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 pregnant nurse is on the unit. Which patient should the charge nurse avoid assigning to her?

  1. AA patient with a fractured wrist
  2. BA patient with type 2 diabetes who needs insulin teaching before discharge
  3. CA patient after a hip replacement
  4. DA patient with a sealed radioactive implant for cervical cancer
2.Prioritization & delegationHard

An infant is choking and cannot cry or breathe. Which technique is correct?

  1. AHolding the infant upside down by the feet
  2. BBack blows and chest thrusts
  3. CA blind finger sweep of the mouth
  4. DAbdominal thrusts, as in adults
3.Infection control & patient safetyMedium

A small fire starts in a waste bin in a patient’s room while the patient is in bed. What does the nurse do first?

  1. AGo and look for the nearest fire extinguisher
  2. BPhone the manager to report the fire
  3. COpen the windows to clear the smoke
  4. DRemove the patient from immediate danger
4.Infection control & patient safetyHard

A patient on chemotherapy develops shingles over several areas on both sides of the body. Which precautions are needed?

  1. AContact precautions only, with gloves for dressing changes
  2. BAirborne and contact precautions until all lesions are crusted
  3. CDroplet precautions until the pain settles
  4. DStandard precautions only, with the lesions covered
5.Lab values & electrolytesMedium

A patient with iron-deficiency anemia started oral iron. Which result is usually the earliest sign that treatment is working?

  1. AA rise in the reticulocyte count
  2. BA fall in the white cell count
  3. CA rise in the platelet count
  4. DA fall in the mean cell volume (MCV)
6.Lab values & electrolytesHard

A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5.6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?

  1. ALow cortisol with a high ACTH
  2. BHigh cortisol with a low ACTH
  3. CHigh cortisol with a high ACTH
  4. DLow cortisol with a low ACTH
7.Clinical nursingMedium

Which adverse effects should be monitored for in a patient receiving IV gentamicin?

  1. AHair loss and weight gain
  2. BConstipation and urinary retention
  3. CKidney damage and hearing loss
  4. DHyperglycaemia and tremor
8.Clinical nursingHard

A patient after major surgery has a falling blood pressure, rising heart rate and a swollen, tense abdomen, though the wound dressing is dry. What should you suspect?

  1. AConstipation
  2. BInternal bleeding
  3. CNormal postoperative swelling with no concern
  4. DUrinary tract infection
9.Med-surg: cardiovascular & respiratoryMedium

A patient with supraventricular tachycardia is to receive IV adenosine. What should the nurse warn them about?

  1. AA burning pain along the arm vein for about a week
  2. BA headache that lasts for several days afterwards
  3. CSeveral hours of drowsiness, slurred speech and confusion afterwards
  4. DBrief flushing or chest tightness and a pause of a few seconds
10.Med-surg: cardiovascular & respiratoryHard

A 25-year-old non-smoker has wheeze and cough that come and go, worse at night and after exercise. Spirometry improves markedly after a bronchodilator. Which diagnosis is most likely?

  1. AIdiopathic pulmonary fibrosis
  2. BAsthma
  3. CHeart failure
  4. DCOPD
11.Med-surg: neuro, endocrine & renalMedium

A patient's fistula starts to bleed at home after the needles were removed. What should they do first?

  1. ARaise the arm and let it bleed freely
  2. BApply a tight tourniquet above the fistula
  3. CWait for the next dialysis session
  4. DPress firmly on the site with clean gauze
12.Med-surg: neuro, endocrine & renalHard

A patient with Parkinson's disease is nil by mouth after abdominal surgery. Their levodopa is due. What is the best action?

  1. AGive double the dose once eating restarts
  2. BOmit the dose until the patient can swallow again
  3. CContact the prescriber or pharmacist about another route
  4. DGive the tablets with a sip of water anyway
13.Med-surg: GI, perioperative & oncologyMedium

Which change suggests that a burn wound is becoming infected?

  1. AA partial-thickness burn becoming deeper, with new discolouration
  2. BDry, healing skin with mild itching
  3. CThe wound becoming pink and a little smaller at each dressing change
  4. DLess exudate on each dressing change
14.Med-surg: GI, perioperative & oncologyHard

After a coughing fit, the external mark on a patient's nasogastric tube has moved 10 cm. Feed is due. What should the nurse do?

  1. AStart the feed at a slow rate and watch for coughing
  2. BGive the medicines only and save the feed for later
  3. CDo not use the tube until its position is confirmed by policy
  4. DPush the tube back to the original mark and start the feed

3Solutions

1.Prioritization & delegation

Answer: D · A patient with a sealed radioactive implant for cervical cancer

Why this is the answer

A sealed radioactive implant (brachytherapy) emits radiation, and pregnant staff should not care for these patients. The other patients pose no special risk to a pregnancy.

