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

An Rh-negative mother has just given birth to an Rh-positive baby. What does the nurse expect to give the mother?

  1. ARh immunoglobulin within 72 hours
  2. BVitamin K to the mother
  3. CA dose of the hepatitis B vaccine instead
  4. DNo treatment is needed
2.Prioritization & delegationHard

Which patient is the best choice for the room closest to the nurses’ station?

  1. AA confused older adult at high risk of falls
  2. BA patient with stable diabetes who walks independently
  3. CA young adult waiting for discharge tomorrow
  4. DA patient admitted for a planned scan, feeling well
3.Infection control & patient safetyMedium

Which patient safety measure is most appropriate for a patient with a latex allergy?

  1. AUsing powdered latex gloves only
  2. BUsing latex gloves and washing hands well afterwards
  3. CAvoiding all gloves during patient care
  4. DUsing latex-free equipment and documenting the allergy clearly
4.Infection control & patient safetyHard

A nurse picks up a heparin vial that contains 10 000 units/mL; the ward usually stocks 1000 units/mL vials. Why is extra care needed?

  1. ABoth vial strengths can be swapped freely
  2. BHeparin concentration has no effect on safety
  3. CUsing the more concentrated vial by mistake would give a tenfold overdose
  4. DThe concentrated vial is safer, because less volume is drawn up
5.Lab values & electrolytesMedium

The heparin infusion rate was changed according to protocol. When is the aPTT usually rechecked?

  1. AAbout 30 minutes after the change
  2. BAbout 3 days after the change
  3. COnly after the infusion is stopped
  4. DAbout 6 hours after the change
6.Lab values & electrolytesHard

Three days after starting haloperidol, a patient has a temperature of 40 °C, severe muscle rigidity and confusion. Which laboratory result would the nurse expect?

  1. AA very high serum lithium
  2. BA very low serum sodium
  3. CA very high creatine kinase (CK)
  4. DA very low white cell count
7.Clinical nursingMedium

Why is serum lactate measured in a patient with suspected sepsis?

  1. AA raised lactate indicates poor tissue perfusion and higher risk
  2. BIt confirms which antibiotic to give
  3. CIt measures the patient's blood glucose
  4. DIt shows whether the patient has a urinary tract infection
8.Clinical nursingHard

A patient with new fast atrial fibrillation has chest pain, a blood pressure of 75/40 mmHg and is confused. What does this indicate?

  1. AHaemodynamic instability needing urgent treatment, possibly electrical cardioversion
  2. BAnxiety about the new diagnosis that will settle with reassurance and rest alone
  3. CA stable rhythm that can safely be reviewed at the next routine ward round
  4. DA normal response to atrial fibrillation needing no action
9.Med-surg: cardiovascular & respiratoryMedium

A patient with supraventricular tachycardia is to receive IV adenosine. What should the nurse warn them about?

  1. AA burning pain along the arm vein for about a week
  2. BBrief flushing or chest tightness and a pause of a few seconds
  3. CA headache that lasts for several days afterwards
  4. DSeveral hours of drowsiness, slurred speech and confusion afterwards
10.Med-surg: cardiovascular & respiratoryHard

A patient's blood gas shows pH 7.26, PaCO₂ 9.0 kPa (68 mmHg) and bicarbonate 25 mmol/L. What does this show?

  1. AAcute respiratory acidosis
  2. BRespiratory alkalosis
  3. CMetabolic alkalosis
  4. DMetabolic acidosis with compensation
11.Med-surg: neuro, endocrine & renalMedium

For which patient with migraine would the nurse question an order for sumatriptan?

  1. AA patient who also has asthma
  2. BA patient with a history of angina
  3. CA patient with an allergy to penicillin
  4. DA patient with well-controlled hypothyroidism
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 side effect of physiotherapy
  2. BA change to progressive MS
  3. CA pseudo-relapse caused by infection
  4. DA true relapse that needs high-dose steroids
13.Med-surg: GI, perioperative & oncologyMedium

Which lung problem is a known toxicity of bleomycin?

  1. APulmonary fibrosis
  2. BPneumothorax from coughing
  3. CLung cancer within weeks
  4. DAsthma from pollen
14.Med-surg: GI, perioperative & oncologyHard

A patient with an epidural after abdominal surgery has BP 82/48 mmHg, a pulse of 70/min and warm feet. Bleeding has been excluded. What is the most likely cause?

  1. ACardiogenic shock after surgery
  2. BSympathetic block from the epidural
  3. CAnaphylaxis to the local anaesthetic
  4. DHypovolaemic shock from blood loss

3Solutions

1.Prioritization & delegation

Answer: A · Rh immunoglobulin within 72 hours

Why this is the answer

Rh immunoglobulin given within 72 hours of birth prevents the mother from forming anti-D antibodies, which could harm a future Rh-positive baby.

