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 takes a telephone order from a provider. What must the nurse do?

  1. ACarry out the order first and ask the provider to confirm it later
  2. BWrite the order down and read it back to the provider to confirm it
  3. CRemember the order and write it in the chart at the end of the shift
  4. DAsk the ward clerk to take the order on the nurse’s behalf instead
2.Prioritization & delegationHard

After report, which patient should the nurse assess first?

  1. ADay 2 after gallbladder surgery: pain 6/10, next analgesic due in 30 minutes
  2. B1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
  3. CCOPD on 2 L/min oxygen: SpO₂ 90%, respiratory rate 22/min, at usual baseline
  4. DType 2 diabetes: glucose 210 mg/dL (11.7 mmol/L) before lunch, no symptoms
3.Infection control & patient safetyMedium

A patient receiving continuous nasogastric feeding has pulled the tube partly out. What should the nurse do first?

  1. AStop the feeding until the tube position is checked
  2. BTape the tube in its new position and continue
  3. CIncrease the feed rate to make up for the lost time
  4. DPush the tube back in and restart the feed
4.Infection control & patient safetyHard

A nurse teaches a patient going home with an MRSA wound infection. Which statement shows a need for further teaching?

  1. A“I will wash my hands after touching my dressing.”
  2. B“I will put used dressings in a sealed bag before throwing them out.”
  3. C“I can share towels with my family if I wash them every week.”
  4. D“I will keep the wound covered with a clean, dry dressing.”
5.Lab values & electrolytesMedium

A nurse has a needlestick injury from a patient with unknown HIV status. Which test is usually done for the nurse as soon as possible?

  1. AA thyroid panel test
  2. BA baseline HIV test
  3. CA serum lipase test
  4. DA sweat chloride test
6.Lab values & electrolytesHard

A trauma patient receives many units of blood quickly and then develops muscle twitching and low blood pressure. Which laboratory value is most likely to explain this?

  1. AA high serum sodium
  2. BA low serum glucose
  3. CA high serum magnesium
  4. DA low ionized calcium
7.Clinical nursingMedium

A patient is receiving enteral feeding through a nasogastric tube. How should they be positioned during feeding?

  1. ALying on the left side with the head down to help the feed drain
  2. BLying completely flat
  3. CWith the head of the bed raised to at least 30 degrees
  4. DIn any position, as long as the feed runs slowly
8.Clinical nursingHard

Why must a unit of red cells be transfused within the set time limit (commonly four hours) after it leaves controlled cold storage?

  1. ABacteria can grow in the blood at room temperature
  2. BThe red cells break down and turn into plasma
  3. CThe bag stops dripping after four hours
  4. DThe blood group of the cells changes after a few hours
9.Med-surg: cardiovascular & respiratoryMedium

According to current guidance, when should oxygen be given to a patient with an acute coronary syndrome?

  1. AAlways at 15 L/min, whatever the saturation
  2. BNever, because oxygen harms heart muscle
  3. COnly once the troponin result is available
  4. DOnly when SpO₂ is below the target range
10.Med-surg: cardiovascular & respiratoryHard

The monitor shows a regular broad-complex tachycardia at 180/min. The patient is alert with BP 126/78 mmHg and no chest pain. What is the most appropriate plan?

  1. AReassure the patient, as this is a normal rhythm
  2. BDeliver an unsynchronised shock immediately, before any other assessment
  3. CStart chest compressions straight away and give a dose of IV adrenaline
  4. DRecord a 12-lead ECG, call senior help and anticipate an antiarrhythmic
11.Med-surg: neuro, endocrine & renalMedium

A patient has acute low back pain with no red flags. Which advice is most appropriate?

  1. AStay as active as possible and use simple pain relief
  2. BWear a rigid back brace all day and night for at least three months
  3. CStay in bed for two weeks until the pain is gone
  4. DAvoid all movement until an MRI scan has been done
12.Med-surg: neuro, endocrine & renalHard

A patient has episodes of severe headache, sweating, palpitations and very high blood pressure. Which condition should be considered?

  1. ADiabetes insipidus
  2. BHypothyroidism
  3. CAddison's disease
  4. DPhaeochromocytoma
13.Med-surg: GI, perioperative & oncologyMedium

Why does a patient need lifelong vitamin B12 injections after total gastrectomy?

  1. AVitamin B12 is lost in the urine after the surgery
  2. BThe small bowel stops absorbing all nutrients
  3. CThe liver can no longer store any vitamins
  4. DIntrinsic factor from the stomach is no longer made
14.Med-surg: GI, perioperative & oncologyHard

On the morning of elective hip surgery, a patient says she took her usual warfarin last night despite being told to stop. What should the nurse do?

  1. AGive a double dose of vitamin K by mouth without waiting for a prescription
  2. BProceed with the usual checklist and say nothing
  3. CTell her the surgery must be cancelled for a month
  4. DInform the surgical and anaesthetic teams, who will check the INR

3Solutions

1.Prioritization & delegation

Answer: B · Write the order down and read it back to the provider to confirm it

Why this is the answer

For telephone and verbal orders, the nurse writes down the full order and reads it back so the provider can confirm it. This “read-back” prevents errors from mishearing.

