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 patient with mild dysphagia after a stroke is eating. Which technique helps make swallowing safer?

  1. ALying flat with the head tilted back
  2. BDrinking thin fluids quickly through a straw between bites
  3. CTalking while eating to stay alert
  4. DSitting upright with the chin tucked down while swallowing
2.Prioritization & delegationHard

A patient has a potassium of 7.0 mEq/L with peaked T waves. Several drugs are prescribed. Which one is usually given first to protect the heart?

  1. AOral sodium bicarbonate
  2. BIV furosemide
  3. COral potassium binder
  4. DIV calcium gluconate
3.Infection control & patient safetyMedium

A peripheral IV site is red, warm and tender along the vein. What should the nurse do?

  1. AApply a warm pack and keep using the same site
  2. BIncrease the infusion rate to finish the bag sooner
  3. CFlush the catheter harder to clear the vein and keep using the same site
  4. DRemove the catheter and insert a new one at another site if still needed
4.Infection control & patient safetyHard

A small-bore feeding tube has just been inserted blindly at the bedside. Which method is the most reliable way to confirm its position before the first feeding?

  1. ABy listening over the stomach while injecting air
  2. BBy checking that the patient can still talk
  3. CBy an x-ray reviewed by a competent clinician
  4. DBy putting the end in water to look for bubbles
5.Lab values & electrolytesMedium

A patient has an absolute neutrophil count of 0.4 × 10³/µL. Which measure is appropriate?

  1. AStrict hand hygiene, temperature checks and no visitors with infections
  2. BSharing a room with another patient who is being treated for pneumonia
  3. CBringing fresh flowers into the room to lift the patient’s mood
  4. DTaking temperatures rectally because readings are more accurate
6.Lab values & electrolytesHard

A health care worker's hepatitis B tests show: HBsAg negative, anti-HBs positive, anti-HBc positive. What does this mean?

  1. ANot immune and never exposed to the virus
  2. BImmunity from vaccination only, never infected
  3. CCurrent chronic hepatitis B infection
  4. DPast infection that has resolved, with immunity
7.Clinical nursingMedium

Which factor is most likely to slow wound healing?

  1. AAdequate fluid intake
  2. BA diet rich in protein
  3. CSmoking
  4. DGood blood glucose control
8.Clinical nursingHard

A dying patient has noisy, rattling breathing caused by secretions in the throat and is unconscious. Which approach is appropriate?

  1. ATell the family that the patient is suffocating and needs ventilation
  2. BReposition, consider prescribed antisecretory drugs and support the family
  3. CStart deep oropharyngeal suctioning every 10 minutes through the night
  4. DBegin rapid intravenous fluids to thin and clear the secretions
9.Med-surg: cardiovascular & respiratoryMedium

A patient has had atrial fibrillation for more than 48 hours and is listed for elective cardioversion. Why is anticoagulation needed beforehand?

  1. AAnticoagulants convert AF back to sinus rhythm
  2. BAtrial clots may be dislodged when sinus rhythm returns
  3. CAnticoagulants reduce the electrical energy needed for the shock
  4. DAnticoagulants make the shock less painful
10.Med-surg: cardiovascular & respiratoryHard

A patient on warfarin for atrial fibrillation is prescribed clarithromycin. Which action is most appropriate?

  1. AAsk whether the INR should be checked sooner, as it may rise
  2. BChange nothing, as antibiotics do not affect warfarin
  3. CStop the warfarin for the whole antibiotic course
  4. DDouble the warfarin dose during the course
11.Med-surg: neuro, endocrine & renalMedium

A patient has radioactive iodine treatment for hyperthyroidism. Which advice is correct?

  1. AThere are no precautions, because the dose is tiny
  2. BStay in strict isolation in hospital for several months
  3. CLimit close contact with children and pregnant women for a time
  4. DStart breastfeeding again the next day
12.Med-surg: neuro, endocrine & renalHard

A nurse teaches a patient about peritoneal dialysis. Which statement shows a need for further teaching?

  1. A"If the fluid is cloudy, I'll see if it clears next time."
  2. B"I will weigh myself daily and record my fluid balance."
  3. C"I will check my exit site every day."
  4. D"I will wash my hands carefully before each exchange."
13.Med-surg: GI, perioperative & oncologyMedium

Why is it important to prevent perioperative hypothermia?

  1. AIt reduces the amount of anaesthetic needed, which is unsafe
  2. BIt makes patients wake up from the anaesthetic too quickly
  3. CIt lowers the risk of pain after surgery
  4. DIt increases bleeding, wound infection and heart complications
14.Med-surg: GI, perioperative & oncologyHard

On day 3 after admission, a patient with alcohol dependence becomes confused, with hallucinations, sweating, tremor, fever and tachycardia. What is the most likely cause?

  1. AHepatitis A caught on the ward
  2. BNormal anxiety about being in hospital
  3. CDelirium tremens from alcohol withdrawal
  4. DAn allergic reaction to hospital food

3Solutions

1.Prioritization & delegation

Answer: D · Sitting upright with the chin tucked down while swallowing

Why this is the answer

Sitting upright and tucking the chin narrows the airway entrance and helps food pass into the esophagus. The nurse follows the speech therapist’s plan, which may include thickened fluids.

