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 on a nasal cannula at 6 L/min still has a low SpO₂. What should the nurse do?

  1. ARecheck the SpO₂ at the next routine set of observations in four hours
  2. BRemove the oxygen to see if the SpO₂ changes
  3. CReport it, because a different oxygen device is likely to be needed
  4. DTurn the nasal cannula up to 15 L/min
2.Prioritization & delegationHard

A patient with diabetes takes propranolol. Which sign of hypoglycemia is most likely to still appear?

  1. ASweating
  2. BTremor
  3. CPalpitations
  4. DTachycardia
3.Infection control & patient safetyMedium

Which IV fluid can be given with packed red blood cells in the same line?

  1. A5% dextrose in 0.45% sodium chloride
  2. BLactated Ringer’s (Hartmann’s) solution
  3. C5% dextrose in water
  4. D0.9% sodium chloride
4.Infection control & patient safetyHard

Over a few hours, the emergency department sees many previously healthy people with the same unusual severe symptoms. What should the nurse do?

  1. ATreat each patient and wait to see if more arrive next week
  2. BTell only the patients’ families about the pattern
  3. CReport it to infection prevention and public health authorities promptly
  4. DSend the patients home quickly to avoid crowding the emergency department
5.Lab values & electrolytesMedium

A patient on warfarin has an INR of 7.8 and a nosebleed. Which medication would the nurse expect the provider to prescribe?

  1. AVitamin K (phytonadione)
  2. BNaloxone hydrochloride
  3. CProtamine sulfate
  4. DAcetylcysteine
6.Lab values & electrolytesHard

A patient has fatigue, weight loss, darkening of the skin and low blood pressure. Results: sodium 130 mEq/L, potassium 5.6 mEq/L. Which test pattern would confirm primary adrenal insufficiency (Addison disease)?

  1. AHigh cortisol with a high ACTH
  2. BHigh cortisol with a low ACTH
  3. CLow cortisol with a high ACTH
  4. DLow cortisol with a low ACTH
7.Clinical nursingMedium

Why is lactulose given to a patient with hepatic encephalopathy?

  1. ATo increase the liver's production of albumin
  2. BTo reduce the absorption of ammonia from the gut
  3. CTo lower the blood glucose
  4. DTo stop bleeding from varices
8.Clinical nursingHard

A nurse teaches a patient with hypertension about their medicines. Which statement shows a need for further teaching?

  1. A"I'll keep taking my tablets even if I feel well."
  2. B"I'll get up slowly from sitting."
  3. C"I'll have my blood pressure checked regularly."
  4. D"I'll stop my tablets once my readings are normal."
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. BAnticoagulants reduce the electrical energy needed for the shock
  3. CAnticoagulants make the shock less painful
  4. DAtrial clots may be dislodged when sinus rhythm returns
10.Med-surg: cardiovascular & respiratoryHard

A patient with a COPD exacerbation has been on NIV for two hours. They are now more drowsy, and the pH has fallen further despite a good mask fit. What should the nurse do?

  1. AEscalate urgently for review of intubation or a ceiling of care
  2. BGive a sedative to help the patient tolerate the mask
  3. CRemove the mask and give nebulised bronchodilators only from now on
  4. DContinue NIV unchanged and repeat the blood gas tomorrow morning
11.Med-surg: neuro, endocrine & renalMedium

A patient taking dapagliflozin (an SGLT2 inhibitor) is vomiting, with blood ketones of 4.5 mmol/L but a glucose of only 11 mmol/L. What should be suspected?

  1. AEuglycaemic diabetic ketoacidosis
  2. BHypoglycaemia caused by the vomiting
  3. CHyperosmolar hyperglycaemic state
  4. DA normal side effect needing no action
12.Med-surg: neuro, endocrine & renalHard

A patient with polycystic kidney disease suddenly has the worst headache of their life and neck stiffness. What should the nurse suspect?

  1. APain spreading upwards from a kidney cyst
  2. BA urinary infection that has spread
  3. CA migraine linked to high blood pressure
  4. DA subarachnoid haemorrhage from a brain aneurysm
13.Med-surg: GI, perioperative & oncologyMedium

Which initial treatment is usual for symptomatic hypercalcaemia of malignancy?

  1. AFluid restriction and a thiazide diuretic
  2. BOral calcium tablets and vitamin D
  3. CA high-calcium diet with extra milk
  4. DIV fluids followed by an IV bisphosphonate
14.Med-surg: GI, perioperative & oncologyHard

A patient with a toe ulcer says the leg pain is worse at night and eases when they hang the leg over the side of the bed. What does this suggest?

