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 nurse teaches a patient about levothyroxine. Which statement shows a need for further teaching?

  1. A“I will take it at breakfast with my calcium tablet.”
  2. B“I will keep taking it even when I feel well.”
  3. C“I will take it at the same time each morning.”
  4. D“I will take it on an empty stomach with a glass of water.”
2.Prioritization & delegationHard

A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?

  1. AThe patient’s mood and coping
  2. BMuscle strength in the feet and ankles at the start of each morning
  3. CBreathing strength, such as vital capacity and the ability to cough
  4. DSkin condition over the heels
3.Infection control & patient safetyMedium

A patient is receiving opioids for pain. Which sign usually comes before opioid-induced respiratory depression?

  1. ARising blood pressure
  2. BDiarrhea
  3. CIncreasing sedation
  4. DDilated pupils
4.Infection control & patient safetyHard

A nurse has worked three long shifts in a row and feels exhausted. The manager asks the nurse to stay for another shift. What is the most appropriate response?

  1. AAgree without telling anyone about the fatigue
  2. BExplain that fatigue would make care unsafe and decline the extra shift
  3. CAgree and drink extra coffee to stay alert
  4. DAgree, but skip the independent medication checks to save energy on the shift
5.Lab values & electrolytesMedium

A patient scheduled for surgery this morning has a potassium of 3.0 mEq/L on pre-operative tests. What should the nurse do?

  1. ASend the patient to surgery without comment
  2. BGive an oral potassium dose without a prescription
  3. CRepeat the test after the surgery is finished
  4. DReport it to the surgical team before surgery
6.Lab values & electrolytesHard

A patient on high-dose dexamethasone has a white cell count of 15 × 10³/µL, mostly mature neutrophils with no bands. They have no fever and no signs of infection. What is the most likely explanation?

  1. ACertain sepsis that needs antibiotics started without delay
  2. BA new leukemia that is confirmed by this result alone
  3. CA laboratory error, because steroids always lower the white count
  4. DA steroid effect that moves neutrophils into the circulating blood
7.Clinical nursingMedium

How does ulcerative colitis differ from Crohn's disease?

  1. AUlcerative colitis typically causes patchy "skip" lesions
  2. BUlcerative colitis can affect any part of the gut from mouth to anus
  3. CUlcerative colitis affects only the colon, continuously from the rectum
  4. DUlcerative colitis always affects the full thickness of the bowel wall
8.Clinical nursingHard

A patient is admitted with suspected meningococcal disease. Which infection control measure is usually needed?

  1. ANo precautions, because it is not contagious
  2. BIsolation only after the patient has gone home
  3. CAirborne precautions with a negative-pressure room for the whole hospital stay
  4. DDroplet precautions until 24 hours of effective antibiotics have been given
9.Med-surg: cardiovascular & respiratoryMedium

A patient with angle-closure glaucoma needs nebulised ipratropium. What precaution is sensible?

  1. AUse a mouthpiece or protect the eyes from the mist
  2. BGive it only with the patient lying completely flat
  3. CMix it with an eye drop before putting it in the nebuliser
  4. DRun it at the highest possible gas flow
10.Med-surg: cardiovascular & respiratoryHard

A patient with COPD who is known to retain CO₂ arrives on 15 L/min oxygen. They are now drowsy with SpO₂ 99%. What is the most appropriate action?

  1. AKeep the oxygen at 15 L/min because the saturation is excellent
  2. BRemove the oxygen completely and observe
  3. CGive a sedative to help the patient rest
  4. DReduce the oxygen to aim for 88–92% and get a blood gas
11.Med-surg: neuro, endocrine & renalMedium

Which urine finding best distinguishes diabetes insipidus from SIADH?

  1. ADI gives glucose in the urine; SIADH gives protein
  2. BDI gives concentrated urine; SIADH gives dilute urine
  3. CDI gives dilute urine; SIADH gives concentrated urine
  4. DBoth conditions give very concentrated urine
12.Med-surg: neuro, endocrine & renalHard

A patient with a long-term catheter has fever and rigors, and a catheter UTI is suspected. Which action is recommended before starting antibiotics?

  1. AFlush the catheter with saline and continue
  2. BTake a sample from the drainage bag and send it to the lab
  3. CRemove the catheter and leave it out permanently
  4. DReplace the catheter and take a sample from the new one
13.Med-surg: GI, perioperative & oncologyMedium

Which wound drain observation should be reported immediately?

  1. ASmall amounts of pink serous fluid
  2. BA sudden large volume of fresh red blood
  3. CA little dried blood around the drain site
  4. DDrainage slowly falling each day
14.Med-surg: GI, perioperative & oncologyHard

A patient taking oral capecitabine reports red, painful, peeling palms and soles. What should the nurse do?

  1. ATell the patient to take a double dose next time
  2. BReport it; this is hand-foot syndrome and treatment may need changing
  3. CAdvise hot soaks for the hands and feet
  4. DReassure that it is a sign of an unrelated allergy to washing powder

3Solutions

1.Prioritization & delegation

Answer: A · “I will take it at breakfast with my calcium tablet.”

Why this is the answer

Levothyroxine is best absorbed on an empty stomach and is separated from calcium and iron by several hours. It is usually lifelong, so it is not stopped when the patient feels better.

