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

Which patient is most suitable for the nurse to assign to a nurse who has just finished orientation?

  1. AA patient with a new tracheostomy who needs frequent suctioning
  2. BA patient with stable cellulitis on scheduled IV antibiotics
  3. CA patient with sepsis whose blood pressure is falling
  4. DA patient on a continuous heparin infusion with rising aPTT values
2.Prioritization & delegationHard

Six hours after surgery, a patient has not passed urine, feels the urge to go and has a firm swelling above the pubic bone. What is the most likely problem?

  1. AUrinary retention
  2. BDehydration from fasting before surgery
  3. CA normal effect of the anesthetic
  4. DAcute kidney injury with no urine made
3.Infection control & patient safetyMedium

How should a nurse handle soiled bed linen?

  1. AHold it away from the uniform and place it straight into a linen bag
  2. BCarry it bundled against the body to the soiled utility room down the hall
  3. CPut it on the floor until the bed is made
  4. DShake it out first to check for lost items
4.Infection control & patient safetyHard

A patient refuses to wear an identification wristband. What should the nurse do?

  1. AForce the band onto the patient’s wrist
  2. BExplain why it is needed, use other ID methods per policy and document
  3. CAccept the refusal and identify the patient by room number and bed space instead
  4. DStop giving the patient any care until they agree to wear the band
5.Lab values & electrolytesMedium

A urine culture report states "mixed growth of three organisms, likely contamination." What is the nurse's best response?

  1. ADiscard the report, because a mixed growth is always normal
  2. BStart treatment for all three organisms with three antibiotics
  3. CInform the provider and arrange a new, correctly collected sample
  4. DRecord the result as a confirmed urinary tract infection
6.Lab values & electrolytesHard

During surgery under general anesthesia, a patient develops a rising end-tidal CO2, muscle rigidity and tachycardia, then a high potassium and a rising temperature. Which condition is most likely?

  1. AAcute hemolytic transfusion reaction
  2. BHypoglycemia from fasting
  3. CHypovolemic shock
  4. DMalignant hyperthermia
7.Clinical nursingMedium

A patient has lost more than 10% of their body weight without trying over the last few months and has a low BMI. What is the most appropriate action?

  1. AEncourage a low-calorie diet
  2. BRestrict fluids to encourage appetite and give a low-protein diet instead
  3. CWeigh the patient again in six months and review at that point
  4. DRefer to the dietitian and start a nutrition care plan with food charts
8.Clinical nursingHard

In triage, which patient should be seen first?

  1. AA patient with a sprained ankle and mild swelling
  2. BA patient with a two-day history of sore throat
  3. CA patient asking for a repeat prescription
  4. DA patient with noisy breathing and swollen lips after eating peanuts
9.Med-surg: cardiovascular & respiratoryMedium

A patient on furosemide has a serum potassium of 3.0 mmol/L (3.0 mEq/L). Which symptoms may this cause?

  1. AFacial flushing, fever and a skin rash
  2. BMuscle weakness, cramps and an irregular pulse
  3. CTingling around the lips and painful spasm of the hands
  4. DSevere headache and a stiff neck
10.Med-surg: cardiovascular & respiratoryHard

A patient who has had a total laryngectomy becomes breathless and needs oxygen. How should it be given?

  1. AVia a non-rebreather mask over the mouth only
  2. BVia a mask or humidified device over the neck stoma
  3. CVia a standard face mask over the nose and mouth
  4. DVia nasal cannula at 2 L/min
11.Med-surg: neuro, endocrine & renalMedium

After pituitary surgery, a patient passes 400 mL of urine per hour for three hours with a low specific gravity. What should the nurse suspect?

  1. ANormal diuresis
  2. BSIADH
  3. CAcute kidney injury
  4. DDiabetes insipidus
12.Med-surg: neuro, endocrine & renalHard

A patient with hypopituitarism needs both hydrocortisone and levothyroxine. Which is usually started first?

  1. ALevothyroxine
  2. BHydrocortisone
  3. CNeither, until symptoms appear
  4. DBoth on the same day, in any order
13.Med-surg: GI, perioperative & oncologyMedium

What is the first priority when a patient arrives in recovery after a general anaesthetic?

  1. AThe drug history
  2. BAirway and breathing
  3. CThe wound dressing and drains
  4. DA drink of water
14.Med-surg: GI, perioperative & oncologyHard

Two hours after a meal, a patient who had a gastrectomy becomes shaky, sweaty and confused. What is the most likely cause and first action?

  1. AAn anastomotic leak; insert a nasogastric tube at once
  2. BLate dumping with low blood glucose; check capillary glucose
  3. CEarly dumping from fluid shifts; give a large drink of water
  4. DVitamin B12 deficiency; give an injection now

3Solutions

1.Prioritization & delegation

Answer: B · A patient with stable cellulitis on scheduled IV antibiotics

Why this is the answer

A newly oriented nurse is best given stable patients with predictable care. The other patients have changing or high-risk conditions that need more experience and close monitoring.