Answer

A · Rh immunoglobulin within 72 hours
2.Prioritization & delegation

Answer: A · A confused older adult at high risk of falls

Why this is the answer

A confused patient at high risk of falls benefits from being close to staff, so they can be observed and helped quickly. The other patients are stable and independent.

Answer

A · A confused older adult at high risk of falls
3.Infection control & patient safety

Answer: D · Using latex-free equipment and documenting the allergy clearly

Why this is the answer

The allergy is documented and the patient wears an allergy band. Latex-free gloves, catheters and other equipment are used, and the room may be cleared of latex products. Powdered latex gloves are especially risky because the powder carries the protein into the air.

Answer

D · Using latex-free equipment and documenting the allergy clearly
4.Infection control & patient safety

Answer: C · Using the more concentrated vial by mistake would give a tenfold overdose

Why this is the answer

Mix-ups between heparin strengths have caused deaths. The nurse checks the concentration on the label every time and uses an independent double check, and many hospitals limit which strengths are stocked.

Answer

C · Using the more concentrated vial by mistake would give a tenfold overdose
5.Lab values & electrolytes

Answer: D · About 6 hours after the change

Why this is the answer

Most weight-based heparin protocols check the aPTT (or anti-Xa level) about 6 hours after starting or changing the rate, because it takes this long to reach a new steady state. Checking too early can lead to wrong adjustments.

Answer

D · About 6 hours after the change
6.Lab values & electrolytes

Answer: C · A very high creatine kinase (CK)

Why this is the answer

These signs suggest neuroleptic malignant syndrome, a medical emergency. Muscle rigidity releases CK, often to very high levels, and the white count is often raised. Myoglobin can damage the kidneys. The antipsychotic is stopped and supportive care is started.

Answer

C · A very high creatine kinase (CK)
7.Clinical nursing

Answer: A · A raised lactate indicates poor tissue perfusion and higher risk

Why this is the answer

Lactate rises when tissues are poorly perfused. A high lactate in sepsis signals greater severity and is used to guide fluid resuscitation.

Answer

A · A raised lactate indicates poor tissue perfusion and higher risk
8.Clinical nursing

Answer: A · Haemodynamic instability needing urgent treatment, possibly electrical cardioversion

Why this is the answer

A tachyarrhythmia with adverse features such as shock, myocardial ischaemia or reduced consciousness is unstable. Urgent senior help is needed, and synchronised cardioversion is often used.

Answer

A · Haemodynamic instability needing urgent treatment, possibly electrical cardioversion
9.Med-surg: cardiovascular & respiratory

Answer: B · Brief flushing or chest tightness and a pause of a few seconds

Why this is the answer

Adenosine is given as a rapid IV bolus followed by a saline flush, with continuous ECG monitoring. It briefly blocks AV node conduction, often causing a few seconds of asystole, flushing, chest discomfort, breathlessness or a sense of doom. The effects last only seconds.

Answer

B · Brief flushing or chest tightness and a pause of a few seconds
10.Med-surg: cardiovascular & respiratory

Answer: A · Acute respiratory acidosis

Why this is the answer

A low pH with raised PaCO₂ is respiratory acidosis. A normal bicarbonate (about 22–26 mmol/L) shows the kidneys have not yet compensated, so the problem is acute, as in opioid toxicity, exhaustion or an acute COPD exacerbation. Treatment targets ventilation.

Answer

A · Acute respiratory acidosis
11.Med-surg: neuro, endocrine & renal

Answer: B · A patient with a history of angina

Why this is the answer

Triptans constrict blood vessels, including the coronary arteries. They are contraindicated in coronary artery disease, previous stroke and uncontrolled hypertension.

Answer

B · A patient with a history of angina
12.Med-surg: neuro, endocrine & renal

Answer: C · 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

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

Answer: A · Pulmonary fibrosis

Why this is the answer

Bleomycin can cause pneumonitis and pulmonary fibrosis, especially at higher cumulative doses, in older patients and with high oxygen concentrations. Breathlessness or a new cough must be reported.

Answer

A · Pulmonary fibrosis
14.Med-surg: GI, perioperative & oncology

Answer: B · Sympathetic block from the epidural

Why this is the answer

Epidural local anaesthetic can block sympathetic outflow, causing vasodilation and hypotension. Management follows the epidural protocol: assess, lie the patient flat, give fluid or vasopressors as prescribed and inform the anaesthetist. Bleeding must always be considered too.

Answer

B · Sympathetic block from the epidural

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