  1. ALymphoedema
  2. BArterial insufficiency
  3. CNeuropathic itching
  4. DVenous insufficiency

3Solutions

1.Prioritization & delegation

Answer: C · Report it, because a different oxygen device is likely to be needed

Why this is the answer

Standard nasal cannulas are usually run at up to about 6 L/min; higher flows dry the nose without much benefit. If the patient still needs more oxygen, the nurse assesses and escalates for a different device.

Answer

C · Report it, because a different oxygen device is likely to be needed
2.Prioritization & delegation

Answer: A · Sweating

Why this is the answer

Beta-blockers can hide tachycardia, palpitations and tremor during hypoglycemia. Sweating is mainly cholinergic, so it usually remains, and patients are taught to check glucose when they sweat.

Answer

A · Sweating
3.Infection control & patient safety

Answer: D · 0.9% sodium chloride

Why this is the answer

Only 0.9% sodium chloride is compatible with blood. Dextrose (glucose) solutions can cause red cells to clump and break down, and the calcium in lactated Ringer’s (Hartmann’s) can cause clotting.

Answer

D · 0.9% sodium chloride
4.Infection control & patient safety

Answer: C · Report it to infection prevention and public health authorities promptly

Why this is the answer

Clusters of similar unusual illness can signal an outbreak or bioterrorism. Early reporting allows public health to investigate, guide precautions and treatment, and protect the community.

Answer

C · Report it to infection prevention and public health authorities promptly
5.Lab values & electrolytes

Answer: A · Vitamin K (phytonadione)

Why this is the answer

Warfarin blocks vitamin K–dependent clotting factors, and vitamin K restores their production over hours. For serious bleeding, a prothrombin complex concentrate may also be given to replace factors at once. The warfarin is held.

Answer

A · Vitamin K (phytonadione)
6.Lab values & electrolytes

Answer: C · Low cortisol with a high ACTH

Why this is the answer

In primary adrenal insufficiency the adrenal glands fail, so cortisol is low and the pituitary responds with high ACTH, which also darkens the skin. Low cortisol with low ACTH suggests a pituitary cause. An ACTH stimulation test confirms the diagnosis.

Answer

C · Low cortisol with a high ACTH
7.Clinical nursing

Answer: B · To reduce the absorption of ammonia from the gut

Why this is the answer

Lactulose acidifies the colon and speeds transit, reducing ammonia absorption. The dose is usually adjusted to give two to three soft stools a day.

Answer

B · To reduce the absorption of ammonia from the gut
8.Clinical nursing

Answer: D · "I'll stop my tablets once my readings are normal."

Why this is the answer

Hypertension usually needs long-term treatment; stopping because readings are normal often makes blood pressure rise again. Patients should discuss any changes with their prescriber.

Answer

D · "I'll stop my tablets once my readings are normal."
9.Med-surg: cardiovascular & respiratory

Answer: D · 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

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

Answer: A · Escalate urgently for review of intubation or a ceiling of care

Why this is the answer

Worsening acidosis and consciousness on NIV mean treatment is failing. Senior review is needed to decide on intubation and ventilation or, if agreed in advance, a ceiling of care. Ideally the plan for NIV failure is documented when NIV is started. Sedation would depress breathing further.

Answer

A · Escalate urgently for review of intubation or a ceiling of care
11.Med-surg: neuro, endocrine & renal

Answer: A · Euglycaemic diabetic ketoacidosis

Why this is the answer

SGLT2 inhibitors lower glucose by increasing urinary glucose loss, so DKA can occur with only moderately raised glucose. Ketones should be checked in any unwell patient on these drugs, and the drug is stopped during acute illness (sick-day rules).

Answer

A · Euglycaemic diabetic ketoacidosis
12.Med-surg: neuro, endocrine & renal

Answer: D · A subarachnoid haemorrhage from a brain aneurysm

Why this is the answer

Adult polycystic kidney disease is associated with berry aneurysms. A sudden thunderclap headache suggests subarachnoid haemorrhage and needs emergency assessment and CT imaging.

Answer

D · A subarachnoid haemorrhage from a brain aneurysm
13.Med-surg: GI, perioperative & oncology

Answer: D · IV fluids followed by an IV bisphosphonate

Why this is the answer

Hypercalcaemia causes polyuria and dehydration, so IV saline is given first, then a bisphosphonate such as zoledronic acid to reduce bone resorption. Calcium, kidney function and symptoms are monitored.

Answer

D · IV fluids followed by an IV bisphosphonate
14.Med-surg: GI, perioperative & oncology

Answer: B · Arterial insufficiency

Why this is the answer

Rest pain eased by dependency is typical of severe peripheral arterial disease. Elevating the leg worsens pain, and compression is avoided. Vascular assessment is needed.

Answer

B · Arterial insufficiency

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