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 sees a nursing assistant leave a confused patient’s bed in the highest position after care. What should the nurse do?

  1. AAsk the family to lower the bed when they next visit
  2. BLeave it because the patient is asleep
  3. CLower the bed now and remind the assistant why it matters
  4. DWrite it in the assistant’s yearly review only
2.Prioritization & delegationHard

A patient who is 7 weeks pregnant has one-sided lower abdominal pain, pain in the shoulder tip, a heart rate of 120/min and a blood pressure of 88/54 mmHg. What is most likely?

  1. AA normal early pregnancy
  2. BSevere morning sickness
  3. CA urinary tract infection
  4. DA ruptured ectopic pregnancy
3.Infection control & patient safetyMedium

Which household item is a strangulation risk for young children?

  1. ASoft cotton socks
  2. BA large wooden building block
  3. CLooped cords on window blinds
  4. DA plastic picture book
4.Infection control & patient safetyHard

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

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

A patient has a sodium of 152 mEq/L. Which findings would the nurse expect?

  1. AWeight gain with swollen ankles
  2. BThirst, dry mucous membranes and restlessness
  3. CBradycardia with peaked T waves
  4. DMuscle twitching with a positive Trousseau’s sign
6.Lab values & electrolytesHard

A patient’s vancomycin trough is 28 mcg/mL; the target set by the prescriber is 15–20 mcg/mL. The next dose is due now. What is the best action?

  1. AHold the dose, inform the prescriber and check kidney function
  2. BGive the dose as scheduled and recheck the trough level in a week
  3. CGive the dose over a shorter time to reduce exposure
  4. DGive a double dose to finish the course faster
7.Clinical nursingMedium

A patient who injects drugs has a fever, a new heart murmur and small dark lines under the nails. What is the likely diagnosis?

  1. AMyocardial infarction
  2. BRheumatic fever
  3. CPericarditis
  4. DInfective endocarditis
8.Clinical nursingHard

A patient after a total hip replacement suddenly has severe hip pain, a shortened leg and the leg is rotated. What is the most likely complication?

  1. ADislocation of the prosthesis
  2. BUrinary retention
  3. CWound infection
  4. DDeep vein thrombosis in the calf
9.Med-surg: cardiovascular & respiratoryMedium

Why should a simple face mask not be used with an oxygen flow below about 5 L/min?

  1. AExhaled CO₂ can collect in the mask and be rebreathed
  2. BOxygen cannot be humidified at low flows
  3. CThe mask delivers too much oxygen at low flows
  4. DThe elastic strap is too loose at low flows
10.Med-surg: cardiovascular & respiratoryHard

A patient receiving noradrenaline (norepinephrine) through a peripheral cannula has pale, cold skin around the site. What should the nurse do?

  1. AContinue the infusion, as this is expected
  2. BMassage the area firmly to spread the drug out into the surrounding tissue
  3. CIncrease the rate so the drug enters the vein faster and leaks less
  4. DStop it at that site, inform the team and follow the extravasation policy
11.Med-surg: neuro, endocrine & renalMedium

A patient receives phenytoin through a nasogastric tube along with continuous enteral feed. Which issue should the nurse know about?

  1. AThe feed increases phenytoin levels and causes toxicity within hours
  2. BPhenytoin must be crushed and mixed into the feed bag
  3. CPhenytoin makes the feed curdle, so the two must never be used in one patient
  4. DThe feed can reduce phenytoin absorption, so the feed is often paused around the dose
12.Med-surg: neuro, endocrine & renalHard

Why may nitrofurantoin be avoided in an older patient with significantly reduced kidney function?

  1. AIt cures kidney disease too quickly
  2. BIt turns the urine red in kidney disease
  3. CIt cannot be taken with food in kidney disease
  4. DIt works less well and is more likely to be toxic
13.Med-surg: GI, perioperative & oncologyMedium

What is a Curling's ulcer?

  1. AA leg ulcer caused by venous disease after long bed rest
  2. BA burn on the sole of the foot
  3. CA stress ulcer of the stomach or duodenum after a major burn
  4. DA pressure ulcer under a splint that has been left on too long
14.Med-surg: GI, perioperative & oncologyHard

A patient with small bowel obstruction has a nasogastric tube draining 2 L a day. Which nursing focus is most important?

  1. AAccurate fluid balance with IV replacement and electrolyte checks
  2. BClamping the tube for long periods to save the stomach fluid
  3. CGiving oral fluids freely to replace what the tube removes
  4. DRemoving the tube once 1 L has drained to prevent losses

3Solutions

1.Prioritization & delegation

Answer: C · Lower the bed now and remind the assistant why it matters

Why this is the answer

A high bed increases the risk of a serious fall, so the nurse corrects it at once and gives brief, clear feedback. Leaving it or delaying feedback leaves the patient at risk.

