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

On the first day after abdominal surgery, a patient has a temperature of 37.9 °C and reduced breath sounds at the lung bases. Which nursing action is most helpful?

  1. AKeep the patient lying flat in bed to rest the incision fully
  2. BGive a cough suppressant so that the incision is not strained
  3. CRestrict oral fluids so that the lungs do not fill up with extra fluid
  4. DEncourage deep breathing, coughing and use of the incentive spirometer
2.Prioritization & delegationHard

After handover on a medical unit, which patient should the nurse see first?

  1. APneumonia on 2 L/min oxygen, SpO₂ 93%, talking in full sentences
  2. BDay 2 after a hernia repair, pain 6/10, oral analgesic due in 20 minutes, wants it now
  3. CDeep vein thrombosis on a heparin infusion, aPTT in the target range
  4. DNew atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.Infection control & patient safetyMedium

A patient has fallen, and the nurse completes an incident report. Which statement about this report is correct?

  1. AIt is written factually and does not replace documenting the fall in the patient’s record
  2. BIt is only needed when the patient is injured
  3. CA copy of it is placed in the patient’s chart so all staff know about the fall
  4. DIt replaces the need to document the fall in the patient’s record
4.Infection control & patient safetyHard

Which position is especially dangerous for a patient in physical restraints?

  1. ASitting upright in bed
  2. BLying on the back with the head raised
  3. CLying on the side
  4. DLying face down (prone)
5.Lab values & electrolytesMedium

Why is a blood β-hydroxybutyrate level often preferred to a urine ketone dipstick in DKA?

  1. AIt shows the average ketone level over the past three months
  2. BIt measures the main ketone in DKA, and the dipstick may miss it
  3. CThe urine dipstick only detects ketones in people without diabetes
  4. DIt is the only test that can measure glucose and ketones together
6.Lab values & electrolytesHard

A patient has a hemoglobin of 11.2 g/dL (112 g/L), an MCV of 64 fL, a normal ferritin and a normal-to-high red cell count. What is the most likely cause?

  1. AIron deficiency
  2. BVitamin B12 deficiency
  3. CAcute blood loss
  4. DThalassemia trait
7.Clinical nursingMedium

During a red cell transfusion, when are serious acute reactions most likely to start?

  1. AOnly after the unit has finished
  2. BAbout 24 hours later
  3. CIn the first 15 minutes
  4. DAfter the third unit only
8.Clinical nursingHard

A patient rescued from a house fire has soot around the mouth, singed nasal hairs and a hoarse voice. What is the main concern?

  1. ADehydration from sweating
  2. BHypothermia from the fire service water
  3. CA minor throat infection
  4. DAirway swelling from inhalation injury
9.Med-surg: cardiovascular & respiratoryMedium

The monitor shows ventricular fibrillation. The patient is unresponsive and not breathing normally. What is the key treatment?

  1. ASynchronised cardioversion under deep sedation
  2. BCPR and defibrillation as soon as possible
  3. CRapid IV adenosine followed by a flush
  4. DIV atropine and external pacing
10.Med-surg: cardiovascular & respiratoryHard

After four days of antibiotics for pneumonia, a patient still has fever and pleuritic pain. There is dullness and reduced breath sounds at the right base. What complication should be suspected?

  1. AAn allergic reaction to the antibiotic
  2. BA parapneumonic effusion or empyema
  3. CAsthma triggered by the infection
  4. DNormal recovery from pneumonia
11.Med-surg: neuro, endocrine & renalMedium

A patient has a homonymous hemianopia after a stroke. How should the nurse help at first?

  1. AKeep the room dark to reduce visual stimulation
  2. BCover the eye on the affected side with a patch
  3. CPut the call bell and drinks on the side without vision, to train it
  4. DApproach from the seeing side and teach head-turning to scan
12.Med-surg: neuro, endocrine & renalHard

During haemodialysis, a patient suddenly becomes breathless with chest pain, and air is seen in the line. What should the nurse do first?

  1. AContinue the session and recheck in 30 minutes
  2. BSit the patient upright and give a drink of water
  3. CSpeed up the pump to clear the air into the patient
  4. DClamp the lines and lay the patient left side down, head low
13.Med-surg: GI, perioperative & oncologyMedium

Which factor can precipitate hepatic encephalopathy in a patient with cirrhosis?

  1. AA low-salt diet
  2. BConstipation
  3. CA high fluid intake
  4. DRegular gentle walking
14.Med-surg: GI, perioperative & oncologyHard

Which patient has the highest risk of postoperative nausea and vomiting?

  1. AA male smoker having a short procedure without opioids
  2. BA smoker who has never had nausea after surgery
  3. CA man with no history of nausea having local anaesthetic only
  4. DA non-smoking woman with motion sickness who will need opioids

3Solutions

1.Prioritization & delegation

Answer: D · Encourage deep breathing, coughing and use of the incentive spirometer

Why this is the answer

Reduced basal breath sounds and a mild temperature early after surgery often mean atelectasis. Deep breathing, coughing, incentive spirometry and early mobilization help re-expand the lungs.

