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 has a sudden nosebleed, is alert and is breathing normally. What does the nurse do first?

  1. ALie the patient flat on their back with a pillow under the knees
  2. BAsk the patient to blow the nose hard to clear the clots
  3. CSit the patient up, lean them forward and pinch the soft part of the nose
  4. DTilt the head back and apply ice to the back of the neck
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. BOral potassium binder
  3. CIV calcium gluconate
  4. DIV furosemide
3.Infection control & patient safetyMedium

A patient is booked for an MRI scan. What must the nurse check beforehand?

  1. AWhether the patient’s blood glucose has been in the normal range today
  2. BWhether the patient has eaten a large meal recently
  3. CWhether the patient has any metal implants or devices, such as a pacemaker
  4. DWhether the patient has had a hearing test this year
4.Infection control & patient safetyHard

A patient’s cardiac monitor alarms often because of artifact, and a colleague suggests turning the alarm off. What is the best response?

  1. ATurn the alarm volume down as low as it will go
  2. BKeep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
  3. CTurn the alarm off and check the monitor screen at the nurses’ station every hour instead
  4. DDisconnect the monitor overnight so the patient can sleep
5.Lab values & electrolytesMedium

A patient has a hematocrit of 54%, a high BUN and a urine specific gravity of 1.034. What does this pattern suggest?

  1. AFluid overload
  2. BDehydration with hemoconcentration
  3. CAcute blood loss with dilution
  4. DKidney failure with dilute urine
6.Lab values & electrolytesHard

A patient's potassium is 7.2 mEq/L, and the monitor shows wide QRS complexes. Several treatments are prescribed. Which should be given first?

  1. AAn oral potassium binder dose
  2. BUrgent hemodialysis session
  3. CIV furosemide (a loop diuretic)
  4. DIV calcium gluconate (or chloride)
7.Clinical nursingMedium

Before giving a beta-blocker, which observation is most important to check?

  1. ABlood glucose only
  2. BTemperature only
  3. CHeart rate and blood pressure
  4. DBowel movements
8.Clinical nursingHard

A patient with poorly controlled hyperthyroidism develops a high fever, very fast heart rate, agitation and vomiting during an infection. What is likely?

  1. AMyxoedema coma
  2. BAddisonian crisis
  3. CHypoglycaemia
  4. DThyroid storm
9.Med-surg: cardiovascular & respiratoryMedium

Which laboratory test is used to adjust an unfractionated heparin infusion?

  1. ASerum fibrinogen level
  2. BD-dimer level
  3. CaPTT (or anti-Xa level)
  4. DINR (international normalised ratio)
10.Med-surg: cardiovascular & respiratoryHard

A nurse is planning care for four patients. Which patient should be assessed first?

  1. AA patient with COPD whose SpO₂ fell from 90% to 83% with new drowsiness
  2. BA patient with stable heart failure waiting for the daily weight
  3. CA patient with a venous ulcer due for a dressing change
  4. DA patient with controlled hypertension asking about salt
11.Med-surg: neuro, endocrine & renalMedium

Which statement about hyperosmolar hyperglycaemic state (HHS) is correct?

  1. AIt develops within minutes and is less dangerous than DKA
  2. BIt mainly affects older people with type 2 diabetes, over days
  3. CIt is seen mainly in young children with type 1 diabetes
  4. DIt always causes high blood ketones and a severe metabolic acidosis
12.Med-surg: neuro, endocrine & renalHard

Why might a frail 88-year-old with type 2 diabetes have a less strict HbA1c target?

  1. ABecause older people cannot use any glucose medicines
  2. BTo reduce the risk of hypos, falls and confusion
  3. CBecause diabetes cannot damage older people
  4. DTo save money on blood tests and drugs
13.Med-surg: GI, perioperative & oncologyMedium

How are skin staples usually removed from a healed incision?

  1. AAlternate staples first, then the rest if the wound holds
  2. BThe staples are left in permanently under the skin
  3. COnly the staples at each end, leaving the others for good
  4. DAll staples at once by pulling each one straight up from the skin
14.Med-surg: GI, perioperative & oncologyHard

On the ward after surgery, a patient has a red, blistered area of skin under where the diathermy plate was. What should the nurse do?

  1. AApply a hot water bottle to improve the circulation
  2. BIgnore it because skin changes after surgery are normal and expected to fade
  3. CWash it with alcohol and leave it uncovered
  4. DTreat it as a possible burn, report it and complete an incident form

3Solutions

1.Prioritization & delegation

Answer: C · Sit the patient up, lean them forward and pinch the soft part of the nose

Why this is the answer

Leaning forward keeps blood out of the airway and stomach, and firm pressure on the soft part of the nose usually stops the bleeding. Tilting the head back or lying flat lets blood run into the throat.