Answer

D · Sitting upright with the chin tucked down while swallowing
2.Prioritization & delegation

Answer: D · IV calcium gluconate

Why this is the answer

IV calcium stabilizes the cardiac cell membranes within minutes and is given first when hyperkalemia changes the ECG. Insulin with glucose, binders and diuretics then lower the potassium.

Answer

D · IV calcium gluconate
3.Infection control & patient safety

Answer: D · Remove the catheter and insert a new one at another site if still needed

Why this is the answer

Redness, warmth and tenderness along the vein indicate phlebitis, which can lead to infection. The catheter is removed and, if IV access is still needed, a new one is placed at a different site.

Answer

D · Remove the catheter and insert a new one at another site if still needed
4.Infection control & patient safety

Answer: C · By an x-ray reviewed by a competent clinician

Why this is the answer

An x-ray is the most reliable way to confirm the position of a newly placed blind-inserted feeding tube, and US guidance recommends it before first use. In the UK, testing a gastric aspirate (pH 5.5 or below) is the first-line check for nasogastric tubes, with x-ray used when no aspirate is obtained or the pH is too high. Both reject air auscultation and the bubble test, and a tube in the airway can still allow talking.

Answer

C · By an x-ray reviewed by a competent clinician
5.Lab values & electrolytes

Answer: A · Strict hand hygiene, temperature checks and no visitors with infections

Why this is the answer

Severe neutropenia carries a high risk of infection. Hand hygiene, early recognition of fever and protection from sources of infection are key. Flowers can carry organisms, rectal procedures can injure the mucosa, and a roommate with pneumonia is an infection risk.Checked against: Low white blood cell count and cancer · MedlinePlus (NIH) (2025)

Answer

A · Strict hand hygiene, temperature checks and no visitors with infections
6.Lab values & electrolytes

Answer: D · Past infection that has resolved, with immunity

Why this is the answer

The vaccine contains only surface antigen, so vaccination produces anti-HBs alone. A positive anti-HBc shows past or current infection; with HBsAg negative and anti-HBs positive, the infection has cleared and the person is immune.Checked against: Hepatitis Testing · MedlinePlus (NIH)

Answer

D · Past infection that has resolved, with immunity
7.Clinical nursing

Answer: C · Smoking

Why this is the answer

Smoking causes vasoconstriction and reduces tissue oxygen, slowing healing and increasing infection risk. Poor nutrition, diabetes, infection and steroids also impair healing.

Answer

C · Smoking
8.Clinical nursing

Answer: B · Reposition, consider prescribed antisecretory drugs and support the family

Why this is the answer

The "death rattle" is managed by repositioning, mouth care and sometimes drugs that reduce secretions. Explaining it to relatives eases their distress.

Answer

B · Reposition, consider prescribed antisecretory drugs and support the family
9.Med-surg: cardiovascular & respiratory

Answer: B · Atrial clots may be dislodged when sinus rhythm returns

Why this is the answer

After 48 hours of AF, atrial thrombus may be present. Restoring organised contraction can expel it and cause a stroke. Patients are usually anticoagulated for at least three weeks before (or a transoesophageal echo excludes clot) and for at least four weeks afterwards.

Answer

B · Atrial clots may be dislodged when sinus rhythm returns
10.Med-surg: cardiovascular & respiratory

Answer: A · Ask whether the INR should be checked sooner, as it may rise

Why this is the answer

Several antibiotics, including macrolides such as clarithromycin, some fluoroquinolones and co-trimoxazole, can raise the INR and the bleeding risk. Closer INR monitoring and possible dose adjustment are needed. Stopping or doubling warfarin without advice is unsafe.

Answer

A · Ask whether the INR should be checked sooner, as it may rise
11.Med-surg: neuro, endocrine & renal

Answer: C · Limit close contact with children and pregnant women for a time

Why this is the answer

After radioiodine, patients are advised to limit close and prolonged contact, especially with young children and pregnant women, for a period set by the department. It is contraindicated in pregnancy and breastfeeding.

Answer

C · Limit close contact with children and pregnant women for a time
12.Med-surg: neuro, endocrine & renal

Answer: A · "If the fluid is cloudy, I'll see if it clears next time."

Why this is the answer

Cloudy effluent may be the first sign of peritonitis and must be reported to the PD unit straight away, keeping the bag for testing. Waiting can allow a serious infection to develop.

Answer

A · "If the fluid is cloudy, I'll see if it clears next time."
13.Med-surg: GI, perioperative & oncology

Answer: D · It increases bleeding, wound infection and heart complications

Why this is the answer

Even mild hypothermia impairs clotting, increases surgical site infection and cardiac events, and causes shivering and discomfort. Forced-air warming, warmed fluids and covering the patient help prevent it.

Answer

D · It increases bleeding, wound infection and heart complications
14.Med-surg: GI, perioperative & oncology

Answer: C · Delirium tremens from alcohol withdrawal

Why this is the answer

Delirium tremens usually develops 2–3 days after stopping alcohol and is a medical emergency. It is treated with benzodiazepines, fluids, thiamine and close monitoring, ideally prevented by a withdrawal protocol.

Answer

C · Delirium tremens from alcohol withdrawal

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