prescriber afterwards
  2. BNot give it, and contact the pharmacy to obtain the correct drug
  3. CGive it, because the two drug names are almost the same
  4. DGive half the dose of hydroxyzine as a compromise
5.Lab values & electrolytesMedium

A patient on phenytoin has a level of 28 mcg/mL (usual range about 10–20 mcg/mL). Which findings would the nurse expect?

  1. ANystagmus, unsteady gait and slurred speech
  2. BHunger and weight gain
  3. CHyperactive behavior and insomnia only
  4. DTall, peaked T waves
6.Lab values & electrolytesHard

An aPTT result is extremely high, but the nurse learns that the sample was taken from the arm where the heparin infusion runs. What is the best action?

  1. AGive protamine at once to reverse the heparin
  2. BRequest a new sample from the opposite arm before the dose is adjusted
  3. CStop the heparin infusion permanently and inform the provider
  4. DAccept the result and halve the infusion rate
7.Clinical nursingMedium

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

  1. AOn both shoulders and both hips only
  2. BIn standard numbered positions across the front and left of the chest
  3. CIn a straight line down the centre of the sternum from top to bottom
  4. DAnywhere on the chest where the skin is clear
8.Clinical nursingHard

A patient with back pain develops numbness around the anus and genitals and new difficulty passing urine. Which condition should be suspected?

  1. AConstipation
  2. BCauda equina syndrome
  3. CSimple muscle strain
  4. DKidney stones
9.Med-surg: cardiovascular & respiratoryMedium

A patient on home oxygen has dry, sore lips. Which product is safest to use?

  1. AA water-based lubricant
  2. BAn oil-based balm
  3. CPetroleum jelly
  4. DAn alcohol-based gel
10.Med-surg: cardiovascular & respiratoryHard

A nurse phones the doctor about a patient with pneumonia whose observations are worsening. Using SBAR, which statement is the clearest "recommendation"?

  1. A"He is 72 and was admitted yesterday with community-acquired pneumonia."
  2. B"I think he may have sepsis; please review him within 30 minutes."
  3. C"I am calling about the patient in bed 6."
  4. D"His heart rate is 124/min, his BP is 88/50 mmHg and he is confused."
11.Med-surg: neuro, endocrine & renalMedium

A patient with a new ileal conduit has threads of mucus in their urine. What should the nurse explain?

  1. AThis is a sign that the stoma is dying
  2. BThis is normal, because the conduit is made from bowel
  3. CThis proves a serious kidney infection
  4. DThe kidneys have stopped working properly after surgery
12.Med-surg: neuro, endocrine & renalHard

A patient with cranial diabetes insipidus starts desmopressin. Which complication should the nurse monitor for?

  1. AHyponatraemia
  2. BSevere diarrhoea
  3. CHyperglycaemia
  4. DHyperkalaemia
13.Med-surg: GI, perioperative & oncologyMedium

Why is the time a surgical limb tourniquet is inflated carefully recorded?

  1. AThe surgeon is paid per minute of use
  2. BLong inflation can cause nerve and muscle damage
  3. CThe tourniquet slowly loses all its air after one minute
  4. DIt shows how long the anaesthetic gas was used
14.Med-surg: GI, perioperative & oncologyHard

A patient on immunotherapy for melanoma has six watery stools a day and abdominal cramps. What should the nurse do?

  1. AAdvise eating more fibre and fruit to firm up the stools
  2. BEscalate urgently, as immune-related colitis is likely
  3. CReassure that diarrhoea is normal and harmless
  4. DGive loperamide and review next week

3Solutions

1.Prioritization & delegation

Answer: C · Do not measure blood pressure on the left arm

Why this is the answer

Blood pressure cuffs, tight bands and heavy loads can damage or block a fistula. The arm with the access is protected, and the nurse checks it for a thrill and bruit.

Answer

C · Do not measure blood pressure on the left arm
2.Prioritization & delegation

Answer: B · The Glasgow Coma Scale score falls from 15 to 12

Why this is the answer

A falling GCS suggests rising pressure inside the skull, which can be fatal, and needs urgent escalation. Fracture pain needs treatment too, but it does not threaten life in the same way.

