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. CKeep the left arm wrapped tightly in a bandage at night
  4. DDo not measure blood pressure on the left arm
2.Prioritization & delegationHard

A 2-month-old infant has a spiral fracture of the femur. The parents say the baby rolled off the sofa. What should the nurse recognize?

  1. AInfants of this age often roll off furniture and break bones in this way
  2. BA spiral fracture in an infant is always caused by birth trauma
  3. CNo further action is needed once the fracture is treated
  4. DThe injury does not fit the infant’s development, so possible abuse must be reported
3.Infection control & patient safetyMedium

The barcode scanner warns that the medication does not match the patient’s record. What should the nurse do?

  1. AGive the medication and report the warning later in the shift
  2. BStop and find out why before giving the medication
  3. COverride the warning and give the medication
  4. DScan a different patient’s wristband
4.Infection control & patient safetyHard

A patient refuses to wear an identification wristband. What should the nurse do?

  1. AStop giving the patient any care until they agree to wear the band
  2. BExplain why it is needed, use other ID methods per policy and document
  3. CForce the band onto the patient’s wrist
  4. DAccept the refusal and identify the patient by room number and bed space instead
5.Lab values & electrolytesMedium

A patient taking furosemide has a potassium of 3.3 mEq/L and is told to eat more potassium-rich foods. Which snack is the best choice?

  1. ARice cakes
  2. BDried apricots
  3. CWhite bread
  4. DPlain crackers
6.Lab values & electrolytesHard

A patient who had pituitary surgery has fatigue and cold intolerance. The free T4 is low and the TSH is low. What does this pattern suggest?

  1. AHyperthyroidism from overactivity of the thyroid gland
  2. BPrimary hypothyroidism from failure of the thyroid gland
  3. CNormal thyroid function with a laboratory error in T4
  4. DSecondary (central) hypothyroidism from pituitary failure
7.Clinical nursingMedium

What happens in third-degree (complete) heart block?

  1. AThe atria beat chaotically with no P waves, and the ventricular rate is irregular
  2. BEvery impulse reaches the ventricles, but each one is slightly delayed
  3. CThe ventricles beat very fast and regularly
  4. DNo impulses from the atria reach the ventricles, so they beat independently
8.Clinical nursingHard

In a patient with a head injury, which is usually the earliest sign of rising intracranial pressure?

  1. AA fixed, dilated pupil on both sides
  2. BIrregular breathing pauses
  3. CA slow pulse with high blood pressure
  4. DA change in level of consciousness
9.Med-surg: cardiovascular & respiratoryMedium

The telemetry monitor suddenly shows a chaotic waveform resembling ventricular fibrillation, but the patient is talking and brushing their teeth. What should the nurse do first?

  1. ACheck the patient and the electrodes, as this is likely artefact
  2. BGive IV amiodarone as a bolus
  3. CDeliver an immediate defibrillation shock before checking anything
  4. DStart chest compressions straight away and call the arrest team
10.Med-surg: cardiovascular & respiratoryHard

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia nasal cannula at 2 L/min
  2. BVia a non-rebreather mask over the mouth only
  3. CVia a standard face mask over the nose and mouth
  4. DVia a mask or humidified device over the neck stoma
11.Med-surg: neuro, endocrine & renalMedium

A patient on gliclazide (a sulfonylurea) is admitted with hypoglycaemia. Why is extended monitoring needed?

  1. AThe drug acts for many hours, so the low glucose can return
  2. BThe drug acts only at night, so morning checks are not useful
  3. CThe drug raises glucose after a delay of several hours
  4. DSulfonylureas cannot cause hypoglycaemia on their own
12.Med-surg: neuro, endocrine & renalHard

A patient with acute ischaemic stroke is not a thrombolysis candidate. On day 1 the BP is 190/100 mmHg with no other emergency. What is generally appropriate?

  1. ALower it rapidly to 110/70 mmHg with IV drugs
  2. BGive nitrate spray every 5 minutes until below 120 mmHg
  3. CAvoid aggressive lowering and follow the stroke team's targets
  4. DLie the patient flat and give a large fluid bolus
13.Med-surg: GI, perioperative & oncologyMedium

Dysphagia that started with solids and now includes liquids, with weight loss, most suggests which cause?

  1. ASimple anxiety about swallowing tablets
  2. BA narrowing such as an oesophageal tumour
  3. CNormal ageing of the swallowing muscles
  4. DA dry mouth from drinking too little water
14.Med-surg: GI, perioperative & oncologyHard

On day 2 of nasogastric feeding, a severely malnourished patient becomes weak and breathless with ankle swelling. Phosphate is 0.4 mmol/L. What is most likely?