Answer

C · Lower the bed now and remind the assistant why it matters
2.Prioritization & delegation

Answer: D · A ruptured ectopic pregnancy

Why this is the answer

A ruptured ectopic pregnancy causes internal bleeding, with abdominal pain, shoulder-tip pain and signs of shock. It is a surgical emergency.

Answer

D · A ruptured ectopic pregnancy
3.Infection control & patient safety

Answer: C · Looped cords on window blinds

Why this is the answer

Young children can become entangled in looped blind and curtain cords. Cordless blinds or cord tie-downs, and keeping cribs away from windows, prevent strangulation.

Answer

C · Looped cords on window blinds
4.Infection control & patient safety

Answer: C · 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

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

Answer: B · Thirst, dry mucous membranes and restlessness

Why this is the answer

Hypernatremia usually means a water deficit, causing thirst, dry mouth, restlessness, agitation and, if severe, seizures. It is corrected slowly to avoid cerebral edema.

Answer

B · Thirst, dry mucous membranes and restlessness
6.Lab values & electrolytes

Answer: A · Hold the dose, inform the prescriber and check kidney function

Why this is the answer

A trough above target means the drug is building up, which raises the risk of kidney damage. The nurse holds the dose and informs the prescriber, who will adjust the dose or interval. The kidney function is checked.

Answer

A · Hold the dose, inform the prescriber and check kidney function
7.Clinical nursing

Answer: D · Infective endocarditis

Why this is the answer

Infective endocarditis causes fever and a new or changing murmur, sometimes with splinter haemorrhages. Several sets of blood cultures are taken before long-course IV antibiotics.

Answer

D · Infective endocarditis
8.Clinical nursing

Answer: A · Dislocation of the prosthesis

Why this is the answer

Hip dislocation after arthroplasty causes sudden pain, shortening and rotation. It needs urgent review and reduction; patients are taught movement precautions.

Answer

A · Dislocation of the prosthesis
9.Med-surg: cardiovascular & respiratory

Answer: A · Exhaled CO₂ can collect in the mask and be rebreathed

Why this is the answer

Simple face masks need about 5–10 L/min to wash exhaled CO₂ out of the mask. At lower flows the patient may rebreathe CO₂; a nasal cannula is more appropriate for low flows.

Answer

A · Exhaled CO₂ can collect in the mask and be rebreathed
10.Med-surg: cardiovascular & respiratory

Answer: D · Stop it at that site, inform the team and follow the extravasation policy

Why this is the answer

Extravasated noradrenaline causes intense local vasoconstriction and tissue necrosis. The infusion is stopped at that site (with a plan to continue elsewhere, since the patient depends on it), the team is informed and the local extravasation protocol is followed. Vasopressors are given through a central line where possible.

Answer

D · Stop it at that site, inform the team and follow the extravasation policy
11.Med-surg: neuro, endocrine & renal

Answer: D · The feed can reduce phenytoin absorption, so the feed is often paused around the dose

Why this is the answer

Enteral feeds can bind phenytoin and greatly reduce how much is absorbed. Local protocols usually pause the feed before and after the dose and flush the tube. Drug levels are monitored.

Answer

D · The feed can reduce phenytoin absorption, so the feed is often paused around the dose
12.Med-surg: neuro, endocrine & renal

Answer: D · It works less well and is more likely to be toxic

Why this is the answer

Nitrofurantoin is concentrated in the urine. With poor kidney function, urine levels fall, so it works less well, and blood levels rise, increasing side effects such as neuropathy. Another antibiotic is usually chosen.

Answer

D · It works less well and is more likely to be toxic
13.Med-surg: GI, perioperative & oncology

Answer: C · A stress ulcer of the stomach or duodenum after a major burn

Why this is the answer

Curling's ulcer is an acute peptic ulcer after severe burns, linked with reduced gut blood flow. Early enteral feeding and acid suppression help prevent it, and GI bleeding is watched for.

Answer

C · A stress ulcer of the stomach or duodenum after a major burn
14.Med-surg: GI, perioperative & oncology

Answer: A · Accurate fluid balance with IV replacement and electrolyte checks

Why this is the answer

Large NG losses cause dehydration, hypokalaemia and a hypochloraemic metabolic alkalosis. The aspirate is measured and recorded, replaced IV as prescribed (often with potassium-containing crystalloid), and urea, creatinine and electrolytes are checked at least daily. Oral fluids would increase the losses and vomiting risk.

Answer

A · Accurate fluid balance with IV replacement and electrolyte checks

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