Answer

D · Encourage deep breathing, coughing and use of the incentive spirometer
2.Prioritization & delegation

Answer: D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy

Why this is the answer

Rapid atrial fibrillation with hypotension and dizziness means the heart is not pumping enough blood; the patient is unstable. The other patients are within target or have predictable needs.

Answer

D · New atrial fibrillation, heart rate 150/min, blood pressure 86/50 mmHg, dizzy
3.Infection control & patient safety

Answer: A · It is written factually and does not replace documenting the fall in the patient’s record

Why this is the answer

The nurse documents the facts of the fall, the assessment and the care given in the patient’s record. The incident report is a separate quality-improvement document and is not filed in the chart. Policies differ on whether the record notes that a report was made: many US facilities advise against it, while many UK services record the report reference. Falls are reported whether or not there is an injury.

Answer

A · It is written factually and does not replace documenting the fall in the patient’s record
4.Infection control & patient safety

Answer: D · Lying face down (prone)

Why this is the answer

Restraining a person face down can restrict breathing and has caused deaths from positional asphyxia. Restrained patients are positioned to protect the airway and are watched closely.

Answer

D · Lying face down (prone)
5.Lab values & electrolytes

Answer: B · It measures the main ketone in DKA, and the dipstick may miss it

Why this is the answer

In DKA, β-hydroxybutyrate is the main ketone, but most urine dipsticks detect acetoacetate, so they can underestimate ketosis. Blood β-hydroxybutyrate gives a current value that is also useful to monitor recovery.Checked against: Diabetic ketoacidosis - Medical Encyclopedia · MedlinePlus (NIH) (2025)

Answer

B · It measures the main ketone in DKA, and the dipstick may miss it
6.Lab values & electrolytes

Answer: D · Thalassemia trait

Why this is the answer

Thalassemia trait causes microcytosis from reduced globin production, often with a normal or high red cell count and normal ferritin. Iron deficiency has low ferritin. Iron supplements do not help thalassemia trait and can cause iron overload.Checked against: Thalassemia - Medical Encyclopedia · MedlinePlus (NIH) (2026); Red Blood Cell (RBC) Indices · MedlinePlus (NIH) (2024)

Answer

D · Thalassemia trait
7.Clinical nursing

Answer: C · In the first 15 minutes

Why this is the answer

Severe reactions such as ABO incompatibility and anaphylaxis usually begin early. The patient should be watched closely in the first 15 minutes, with observations repeated as per local policy.

Answer

C · In the first 15 minutes
8.Clinical nursing

Answer: D · Airway swelling from inhalation injury

Why this is the answer

These signs suggest inhalation injury, which can cause rapid airway swelling and obstruction. Early senior anaesthetic review is needed, as early intubation may be required. Carbon monoxide poisoning must also be considered.

Answer

D · Airway swelling from inhalation injury
9.Med-surg: cardiovascular & respiratory

Answer: B · CPR and defibrillation as soon as possible

Why this is the answer

Ventricular fibrillation is a cardiac arrest rhythm. High-quality CPR and early unsynchronised defibrillation are the interventions that improve survival. Synchronised cardioversion is for tachyarrhythmias with a pulse; atropine and pacing are for bradycardia.

Answer

B · CPR and defibrillation as soon as possible
10.Med-surg: cardiovascular & respiratory

Answer: B · A parapneumonic effusion or empyema

Why this is the answer

Persistent fever and signs of pleural fluid suggest a parapneumonic effusion, which may become infected (empyema). Ultrasound and diagnostic pleural aspiration are needed, and an infected collection usually needs a chest drain in addition to antibiotics.

Answer

B · A parapneumonic effusion or empyema
11.Med-surg: neuro, endocrine & renal

Answer: D · Approach from the seeing side and teach head-turning to scan

Why this is the answer

Initially, placing important items and approaching from the side with intact vision improves safety. Over time the patient is taught to scan by turning the head towards the lost field. Patching one eye does not help, because both eyes have lost the same half-field.

Answer

D · Approach from the seeing side and teach head-turning to scan
12.Med-surg: neuro, endocrine & renal

Answer: D · Clamp the lines and lay the patient left side down, head low

Why this is the answer

In suspected air embolism, the blood lines are clamped at once, the pump stopped, and the patient positioned on the left side with the head down to trap air in the right atrium. Oxygen is given and emergency help called.

Answer

D · Clamp the lines and lay the patient left side down, head low
13.Med-surg: GI, perioperative & oncology

Answer: B · Constipation

Why this is the answer

Constipation, GI bleeding, infection, dehydration, low potassium and sedative drugs can trigger encephalopathy. Keeping the bowels open, for example with lactulose, reduces ammonia absorption.

Answer

B · Constipation
14.Med-surg: GI, perioperative & oncology

Answer: D · A non-smoking woman with motion sickness who will need opioids

Why this is the answer

Apfel risk factors are female sex, non-smoking status, a history of PONV or motion sickness, and postoperative opioids. Patients with more factors receive more preventive antiemetics.

Answer

D · A non-smoking woman with motion sickness who will need opioids

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