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 teaches a patient about levothyroxine. Which statement shows a need for further teaching?

  1. A“I will take it at the same time each morning.”
  2. B“I will take it on an empty stomach with a glass of water.”
  3. C“I will take it at breakfast with my calcium tablet.”
  4. D“I will keep taking it even when I feel well.”
2.Prioritization & delegationHard

A patient has a chest drain for a pneumothorax. The nurse sees constant bubbling in the water-seal chamber. What does this most likely mean?

  1. AThe suction is set too low and needs to be turned up
  2. BThe lung has fully re-expanded, so the drain is ready to come out
  3. CAn air leak in the patient or the system that needs checking
  4. DThe drain is working normally and no action is needed
3.Infection control & patient safetyMedium

Why are independent double checks used for some medicines, such as insulin and heparin infusions?

  1. ABecause these drugs are very expensive to waste
  2. BA second person checking separately catches missed errors
  3. CTo share responsibility between two nurses if an error happens
  4. DTo make the preparation process faster
4.Infection control & patient safetyHard

A patient with active pulmonary tuberculosis asks visitors to come in. What is the best response?

  1. AAsk visitors to stand in the open doorway instead of entering the room
  2. BExplain the risk, limit visits and teach visitors to use the protection provided
  3. CBan all contact permanently, including phone calls
  4. DAllow any visitor in without any precautions, to support the patient
5.Lab values & electrolytesMedium

On the first day after major surgery, a patient's white cell count is 12.5 × 10³/µL, with no fever or wound signs. What is the best interpretation?

  1. AA laboratory error, since surgery lowers white cells
  2. BA sign of leukemia that needs bone marrow testing
  3. CDefinite wound infection that needs antibiotics now
  4. DA common stress response to surgery that is monitored
6.Lab values & electrolytesHard

A patient without diabetes in the ICU with sepsis has a glucose of 260 mg/dL (14.4 mmol/L) and an HbA1c of 5.2%. What is the best interpretation?

  1. AType 1 diabetes from autoimmune damage
  2. BA meter error, because HbA1c is normal
  3. CLong-standing undiagnosed type 2 diabetes
  4. DStress hyperglycemia from acute illness
7.Clinical nursingMedium

What should a nurse do during a generalised tonic-clonic seizure?

  1. AProtect the head, time the seizure and do not put anything in the mouth
  2. BHold the limbs firmly to stop the jerking and prevent injury
  3. CPut a tongue depressor between the teeth so that the tongue is not bitten
  4. DGive the patient a drink of water
8.Clinical nursingHard

A patient has had diarrhoea for three days and is on a medical ward. What is the most appropriate infection control action?

  1. AMove the patient to a shared bay so single rooms stay available
  2. BIsolate promptly, use contact precautions and send a stool sample
  3. CWait until the diarrhoea has lasted a week before taking any action
  4. DUse alcohol hand rub only and avoid gloves to save resources
9.Med-surg: cardiovascular & respiratoryMedium

Why are patients with mitral stenosis at high risk of atrial fibrillation?

  1. AThe left atrium enlarges as it pushes blood through the narrow valve
  2. BThe right ventricle shrinks and stops contracting properly over time
  3. CThe coronary arteries become blocked by the valve
  4. DThe narrow valve presses on the sinus node and slows it down directly
10.Med-surg: cardiovascular & respiratoryHard

A 74-year-old man with a known abdominal aortic aneurysm suddenly has severe back and abdominal pain. His heart rate is 128/min and BP 82/50 mmHg. What is the priority?

  1. ACall for emergency help and prepare for urgent vascular surgery
  2. BEncourage him to walk to ease the back pain
  3. CGive oral analgesia and reassess the pain in an hour
  4. DArrange a routine outpatient ultrasound scan of the aneurysm
11.Med-surg: neuro, endocrine & renalMedium

When the nurse squeezes the trapezius muscle, the patient brings a hand up above the collarbone towards the stimulus. Which GCS motor score is this?

  1. A6, obeys commands
  2. B5, localises to pain
  3. C3, abnormal flexion
  4. D4, withdraws from pain
12.Med-surg: neuro, endocrine & renalHard

A patient with multiple sclerosis has had worse leg weakness for one day, together with a fever and burning on passing urine. What is the most likely explanation?

  1. AA true relapse that needs high-dose steroids
  2. BA pseudo-relapse caused by infection
  3. CA side effect of physiotherapy
  4. DA change to progressive MS
13.Med-surg: GI, perioperative & oncologyMedium

Why is pethidine (meperidine) generally avoided for regular pain relief?

  1. AIt always causes severe diarrhoea
  2. BA metabolite can build up and cause seizures
  3. CIt can only be given by mouth
  4. DIt has no pain-relieving effect at all in adults
14.Med-surg: GI, perioperative & oncologyHard

A patient on warfarin has a major upper GI bleed with an INR of 5. Which treatment should the nurse anticipate to reverse the warfarin?

  1. AOral aspirin to balance the clotting system quickly
  2. BProtamine sulfate on its own
  3. CProthrombin complex concentrate with IV vitamin K
  4. DMore warfarin to stabilise the INR

3Solutions

1.Prioritization & delegation

Answer: C · “I will take it at breakfast with my calcium tablet.”