Answer

B · The Glasgow Coma Scale score falls from 15 to 12
3.Infection control & patient safety

Answer: A · It can be misread as QID or QOD, so the drug is given too often or too rarely

Why this is the answer

“QD” and “QOD” can be confused with each other and with “QID”, leading to serious dosing errors. The word “daily” or “every other day” is written in full instead.

Answer

A · It can be misread as QID or QOD, so the drug is given too often or too rarely
4.Infection control & patient safety

Answer: B · Not give it, and contact the pharmacy to obtain the correct drug

Why this is the answer

Hydralazine is an antihypertensive, while hydroxyzine is an antihistamine used for itching and anxiety. Giving the wrong drug is a medication error. The nurse withholds it, gets the correct drug and reports the dispensing error.

Answer

B · Not give it, and contact the pharmacy to obtain the correct drug
5.Lab values & electrolytes

Answer: A · Nystagmus, unsteady gait and slurred speech

Why this is the answer

Phenytoin toxicity causes nystagmus, ataxia, slurred speech and drowsiness. The nurse holds the dose and informs the prescriber. Low albumin increases the free (active) drug, so toxicity can occur even with a normal total level.

Answer

A · Nystagmus, unsteady gait and slurred speech
6.Lab values & electrolytes

Answer: B · Request a new sample from the opposite arm before the dose is adjusted

Why this is the answer

Blood drawn from the infusion arm contains heparin from the drip, so the aPTT is falsely high. A sample from the other arm gives a true result. Changing the dose on a false result could cause clotting.

Answer

B · Request a new sample from the opposite arm before the dose is adjusted
7.Clinical nursing

Answer: B · In standard numbered positions across the front and left of the chest

Why this is the answer

The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.

Answer

B · In standard numbered positions across the front and left of the chest
8.Clinical nursing

Answer: B · Cauda equina syndrome

Why this is the answer

Saddle anaesthesia, bladder or bowel dysfunction and leg symptoms with back pain suggest cauda equina syndrome. It needs an emergency MRI and surgical review to prevent permanent loss of function.

Answer

B · Cauda equina syndrome
9.Med-surg: cardiovascular & respiratory

Answer: A · A water-based lubricant

Why this is the answer

Oil-based products such as petroleum jelly can ignite or burn intensely in high oxygen concentrations and have caused facial burns. Water-based products are recommended. Oxygen cylinders are kept upright and secured, away from heat and flames.

Answer

A · A water-based lubricant
10.Med-surg: cardiovascular & respiratory

Answer: B · "I think he may have sepsis; please review him within 30 minutes."

Why this is the answer

In SBAR, the recommendation states clearly what the nurse needs and how quickly, such as a review within a set time. The other statements belong to situation, background and assessment. Structured communication reduces delays in escalation.

Answer

B · "I think he may have sepsis; please review him within 30 minutes."
11.Med-surg: neuro, endocrine & renal

Answer: B · This is normal, because the conduit is made from bowel

Why this is the answer

An ileal conduit uses a piece of small bowel, which keeps making mucus. Mucus in the urine is expected. Good fluid intake helps keep it moving. Fever, cloudy foul urine or a change in stoma colour should be reported.

Answer

B · This is normal, because the conduit is made from bowel
12.Med-surg: neuro, endocrine & renal

Answer: A · Hyponatraemia

Why this is the answer

Desmopressin is a synthetic ADH analogue. If the patient continues drinking large amounts, water retention can cause hyponatraemia, with headache, confusion or seizures. Patients are advised to drink to thirst, and sodium, weight and fluid balance are monitored.

Answer

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

Answer: B · Long inflation can cause nerve and muscle damage

Why this is the answer

A tourniquet creates a bloodless field but causes limb ischaemia. Inflation time and pressure are recorded and the surgeon is told at set intervals, as long inflation can damage nerves and muscle.

Answer

B · Long inflation can cause nerve and muscle damage
14.Med-surg: GI, perioperative & oncology

Answer: B · Escalate urgently, as immune-related colitis is likely

Why this is the answer

Severe diarrhoea on checkpoint inhibitors suggests immune-mediated colitis, which can perforate. It needs urgent assessment, infection testing and often high-dose steroids, not only antidiarrhoeals.

Answer

B · Escalate urgently, as immune-related colitis is likely

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