  1. AToo little calorie intake
  2. BAn allergy to the feed formula
  3. CNormal adjustment to the new feed
  4. DRefeeding syndrome

3Solutions

1.Prioritization & delegation

Answer: D · 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

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

Answer: D · The injury does not fit the infant’s development, so possible abuse must be reported

Why this is the answer

Most 2-month-olds cannot roll, and a spiral fracture in a non-mobile infant suggests a twisting force. Nurses must report suspected abuse according to law and policy.

Answer

D · The injury does not fit the infant’s development, so possible abuse must be reported
3.Infection control & patient safety

Answer: B · Stop and find out why before giving the medication

Why this is the answer

Barcode warnings exist to catch wrong-patient, wrong-drug and wrong-dose errors. The nurse stops and checks the order and the product, and contacts the pharmacy or prescriber. Overriding warnings out of habit causes errors.

Answer

B · Stop and find out why before giving the medication
4.Infection control & patient safety

Answer: B · Explain why it is needed, use other ID methods per policy and document

Why this is the answer

The nurse explains how the band prevents errors. If the patient still refuses, the nurse follows policy for alternative identification using two identifiers, informs the team and documents it.

Answer

B · Explain why it is needed, use other ID methods per policy and document
5.Lab values & electrolytes

Answer: B · Dried apricots

Why this is the answer

Dried fruits such as apricots, raisins and prunes are rich in potassium, as are bananas, oranges, potatoes, beans and tomatoes. Refined grain products such as white bread and crackers are low in potassium.Checked against: Potassium in diet · MedlinePlus (NIH) (2026)

Answer

B · Dried apricots
6.Lab values & electrolytes

Answer: D · Secondary (central) hypothyroidism from pituitary failure

Why this is the answer

In primary hypothyroidism, a low T4 causes a high TSH. A low T4 with a low or inappropriately normal TSH means the pituitary (or hypothalamus) is not producing enough TSH, so the TSH cannot be used alone to monitor treatment.Checked against: Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Hypothyroidism · MedlinePlus (NIH) (2024)

Answer

D · Secondary (central) hypothyroidism from pituitary failure
7.Clinical nursing

Answer: D · No impulses from the atria reach the ventricles, so they beat independently

Why this is the answer

In complete heart block the atria and ventricles are dissociated, and a slow escape rhythm drives the ventricles. Patients may be dizzy or collapse and often need pacing.

Answer

D · No impulses from the atria reach the ventricles, so they beat independently
8.Clinical nursing

Answer: D · A change in level of consciousness

Why this is the answer

Subtle changes in consciousness, such as restlessness, confusion or a falling GCS, are often the first signs. Pupil changes and Cushing's triad (hypertension, bradycardia, irregular breathing) are late signs.

Answer

D · A change in level of consciousness
9.Med-surg: cardiovascular & respiratory

Answer: A · Check the patient and the electrodes, as this is likely artefact

Why this is the answer

Movement, loose electrodes and muscle activity can create artefact that looks like VF. A conscious, talking patient cannot be in VF. The nurse assesses the patient and checks the leads and electrodes, then reattaches them if needed.

Answer

A · Check the patient and the electrodes, as this is likely artefact
10.Med-surg: cardiovascular & respiratory

Answer: D · Via a mask or humidified device over the neck stoma

Why this is the answer

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

Answer

D · Via a mask or humidified device over the neck stoma
11.Med-surg: neuro, endocrine & renal

Answer: A · The drug acts for many hours, so the low glucose can return

Why this is the answer

Sulfonylureas stimulate the pancreas to release insulin and have long durations of action, especially in older people and those with renal impairment. Hypoglycaemia can recur after initial treatment, so prolonged glucose monitoring is needed.

Answer

A · The drug acts for many hours, so the low glucose can return
12.Med-surg: neuro, endocrine & renal

Answer: C · Avoid aggressive lowering and follow the stroke team's targets

Why this is the answer

After ischaemic stroke, the penumbra depends on blood pressure for perfusion. Unless thrombolysis is planned or there is another emergency (such as aortic dissection or acute heart failure), guidelines often accept higher pressures early (for example treating only above 220/120 mmHg in some guidance). Targets are set by the stroke team.

Answer

C · Avoid aggressive lowering and follow the stroke team's targets
13.Med-surg: GI, perioperative & oncology

Answer: B · A narrowing such as an oesophageal tumour

Why this is the answer

Progressive dysphagia, solids first then liquids, with weight loss, is typical of a mechanical obstruction such as oesophageal cancer or a stricture. It needs an urgent referral for endoscopy.

Answer

B · A narrowing such as an oesophageal tumour
14.Med-surg: GI, perioperative & oncology

Answer: D · Refeeding syndrome

Why this is the answer

Refeeding syndrome causes low phosphate, potassium and magnesium with fluid retention, heart failure and muscle weakness. The team slows the feed, replaces electrolytes, gives thiamine and monitors closely.

Answer

D · Refeeding syndrome

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