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 nursing assistant refuses a delegated task, saying they have not been trained to do it. What is the best response from the nurse?

  1. AThank the assistant, make sure the task is done safely and arrange training
  2. BTell the assistant it is in the job description and must be done
  3. CLeave the task for the next shift, when someone trained is on
  4. DReport the assistant to the manager for refusing a task
2.Prioritization & delegationHard

An older patient has bruises of different ages and seems frightened when a relative visits. What is the nurse’s priority?

  1. AAsk the relative directly in front of the patient whether they hit her
  2. BIgnore it, because older people bruise easily
  3. CEnsure the patient’s safety, document the findings and report as required
  4. DTell the patient she must leave home and go to live somewhere else
3.Infection control & patient safetyMedium

Why are patients on long-term corticosteroids at higher risk from infections?

  1. ASteroids suppress the immune response and can hide signs of infection
  2. BSteroids kill the patient’s normal skin bacteria
  3. CSteroids make the patient’s blood more acidic, which helps bacteria grow
  4. DSteroids only affect the risk of fungal skin rashes
4.Infection control & patient safetyHard

A nurse has raised a safety concern about an order with the prescriber, who dismissed it without addressing it. What should the nurse do next?

  1. ARefuse to care for the patient for the rest of the shift until the prescriber apologizes
  2. BCarry out the order as written, because the prescriber has heard the concern
  3. CState the concern clearly a second time and, if still unresolved, use the chain of command
  4. DDiscuss the concern with the patient and let them decide
5.Lab values & electrolytesMedium

A patient has burning on urination and frequency. The dipstick is positive for nitrites and leukocyte esterase, and a urine culture is ordered. When should the sample be taken?

  1. AAt any time, as antibiotics do not matter
  2. BAfter the symptoms have fully settled
  3. CBefore the first dose of antibiotic
  4. DAfter 3 days of antibiotic treatment
6.Lab values & electrolytesHard

A patient using an insulin pump has a glucose of 300 mg/dL (16.7 mmol/L) that has not fallen 2 hours after a correction bolus through the pump. Blood ketones are 1.8 mmol/L. What is the most likely problem and action?

  1. ANormal pump function; wait for the next mealtime bolus to lower the glucose
  2. BInsulin overdose from the pump; suspend the pump and stop all insulin for a day
  3. CRebound after a hypo; give fast-acting carbohydrate and recheck in 15 minutes
  4. DInsulin delivery failure; inject a correction dose by pen and change the set
7.Clinical nursingMedium

A patient receiving warfarin has an INR far above the target range and bruising. Which drug may be prescribed to reverse the effect?

  1. AVitamin K
  2. BAspirin
  3. CProtamine sulfate
  4. DNaloxone
8.Clinical nursingHard

Which drug group is first-line for a prolonged convulsive seizure?

  1. AAntihistamines, such as chlorphenamine
  2. BBeta-blockers, such as bisoprolol or atenolol
  3. COpioids, such as morphine or diamorphine, given intravenously
  4. DBenzodiazepines, such as buccal midazolam or IV lorazepam
9.Med-surg: cardiovascular & respiratoryMedium

Analysis of a pleural effusion shows it is an exudate (high protein and LDH compared with blood). Which cause is most likely?

  1. ANephrotic syndrome with protein lost in urine
  2. BHeart failure with raised venous pressure
  3. CPneumonia or cancer affecting the pleura
  4. DLiver cirrhosis with a low albumin
10.Med-surg: cardiovascular & respiratoryHard

A patient with severe chronic kidney disease needs therapeutic anticoagulation for a DVT. Why might unfractionated heparin be chosen instead of a low-molecular-weight heparin?

  1. AUnfractionated heparin has no bleeding risk at all
  2. BLMWH is cleared by the kidneys and can accumulate
  3. CUnfractionated heparin is taken by mouth
  4. DLMWH cannot be given to anyone over 60
11.Med-surg: neuro, endocrine & renalMedium

Why is once-daily prednisolone usually taken in the morning with food?

  1. ATo match the natural cortisol rhythm and protect the stomach
  2. BBecause it cannot be absorbed at night
  3. CBecause it causes drowsiness and is safer to take during the day
  4. DBecause food doubles the strength of the dose
12.Med-surg: neuro, endocrine & renalHard

Which task for a patient with a urinary catheter can the nurse delegate to a healthcare assistant (nursing assistant)?

  1. ADeciding whether the catheter can be removed
  2. BAssessing a patient whose irrigation is not draining
  3. CEmptying the drainage bag and recording the volume
  4. DTeaching self-catheterisation for the first time
13.Med-surg: GI, perioperative & oncologyMedium

Which is correct when caring for a patient with a PICC line?

  1. AAvoid taking blood pressure on the arm with the line
  2. BLeave the external length unchecked once it is placed
  3. CUse the PICC arm for heavy lifting to keep it flexible
  4. DFlush the line only when it blocks
14.Med-surg: GI, perioperative & oncologyHard

After a coughing fit, the external mark on a patient's nasogastric tube has moved 10 cm. Feed is due. What should the nurse do?

