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’s chest tube becomes disconnected from the drainage system. What should the nurse do first?

  1. APlace the end of the tube in a bottle of sterile water
  2. BWait for the provider to arrive before doing anything else
  3. CClamp the tube for the rest of the shift
  4. DRemove the tube and cover the site
2.Prioritization & delegationHard

Which child should the nurse see first?

  1. AAn infant with RSV who has nasal flaring, chest retractions and an SpO₂ of 89%
  2. BA teenager with asthma whose peak flow is 90% of their personal best
  3. CA toddler with a temperature of 38.4 °C who is playing with toys
  4. DA school-aged child with a leg cast who is asking for a drink
3.Infection control & patient safetyMedium

An alcohol-based skin prep has been used before surgery with electrosurgery. What must happen before the drapes are placed?

  1. AThe prep must be covered with the drapes while it is still wet
  2. BThe prep must be warmed with a hair dryer
  3. CThe prep must be wiped off with saline
  4. DThe prep must be fully dry and any pooled liquid removed
4.Infection control & patient safetyHard

Which patient most needs fall precautions?

  1. AAn older patient, newly confused, on a sedative, with an unsteady gait
  2. BA patient awaiting discharge who walks independently
  3. CAn alert patient on bed rest who follows instructions
  4. DA young adult with a broken finger who walks steadily and safely unaided
5.Lab values & electrolytesMedium

A trauma patient receives 2 L of IV crystalloid. The hemoglobin falls from 13.0 to 11.4 g/dL (130 to 114 g/L), and the vital signs are now stable. Which explanation is most likely?

  1. ADilution of the blood by the IV fluid
  2. BA sudden failure of the bone marrow
  3. CIncreased red cell production
  4. DA laboratory error in the first sample
6.Lab values & electrolytesHard

A patient on long-term amiodarone has fatigue and weight gain. TSH is 11 mIU/L and the free T4 is low. What is the most likely explanation?

  1. AAmiodarone-induced hypothyroidism
  2. BA normal response to amiodarone needing no action
  3. CSecondary hypothyroidism from pituitary failure
  4. DAmiodarone-induced hyperthyroidism
7.Clinical nursingMedium

An older adult has left lower abdominal pain, fever and a raised CRP. Which condition is most likely?

  1. AGastric ulcer
  2. BAppendicitis
  3. CDiverticulitis
  4. DBiliary colic
8.Clinical nursingHard

A severely hypothermic patient is in cardiac arrest. Why is resuscitation usually continued until they are rewarmed?

  1. AAdrenaline works better in cold patients
  2. BCold patients cannot be defibrillated at all, so CPR is the only possible treatment
  3. CThe cold protects the brain, so recovery may be possible after long resuscitation
  4. DHypothermia always causes brain death quickly
9.Med-surg: cardiovascular & respiratoryMedium

Which statement about a spacer for a metered-dose inhaler is correct?

  1. AIt means the steroid preventer inhaler can be stopped altogether
  2. BIt is designed to be used with dry-powder inhalers
  3. CIt makes each puff of the drug stronger than usual
  4. DLess coordination is needed, and more drug reaches the lungs
10.Med-surg: cardiovascular & respiratoryHard

A hypotensive patient has a temperature of 39.2 °C, warm flushed skin, a bounding pulse and a fast heart rate. Which type of shock is most likely?

  1. AObstructive shock from tamponade
  2. BHypovolaemic shock from bleeding
  3. CCardiogenic shock
  4. DEarly septic (distributive) shock
11.Med-surg: neuro, endocrine & renalMedium

A patient with migraine takes painkillers or triptans on most days and now has a headache almost every day. What is the likely problem?

  1. AAn allergy to the painkillers
  2. BNormal progress of migraine
  3. CMedication overuse headache
  4. DA brain tumour, which is almost certain
12.Med-surg: neuro, endocrine & renalHard

A patient's potassium is 7.1 mmol/L, and the ECG shows peaked T waves and broad QRS complexes. What is the first treatment?

  1. AOral potassium binder
  2. BIV furosemide
  3. COral sodium bicarbonate
  4. DIV calcium gluconate
13.Med-surg: GI, perioperative & oncologyMedium

What is the main clinical difference between small and large bowel obstruction?

  1. ASmall bowel: no vomiting at all; large bowel: early profuse vomiting with no distension
  2. BSmall bowel: early vomiting, less distension; large bowel: later vomiting, marked distension
  3. CSmall bowel: marked distension only; large bowel: no pain, no vomiting and no distension at all
  4. DThere is no clinical difference; only a CT scan can tell them apart
14.Med-surg: GI, perioperative & oncologyHard

During a nasogastric feed, a patient starts coughing and SpO₂ falls from 96% to 89%. What should the nurse do first?

  1. AStop the feed and assess the airway and breathing
  2. BLay the patient flat to help them rest
  3. CIncrease the feed rate to finish it sooner
  4. DGive a drink of water to clear the throat

3Solutions

1.Prioritization & delegation

Answer: A · Place the end of the tube in a bottle of sterile water

Why this is the answer

Putting the tube end in sterile water creates a temporary water seal until a new drainage system is connected. Long clamping can cause a tension pneumothorax, and the nurse does not remove the tube.