Answer

D · A patient with a sealed radioactive implant for cervical cancer
2.Prioritization & delegation

Answer: B · Back blows and chest thrusts

Why this is the answer

For a choking infant, the nurse gives cycles of five back blows and five chest thrusts. Abdominal thrusts are not used in infants, and blind finger sweeps can push the object deeper.

Answer

B · Back blows and chest thrusts
3.Infection control & patient safety

Answer: D · Remove the patient from immediate danger

Why this is the answer

Rescue comes first: move the patient away from the fire. Then raise the alarm, contain the fire by closing doors, and extinguish it if safe. Opening windows feeds the fire with oxygen.

Answer

D · Remove the patient from immediate danger
4.Infection control & patient safety

Answer: B · Airborne and contact precautions until all lesions are crusted

Why this is the answer

Lesions over several areas on both sides mean disseminated zoster, which can spread through the air like chickenpox. Airborne and contact precautions are used until all lesions are dry and crusted. Localized zoster in an immunocompromised patient also needs airborne and contact precautions, but only until dissemination is ruled out.

Answer

B · Airborne and contact precautions until all lesions are crusted
5.Lab values & electrolytes

Answer: A · A rise in the reticulocyte count

Why this is the answer

Once iron is available, the marrow releases more young red cells, so the reticulocyte count rises within about 1–2 weeks. The hemoglobin rises more slowly over weeks, and iron stores take months to refill.Checked against: Reticulocyte Count · MedlinePlus (NIH) (2024)

Answer

A · A rise in the reticulocyte count
6.Lab values & electrolytes

Answer: A · Low cortisol with a high ACTH

Why this is the answer

In primary adrenal insufficiency the adrenal glands fail, so cortisol is low and the pituitary responds with high ACTH, which also darkens the skin. Low cortisol with low ACTH suggests a pituitary cause. An ACTH stimulation test confirms the diagnosis.Checked against: Adrenocorticotropic Hormone (ACTH) · MedlinePlus (NIH) (2023); Cortisol Test · MedlinePlus (NIH) (2024)

Answer

A · Low cortisol with a high ACTH
7.Clinical nursing

Answer: C · Kidney damage and hearing loss

Why this is the answer

Gentamicin is nephrotoxic and ototoxic. Blood levels and renal function are monitored, and any tinnitus, dizziness or hearing change is reported.

Answer

C · Kidney damage and hearing loss
8.Clinical nursing

Answer: B · Internal bleeding

Why this is the answer

Haemodynamic signs of shock with abdominal distension suggest intra-abdominal haemorrhage, even without visible blood loss. Urgent surgical review is required.

Answer

B · Internal bleeding
9.Med-surg: cardiovascular & respiratory

Answer: D · Brief flushing or chest tightness and a pause of a few seconds

Why this is the answer

Adenosine is given as a rapid IV bolus followed by a saline flush, with continuous ECG monitoring. It briefly blocks AV node conduction, often causing a few seconds of asystole, flushing, chest discomfort, breathlessness or a sense of doom. The effects last only seconds.

Answer

D · Brief flushing or chest tightness and a pause of a few seconds
10.Med-surg: cardiovascular & respiratory

Answer: B · Asthma

Why this is the answer

Asthma typically causes variable symptoms with reversible airflow obstruction. COPD usually affects older people with a smoking history and causes persistent, poorly reversible obstruction. Fibrosis gives a restrictive pattern.

Answer

B · Asthma
11.Med-surg: neuro, endocrine & renal

Answer: D · Press firmly on the site with clean gauze

Why this is the answer

Firm, direct pressure with clean gauze or a dressing is applied to the site. A tourniquet could clot the fistula. If bleeding does not stop, the patient calls emergency services, because fistula bleeding can be heavy.

Answer

D · Press firmly on the site with clean gauze
12.Med-surg: neuro, endocrine & renal

Answer: C · Contact the prescriber or pharmacist about another route

Why this is the answer

Omitting Parkinson's medication can cause severe rigidity, swallowing failure and, rarely, a life-threatening withdrawal syndrome. Alternatives such as giving it by nasogastric tube or a dopamine agonist patch should be arranged urgently.

Answer

C · Contact the prescriber or pharmacist about another route
13.Med-surg: GI, perioperative & oncology

Answer: A · A partial-thickness burn becoming deeper, with new discolouration

Why this is the answer

Signs of burn wound infection include conversion to a deeper burn, new dark or green discolouration, increasing pain, offensive exudate, spreading redness and systemic signs such as fever or tachycardia.

Answer

A · A partial-thickness burn becoming deeper, with new discolouration
14.Med-surg: GI, perioperative & oncology

Answer: C · Do not use the tube until its position is confirmed by policy

Why this is the answer

A change in external length means the tube may have moved. Pushing it back blindly is unsafe. It is not used until placement is confirmed by pH or X-ray, or it is replaced.

Answer

C · Do not use the tube until its position is confirmed by policy

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