Answer

A · “I will take it at breakfast with my calcium tablet.”
2.Prioritization & delegation

Answer: C · Breathing strength, such as vital capacity and the ability to cough

Why this is the answer

Guillain-Barré syndrome causes ascending weakness that can involve the respiratory muscles. Falling vital capacity or a weak cough can mean the patient needs ventilation, so breathing is monitored closely.

Answer

C · Breathing strength, such as vital capacity and the ability to cough
3.Infection control & patient safety

Answer: C · Increasing sedation

Why this is the answer

Sedation increases before respiratory depression occurs, so sedation levels are checked regularly along with breathing. A patient who is getting harder to wake needs the opioid held and the prescriber informed.

Answer

C · Increasing sedation
4.Infection control & patient safety

Answer: B · Explain that fatigue would make care unsafe and decline the extra shift

Why this is the answer

Long hours and fatigue increase errors and injuries. Nurses have a professional responsibility to judge whether they are fit to work safely and to say so clearly.

Answer

B · Explain that fatigue would make care unsafe and decline the extra shift
5.Lab values & electrolytes

Answer: D · Report it to the surgical team before surgery

Why this is the answer

Hypokalemia increases the risk of arrhythmias during anesthesia and can prolong muscle weakness. Abnormal pre-operative results are reported to the surgeon and anesthetist, who decide whether to correct it or delay surgery.Checked against: Hypokalemia · StatPearls (NCBI Bookshelf) (2025)

Answer

D · Report it to the surgical team before surgery
6.Lab values & electrolytes

Answer: D · A steroid effect that moves neutrophils into the circulating blood

Why this is the answer

Corticosteroids raise the neutrophil count by releasing marginated neutrophils and slowing their exit from the blood, usually without a left shift. The nurse still assesses carefully, because steroids can also hide the usual signs of infection.

Answer

D · A steroid effect that moves neutrophils into the circulating blood
7.Clinical nursing

Answer: C · Ulcerative colitis affects only the colon, continuously from the rectum

Why this is the answer

Ulcerative colitis involves the mucosa of the colon, spreading continuously from the rectum. Crohn's disease can affect any part of the GI tract, is transmural and has skip lesions.

Answer

C · Ulcerative colitis affects only the colon, continuously from the rectum
8.Clinical nursing

Answer: D · Droplet precautions until 24 hours of effective antibiotics have been given

Why this is the answer

Neisseria meningitidis spreads through droplets and close contact. Droplet precautions are used until 24 hours of effective antibiotics, and public health arranges prophylaxis for close contacts.

Answer

D · Droplet precautions until 24 hours of effective antibiotics have been given
9.Med-surg: cardiovascular & respiratory

Answer: A · Use a mouthpiece or protect the eyes from the mist

Why this is the answer

Ipratropium is an antimuscarinic bronchodilator. Mist escaping from a face mask can reach the eyes, dilate the pupil and trigger acute angle-closure glaucoma in susceptible patients. A mouthpiece or eye protection reduces the risk.

Answer

A · Use a mouthpiece or protect the eyes from the mist
10.Med-surg: cardiovascular & respiratory

Answer: D · Reduce the oxygen to aim for 88–92% and get a blood gas

Why this is the answer

In patients at risk of hypercapnic respiratory failure, excess oxygen can raise PaCO₂ and cause drowsiness and acidosis. Oxygen is stepped down to a target of 88–92% (for example via a Venturi mask), not stopped abruptly, which could cause dangerous hypoxaemia. An arterial blood gas guides further treatment, which may include NIV.

Answer

D · Reduce the oxygen to aim for 88–92% and get a blood gas
11.Med-surg: neuro, endocrine & renal

Answer: C · DI gives dilute urine; SIADH gives concentrated urine

Why this is the answer

In DI, lack of ADH effect causes large volumes of dilute urine (specific gravity often below 1.005) with high serum sodium. In SIADH, excess ADH causes low urine output with concentrated urine and low serum sodium.

Answer

C · DI gives dilute urine; SIADH gives concentrated urine
12.Med-surg: neuro, endocrine & renal

Answer: D · Replace the catheter and take a sample from the new one

Why this is the answer

Long-term catheters develop a biofilm that contaminates samples. Guidance usually advises replacing the catheter, collecting a sample from the new one and then starting antibiotics. Bag samples are not used.

Answer

D · Replace the catheter and take a sample from the new one
13.Med-surg: GI, perioperative & oncology

Answer: B · A sudden large volume of fresh red blood

Why this is the answer

A sudden increase in bright red drainage suggests active haemorrhage. The nurse checks vital signs and informs the surgical team urgently. Gradually decreasing serosanguinous drainage is expected.

Answer

B · A sudden large volume of fresh red blood
14.Med-surg: GI, perioperative & oncology

Answer: B · Report it; this is hand-foot syndrome and treatment may need changing

Why this is the answer

Palmar-plantar erythrodysaesthesia (hand-foot syndrome) is common with capecitabine and fluorouracil. It is graded and may need a treatment break or dose reduction; emollients and avoiding heat and friction help.

Answer

B · Report it; this is hand-foot syndrome and treatment may need changing

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