Answer

A · Place the end of the tube in a bottle of sterile water
2.Prioritization & delegation

Answer: A · An infant with RSV who has nasal flaring, chest retractions and an SpO₂ of 89%

Why this is the answer

Nasal flaring, retractions and low SpO₂ show respiratory distress, and infants can deteriorate very quickly. A playing child with fever, a thirsty child and a teenager with near-normal peak flow are stable.

Answer

A · An infant with RSV who has nasal flaring, chest retractions and an SpO₂ of 89%
3.Infection control & patient safety

Answer: D · The prep must be fully dry and any pooled liquid removed

Why this is the answer

Wet alcohol prep and its vapors under drapes can be ignited by electrosurgery or lasers. The prep is allowed to dry fully, and pooling in skin folds or linen is prevented.

Answer

D · The prep must be fully dry and any pooled liquid removed
4.Infection control & patient safety

Answer: A · An older patient, newly confused, on a sedative, with an unsteady gait

Why this is the answer

New confusion, a sedative and an unsteady gait are major fall risk factors. The patient needs measures such as a low bed, scheduled toileting, close observation and a medication review.

Answer

A · An older patient, newly confused, on a sedative, with an unsteady gait
5.Lab values & electrolytes

Answer: A · Dilution of the blood by the IV fluid

Why this is the answer

IV fluids dilute the blood, so the hemoglobin falls even without further bleeding. Ongoing bleeding must still be considered, so vital signs, wounds and repeat hemoglobin values are monitored.

Answer

A · Dilution of the blood by the IV fluid
6.Lab values & electrolytes

Answer: A · Amiodarone-induced hypothyroidism

Why this is the answer

Amiodarone is rich in iodine and can cause either hypothyroidism or hyperthyroidism. A high TSH with a low free T4 shows primary hypothyroidism, so thyroid function is monitored before and during therapy; liver tests are monitored too.Checked against: Hypothyroidism · MedlinePlus (NIH) (2024)

Answer

A · Amiodarone-induced hypothyroidism
7.Clinical nursing

Answer: C · Diverticulitis

Why this is the answer

Diverticulitis is inflammation of diverticula, usually in the sigmoid colon, so pain is typically in the left iliac fossa. It is common in older adults.

Answer

C · Diverticulitis
8.Clinical nursing

Answer: C · The cold protects the brain, so recovery may be possible after long resuscitation

Why this is the answer

Hypothermia reduces the brain's oxygen needs, and good recoveries have occurred after long resuscitation. Death is usually not confirmed until the patient has been rewarmed, unless injuries are clearly not survivable.

Answer

C · The cold protects the brain, so recovery may be possible after long resuscitation
9.Med-surg: cardiovascular & respiratory

Answer: D · Less coordination is needed, and more drug reaches the lungs

Why this is the answer

A spacer slows the aerosol and holds it so the patient can inhale it with slow breaths. More drug reaches the lungs and less is deposited in the mouth. It is used with pressurised metered-dose inhalers, not dry-powder devices.

Answer

D · Less coordination is needed, and more drug reaches the lungs
10.Med-surg: cardiovascular & respiratory

Answer: D · Early septic (distributive) shock

Why this is the answer

Early septic shock often causes warm peripheries and bounding pulses because of widespread vasodilation. Cardiogenic, hypovolaemic and obstructive shock usually cause cool, clammy skin from vasoconstriction. Septic shock can later become "cold" as it progresses.

Answer

D · Early septic (distributive) shock
11.Med-surg: neuro, endocrine & renal

Answer: C · Medication overuse headache

Why this is the answer

Frequent use of painkillers or triptans can cause medication overuse headache. Treatment involves withdrawing the overused drug under guidance and starting a preventive treatment if needed.

Answer

C · Medication overuse headache
12.Med-surg: neuro, endocrine & renal

Answer: D · IV calcium gluconate

Why this is the answer

ECG changes mean the heart is at risk. IV calcium is given first to stabilise the myocardium, followed by insulin with glucose (and often nebulised salbutamol) to shift potassium into cells. Binders or dialysis then remove it.

Answer

D · IV calcium gluconate
13.Med-surg: GI, perioperative & oncology

Answer: B · Small bowel: early vomiting, less distension; large bowel: later vomiting, marked distension

Why this is the answer

In proximal small bowel obstruction, vomiting is early and prominent and distension mild. In large bowel obstruction, distension is marked, constipation early and vomiting later (and may be faeculent). Imaging confirms the level and cause.

Answer

B · Small bowel: early vomiting, less distension; large bowel: later vomiting, marked distension
14.Med-surg: GI, perioperative & oncology

Answer: A · Stop the feed and assess the airway and breathing

Why this is the answer

Coughing and desaturation suggest aspiration or a displaced tube. The feed is stopped, the patient is sat up, oxygen is given as needed, and medical review and checking of tube position follow.

Answer

A · Stop the feed and assess the airway and breathing

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