  1. AGive the medicines only and save the feed for later
  2. BPush the tube back to the original mark and start the feed
  3. CStart the feed at a slow rate and watch for coughing
  4. DDo not use the tube until its position is confirmed by policy

3Solutions

1.Prioritization & delegation

Answer: A · Thank the assistant, make sure the task is done safely and arrange training

Why this is the answer

A delegate should refuse a task they are not competent to do. The nurse makes sure the task is done safely now and arranges training for the future. Forcing the task or leaving it undone puts the patient at risk.

Answer

A · Thank the assistant, make sure the task is done safely and arrange training
2.Prioritization & delegation

Answer: C · Ensure the patient’s safety, document the findings and report as required

Why this is the answer

Unexplained bruises of different ages and fear of a carer can suggest abuse. The nurse makes sure the patient is safe, documents objectively and reports according to law and policy.

Answer

C · Ensure the patient’s safety, document the findings and report as required
3.Infection control & patient safety

Answer: A · Steroids suppress the immune response and can hide signs of infection

Why this is the answer

Corticosteroids reduce white cell activity and inflammation, so infections develop more easily and may cause less fever or redness. Nurses watch closely for subtle signs.

Answer

A · Steroids suppress the immune response and can hide signs of infection
4.Infection control & patient safety

Answer: C · State the concern clearly a second time and, if still unresolved, use the chain of command

Why this is the answer

The two-challenge rule says the concern is voiced at least twice to make sure it was heard. If it is still not addressed, the nurse escalates through the chain of command rather than acting against the patient’s safety.

Answer

C · State the concern clearly a second time and, if still unresolved, use the chain of command
5.Lab values & electrolytes

Answer: C · Before the first dose of antibiotic

Why this is the answer

The culture sample is taken before antibiotics, so the organism can be grown and its sensitivities tested. A sample taken after antibiotics may give a false negative culture.

Answer

C · Before the first dose of antibiotic
6.Lab values & electrolytes

Answer: D · Insulin delivery failure; inject a correction dose by pen and change the set

Why this is the answer

A high glucose that does not respond to a pump bolus, with rising ketones, suggests a kinked, blocked or dislodged cannula. Because pumps use only rapid-acting insulin, DKA can develop within hours. The usual advice is to give a correction dose by pen or syringe, change the infusion set, check glucose and ketones often, and seek help if ketones keep rising or vomiting starts.

Answer

D · Insulin delivery failure; inject a correction dose by pen and change the set
7.Clinical nursing

Answer: A · Vitamin K

Why this is the answer

Warfarin inhibits vitamin K-dependent clotting factors. Vitamin K, and for major bleeding prothrombin complex concentrate, reverse it. Protamine reverses heparin.

Answer

A · Vitamin K
8.Clinical nursing

Answer: D · Benzodiazepines, such as buccal midazolam or IV lorazepam

Why this is the answer

Benzodiazepines enhance GABA and are first-line for seizures lasting over five minutes. If seizures continue, second-line antiepileptic drugs are given and senior help is needed.

Answer

D · Benzodiazepines, such as buccal midazolam or IV lorazepam
9.Med-surg: cardiovascular & respiratory

Answer: C · Pneumonia or cancer affecting the pleura

Why this is the answer

Transudates form when hydrostatic or oncotic pressure changes push fluid out of vessels, as in heart failure, cirrhosis and nephrotic syndrome. Exudates form when inflammation or tumour makes the pleura leaky, so protein and LDH are high (Light's criteria). Common causes are pneumonia, cancer, TB and pulmonary embolism.

Answer

C · Pneumonia or cancer affecting the pleura
10.Med-surg: cardiovascular & respiratory

Answer: B · LMWH is cleared by the kidneys and can accumulate

Why this is the answer

Low-molecular-weight heparins are mainly renally excreted, so they accumulate in severe renal impairment and increase bleeding risk. Unfractionated heparin is cleared mainly by other routes, has a short half-life and can be monitored with aPTT and reversed with protamine.

Answer

B · LMWH is cleared by the kidneys and can accumulate
11.Med-surg: neuro, endocrine & renal

Answer: A · To match the natural cortisol rhythm and protect the stomach

Why this is the answer

Morning dosing mimics the normal early-morning cortisol peak, causes less adrenal suppression and less sleep disturbance. Taking it with food reduces gastric irritation.

Answer

A · To match the natural cortisol rhythm and protect the stomach
12.Med-surg: neuro, endocrine & renal

Answer: C · Emptying the drainage bag and recording the volume

Why this is the answer

Emptying and recording urine volume is routine and can be delegated to trained staff. Decisions about removal, assessment of a possible blockage and first-time teaching need the registered nurse.

Answer

C · Emptying the drainage bag and recording the volume
13.Med-surg: GI, perioperative & oncology

Answer: A · Avoid taking blood pressure on the arm with the line

Why this is the answer

BP cuffs and tourniquets on the PICC arm can damage the line. The external length and site are checked, the dressing is kept intact, and the line is flushed and used with aseptic technique according to policy.

Answer

A · Avoid taking blood pressure on the arm with the line
14.Med-surg: GI, perioperative & oncology

Answer: D · Do not use the tube until its position is confirmed by policy

Why this is the answer

A change in external length means the tube may have moved. Pushing it back blindly is unsafe. It is not used until placement is confirmed by pH or X-ray, or it is replaced.

Answer

D · Do not use the tube until its position is confirmed by policy

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