Answer

B · A patient with stable cellulitis on scheduled IV antibiotics
2.Prioritization & delegation

Answer: A · Urinary retention

Why this is the answer

An urge to void with a palpable bladder points to retention, not reduced urine production. The nurse confirms with a bladder scan if available and follows the prescribed plan, such as catheterization.

Answer

A · Urinary retention
3.Infection control & patient safety

Answer: A · Hold it away from the uniform and place it straight into a linen bag

Why this is the answer

Soiled linen is rolled up, held away from the uniform and placed directly into a laundry bag at the bedside. Shaking linen spreads organisms into the air, and the floor is a contaminated surface.

Answer

A · Hold it away from the uniform and place it straight into a linen bag
4.Infection control & patient safety

Answer: B · Explain why it is needed, use other ID methods per policy and document

Why this is the answer

The nurse explains how the band prevents errors. If the patient still refuses, the nurse follows policy for alternative identification using two identifiers, informs the team and documents it.

Answer

B · Explain why it is needed, use other ID methods per policy and document
5.Lab values & electrolytes

Answer: C · Inform the provider and arrange a new, correctly collected sample

Why this is the answer

Several organisms in one urine sample usually mean contamination from the skin or perineum during collection. The provider is informed, and a new clean-catch or catheter-port sample is usually needed before an infection can be confirmed.

Answer

C · Inform the provider and arrange a new, correctly collected sample
6.Lab values & electrolytes

Answer: D · Malignant hyperthermia

Why this is the answer

Malignant hyperthermia is a genetic hypermetabolic reaction to volatile anesthetics or succinylcholine. Muscle cells release calcium, producing CO2, heat, rigidity, hyperkalemia and very high CK. It is treated with dantrolene and stopping the trigger.

Answer

D · Malignant hyperthermia
7.Clinical nursing

Answer: D · Refer to the dietitian and start a nutrition care plan with food charts

Why this is the answer

Large unplanned weight loss with a low BMI means high malnutrition risk. Management includes dietitian referral, food and fluid charts, support with eating and regular weighing.

Answer

D · Refer to the dietitian and start a nutrition care plan with food charts
8.Clinical nursing

Answer: D · A patient with noisy breathing and swollen lips after eating peanuts

Why this is the answer

Stridor and lip swelling suggest anaphylaxis with airway compromise, which is immediately life-threatening. The others can safely wait.

Answer

D · A patient with noisy breathing and swollen lips after eating peanuts
9.Med-surg: cardiovascular & respiratory

Answer: B · Muscle weakness, cramps and an irregular pulse

Why this is the answer

The adult reference range is about 3.5–5.0 mmol/L, so 3.0 mmol/L is low. Hypokalaemia causes weakness, cramps, constipation and arrhythmias, with flattened T waves and U waves on the ECG. Tingling lips and hand spasm suggest low calcium.

Answer

B · Muscle weakness, cramps and an irregular pulse
10.Med-surg: cardiovascular & respiratory

Answer: B · Via a mask or humidified device over the neck stoma

Why this is the answer

A total laryngectomy separates the trachea from the upper airway, so the patient breathes only through the neck stoma. Oxygen and any rescue breaths must be given via the stoma. These patients are "neck breathers" and often carry an alert card.

Answer

B · Via a mask or humidified device over the neck stoma
11.Med-surg: neuro, endocrine & renal

Answer: D · Diabetes insipidus

Why this is the answer

Damage to the posterior pituitary or hypothalamus can stop ADH release, causing cranial DI with large volumes of dilute urine. The nurse reports it, monitors fluid balance and serum sodium closely and anticipates treatment with desmopressin.

Answer

D · Diabetes insipidus
12.Med-surg: neuro, endocrine & renal

Answer: B · Hydrocortisone

Why this is the answer

Starting thyroid replacement first increases metabolism and cortisol clearance and can trigger an adrenal crisis in a patient with low cortisol. Glucocorticoid replacement is started before levothyroxine.

Answer

B · Hydrocortisone
13.Med-surg: GI, perioperative & oncology

Answer: B · Airway and breathing

Why this is the answer

In recovery, residual anaesthetic, opioids and muscle relaxants can cause airway obstruction and respiratory depression. Airway and breathing are assessed first, followed by circulation, consciousness, pain, temperature and the wound.

Answer

B · Airway and breathing
14.Med-surg: GI, perioperative & oncology

Answer: B · Late dumping with low blood glucose; check capillary glucose

Why this is the answer

In late dumping, rapid sugar absorption triggers a large insulin release, followed by reactive hypoglycaemia 1–3 hours after eating. The nurse checks glucose and treats hypoglycaemia; dietary changes help prevent it.

Answer

B · Late dumping with low blood glucose; check capillary glucose

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