Answer

B · Write the order down and read it back to the provider to confirm it
2.Prioritization & delegation

Answer: B · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg

Why this is the answer

Back pain, tachycardia and hypotension after a femoral puncture suggest retroperitoneal bleeding, which can be hidden and fatal. The COPD patient is at baseline, the pain is expected and being treated, and the glucose is high but not an emergency.

Answer

B · 1 hour after femoral cardiac catheterization: new back pain, pulse 118/min, BP 92/58 mmHg
3.Infection control & patient safety

Answer: A · Stop the feeding until the tube position is checked

Why this is the answer

A displaced tube may now sit in the esophagus or airway. The feeding is stopped and the tube is not pushed back blindly. Its position is checked according to policy, or it is replaced.

Answer

A · Stop the feeding until the tube position is checked
4.Infection control & patient safety

Answer: C · “I can share towels with my family if I wash them every week.”

Why this is the answer

MRSA spreads by direct contact and shared items, so towels, razors and linen should not be shared. Hand hygiene, covering the wound and bagging dressings are correct.

Answer

C · “I can share towels with my family if I wash them every week.”
5.Lab values & electrolytes

Answer: B · A baseline HIV test

Why this is the answer

After an occupational exposure, the wound is washed and the incident is reported at once. Baseline tests for HIV, hepatitis B and hepatitis C are taken, and post-exposure prophylaxis is started as soon as possible if indicated, ideally within hours.

Answer

B · A baseline HIV test
6.Lab values & electrolytes

Answer: D · A low ionized calcium

Why this is the answer

Stored blood contains citrate, which binds calcium. During massive transfusion, citrate can lower ionized calcium, causing tetany, hypotension and arrhythmias. Ionized calcium is monitored and replaced as prescribed.

Answer

D · A low ionized calcium
7.Clinical nursing

Answer: C · With the head of the bed raised to at least 30 degrees

Why this is the answer

Keeping the head raised to at least 30–45° during feeding and for a period afterwards lowers the risk of aspiration pneumonia.

Answer

C · With the head of the bed raised to at least 30 degrees
8.Clinical nursing

Answer: A · Bacteria can grow in the blood at room temperature

Why this is the answer

Red cells are stored cold to limit bacterial growth. Once out of controlled storage, the transfusion must be completed within the time limit to reduce the risk of bacterial contamination and transfusion-transmitted infection.

Answer

A · Bacteria can grow in the blood at room temperature
9.Med-surg: cardiovascular & respiratory

Answer: D · Only when SpO₂ is below the target range

Why this is the answer

Routine high-flow oxygen in patients who are not hypoxaemic offers no benefit and may increase infarct size. Oxygen is given when saturation falls below the target (for example below 90% in some guidelines, below 94% in others).

Answer

D · Only when SpO₂ is below the target range
10.Med-surg: cardiovascular & respiratory

Answer: D · Record a 12-lead ECG, call senior help and anticipate an antiarrhythmic

Why this is the answer

A broad-complex tachycardia is treated as ventricular tachycardia until proven otherwise. With a pulse and no adverse features (shock, syncope, chest pain or heart failure), a 12-lead ECG, electrolyte correction and drug treatment such as amiodarone are used, with expert help. Unstable patients need synchronised cardioversion; pulseless VT is defibrillated.

Answer

D · Record a 12-lead ECG, call senior help and anticipate an antiarrhythmic
11.Med-surg: neuro, endocrine & renal

Answer: A · Stay as active as possible and use simple pain relief

Why this is the answer

Most acute low back pain improves within weeks. Staying active, simple analgesia and gradual return to normal activities help recovery. Imaging is usually not needed without red flags.

Answer

A · Stay as active as possible and use simple pain relief
12.Med-surg: neuro, endocrine & renal

Answer: D · Phaeochromocytoma

Why this is the answer

Phaeochromocytoma is a catecholamine-secreting tumour, usually of the adrenal medulla. It causes episodic hypertension, headache, sweating and tachycardia. Before surgery, alpha-blockade is started before any beta-blocker, because beta-blockade alone can cause a hypertensive crisis.

Answer

D · Phaeochromocytoma
13.Med-surg: GI, perioperative & oncology

Answer: D · Intrinsic factor from the stomach is no longer made

Why this is the answer

Parietal cells of the stomach make intrinsic factor, which is needed for B12 absorption in the terminal ileum. Without it, pernicious-type anaemia and neuropathy develop unless B12 is given by injection.

Answer

D · Intrinsic factor from the stomach is no longer made
14.Med-surg: GI, perioperative & oncology

Answer: D · Inform the surgical and anaesthetic teams, who will check the INR

Why this is the answer

Recent warfarin may leave the INR too high for safe surgery or a spinal anaesthetic. The team needs to know at once; they check the INR and decide whether to delay or reverse.

Answer

D · Inform the surgical and anaesthetic teams, who will check the INR

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