Answer

C · Sit the patient up, lean them forward and pinch the soft part of the nose
2.Prioritization & delegation

Answer: C · 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

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

Answer: C · Whether the patient has any metal implants or devices, such as a pacemaker

Why this is the answer

The MRI magnet can move or heat metal objects and can stop some implanted devices from working. Patients are screened for implants, pacemakers, metal fragments and metal items such as jewelry before entering the scanner room.

Answer

C · Whether the patient has any metal implants or devices, such as a pacemaker
4.Infection control & patient safety

Answer: B · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy

Why this is the answer

Disabling alarms is a known cause of missed deterioration. Alarm fatigue is reduced by fixing causes such as poor skin preparation or old electrodes and by setting individual limits according to orders and policy.

Answer

B · Keep the alarm on, fix the cause such as electrode placement, and adjust limits only per policy
5.Lab values & electrolytes

Answer: B · Dehydration with hemoconcentration

Why this is the answer

Loss of plasma water concentrates the red cells (raised hematocrit) and the urine (high specific gravity), and the BUN rises. Fluid overload would cause the opposite pattern.Checked against: Hematocrit Test · MedlinePlus (NIH) (2024); BUN (Blood Urea Nitrogen) · MedlinePlus (NIH) (2024)

Answer

B · Dehydration with hemoconcentration
6.Lab values & electrolytes

Answer: D · IV calcium gluconate (or chloride)

Why this is the answer

With ECG changes, IV calcium is given first to stabilize the cardiac membrane within minutes. It does not lower potassium, so insulin with glucose (and sometimes albuterol/salbutamol) follows to shift potassium into cells, then binders, diuretics or dialysis remove it.Checked against: High potassium level - Medical Encyclopedia · MedlinePlus (NIH) (2025)

Answer

D · IV calcium gluconate (or chloride)
7.Clinical nursing

Answer: C · Heart rate and blood pressure

Why this is the answer

Beta-blockers lower heart rate and blood pressure, so bradycardia or hypotension may require withholding the dose and informing the prescriber.

Answer

C · Heart rate and blood pressure
8.Clinical nursing

Answer: D · Thyroid storm

Why this is the answer

Thyroid storm is a life-threatening worsening of hyperthyroidism, often triggered by infection or surgery. It needs urgent treatment with cooling, beta-blockade and antithyroid drugs.

Answer

D · Thyroid storm
9.Med-surg: cardiovascular & respiratory

Answer: C · aPTT (or anti-Xa level)

Why this is the answer

IV unfractionated heparin has a variable effect and is titrated to the aPTT (or anti-Xa level) according to the prescribed protocol. The platelet count is also checked to detect heparin-induced thrombocytopenia. D-dimer is used to help exclude thrombosis, not to monitor treatment.

Answer

C · aPTT (or anti-Xa level)
10.Med-surg: cardiovascular & respiratory

Answer: A · A patient with COPD whose SpO₂ fell from 90% to 83% with new drowsiness

Why this is the answer

A falling saturation with new drowsiness suggests acute respiratory failure, possibly with hypercapnia, and needs immediate assessment. The other patients are stable and their needs can wait briefly.

Answer

A · A patient with COPD whose SpO₂ fell from 90% to 83% with new drowsiness
11.Med-surg: neuro, endocrine & renal

Answer: B · It mainly affects older people with type 2 diabetes, over days

Why this is the answer

HHS develops over days, often triggered by infection, with extreme hyperglycaemia, very high osmolality and profound dehydration, frequently with confusion. Enough insulin is present to prevent marked ketosis. Mortality is higher than in DKA, and there is a high risk of thrombosis.

Answer

B · It mainly affects older people with type 2 diabetes, over days
12.Med-surg: neuro, endocrine & renal

Answer: B · To reduce the risk of hypos, falls and confusion

Why this is the answer

In frail older adults, tight control brings little long-term benefit and a high risk of hypoglycaemia, which can cause falls, fractures and confusion. Targets are individualised to balance safety and quality of life.

Answer

B · To reduce the risk of hypos, falls and confusion
13.Med-surg: GI, perioperative & oncology

Answer: A · Alternate staples first, then the rest if the wound holds

Why this is the answer

Removing alternate staples first allows the nurse to check that the wound edges stay together. If the wound is secure, the rest are removed, and adhesive strips can be applied for support.

Answer

A · Alternate staples first, then the rest if the wound holds
14.Med-surg: GI, perioperative & oncology

Answer: D · Treat it as a possible burn, report it and complete an incident form

Why this is the answer

A blister under the return electrode suggests a diathermy burn. The nurse assesses and dresses it, informs the team, and reports it as an incident so that the cause can be investigated.

Answer

D · Treat it as a possible burn, report it and complete an incident form

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