Why this is the answer

Levothyroxine is best absorbed on an empty stomach and is separated from calcium and iron by several hours. It is usually lifelong, so it is not stopped when the patient feels better.

Answer

C · “I will take it at breakfast with my calcium tablet.”
2.Prioritization & delegation

Answer: C · An air leak in the patient or the system that needs checking

Why this is the answer

Continuous bubbling in the water-seal chamber signals an air leak. The nurse checks the connections from the patient to the drain and reports a leak that cannot be fixed.

Answer

C · An air leak in the patient or the system that needs checking
3.Infection control & patient safety

Answer: B · A second person checking separately catches missed errors

Why this is the answer

In an independent double check, a second qualified person checks the order, the drug, the dose, the calculation and the pump settings on their own. This catches errors that could cause serious harm with high-alert medications.

Answer

B · A second person checking separately catches missed errors
4.Infection control & patient safety

Answer: B · Explain the risk, limit visits and teach visitors to use the protection provided

Why this is the answer

Visits are limited and supported with education and protection according to policy, while the patient remains in a closed negative-pressure room. Visiting at an open door defeats the negative pressure.

Answer

B · Explain the risk, limit visits and teach visitors to use the protection provided
5.Lab values & electrolytes

Answer: D · A common stress response to surgery that is monitored

Why this is the answer

A mild leukocytosis is common after surgery because of tissue injury and the stress response. It is monitored along with temperature and wound assessment. A rising count after several days, or fever, suggests infection.

Answer

D · A common stress response to surgery that is monitored
6.Lab values & electrolytes

Answer: D · Stress hyperglycemia from acute illness

Why this is the answer

Stress hormones and inflammation raise glucose in acute illness, even without diabetes. A normal HbA1c shows that glucose was normal over the previous months. Stress hyperglycemia is still treated, usually with insulin, because it worsens outcomes.

Answer

D · Stress hyperglycemia from acute illness
7.Clinical nursing

Answer: A · Protect the head, time the seizure and do not put anything in the mouth

Why this is the answer

Remove nearby hazards, cushion the head, note the time and do not restrain or put objects in the mouth. Once jerking stops, place the patient in the recovery position and check the airway.

Answer

A · Protect the head, time the seizure and do not put anything in the mouth
8.Clinical nursing

Answer: B · Isolate promptly, use contact precautions and send a stool sample

Why this is the answer

Unexplained diarrhoea may be infective, for example C. difficile or norovirus. Isolation and testing without delay protect other patients.

Answer

B · Isolate promptly, use contact precautions and send a stool sample
9.Med-surg: cardiovascular & respiratory

Answer: A · The left atrium enlarges as it pushes blood through the narrow valve

Why this is the answer

A narrowed mitral valve raises pressure in the left atrium, which dilates. A stretched atrium is prone to atrial fibrillation, and blood stasis there carries a high risk of clots and stroke. Anticoagulation is therefore essential in mitral stenosis with AF.

Answer

A · The left atrium enlarges as it pushes blood through the narrow valve
10.Med-surg: cardiovascular & respiratory

Answer: A · Call for emergency help and prepare for urgent vascular surgery

Why this is the answer

Sudden abdominal or back pain with hypotension in a patient with an AAA suggests rupture, which is often fatal without urgent repair. The team is called at once, large-bore IV access and blood are arranged, and the patient goes to theatre. Fluid may be limited so the blood pressure is not pushed high (permissive hypotension), as directed by the team.

Answer

A · Call for emergency help and prepare for urgent vascular surgery
11.Med-surg: neuro, endocrine & renal

Answer: B · 5, localises to pain

Why this is the answer

Localising to pain (5) means a purposeful movement towards the source of pain. Withdrawal (4) is pulling away, abnormal flexion (3) is decorticate posturing, and obeying commands (6) needs no pain at all. A central stimulus, such as a trapezius squeeze, is used to test for localising.

Answer

B · 5, localises to pain
12.Med-surg: neuro, endocrine & renal

Answer: B · A pseudo-relapse caused by infection

Why this is the answer

Infection and fever can temporarily worsen existing MS symptoms without new damage (a pseudo-relapse). The infection, here probably a UTI, is treated first. Steroids for a true relapse are considered only if the infection is excluded.

Answer

B · A pseudo-relapse caused by infection
13.Med-surg: GI, perioperative & oncology

Answer: B · A metabolite can build up and cause seizures

Why this is the answer

Pethidine's metabolite norpethidine accumulates with repeated doses or kidney impairment and can cause agitation, tremor and seizures. Other opioids are preferred.

Answer

B · A metabolite can build up and cause seizures
14.Med-surg: GI, perioperative & oncology

Answer: C · Prothrombin complex concentrate with IV vitamin K

Why this is the answer

Major bleeding on warfarin is treated by stopping it and giving prothrombin complex concentrate for rapid reversal with IV vitamin K for a lasting effect. Protamine reverses heparin, not warfarin.

Answer

C · Prothrombin complex concentrate with IV vitamin K

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