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

Four hours after thyroid surgery, which patient finding should the nurse act on first?

  1. AA voice that is getting hoarser, with new noisy breathing
  2. BA request to sit up to drink
  3. CA small amount of serous drainage visible on the neck dressing
  4. DPain at the incision of 4/10
2.Prioritization & delegationHard

A patient with a severe asthma attack had a PaCO₂ of 32 mmHg (4.3 kPa) on arrival. An hour later it is 46 mmHg (6.1 kPa), and the patient seems tired. What does this suggest?

  1. AThe asthma is improving, because the PaCO₂ is now near normal
  2. BThe patient is hyperventilating even more than before and needs calming
  3. CA laboratory error that should be ignored
  4. DRespiratory muscle fatigue with possible impending respiratory failure
3.Infection control & patient safetyMedium

A patient’s identification wristband is missing. A medication is due. What should the nurse do?

  1. AUse the room and bed number to confirm identity
  2. BGive it, because the nurse recognizes the patient from yesterday
  3. CConfirm identity with two identifiers and apply a new wristband first
  4. DSkip the medication until the next day
4.Infection control & patient safetyHard

A nurse is about to give IV morphine. The patient’s respiratory rate is 9/min and they are very drowsy. What should the nurse do?

  1. AGive the dose because pain was reported earlier
  2. BWithhold the dose, assess the patient and inform the prescriber
  3. CGive half the dose
  4. DGive the dose and recheck the respiratory rate tomorrow
5.Lab values & electrolytesMedium

A patient takes high-dose biotin supplements for hair and nails. Why should the nurse report this before blood tests?

  1. ABiotin makes the blood clot in the tube before testing
  2. BBiotin lowers the hemoglobin by destroying the red cells
  3. CBiotin can distort some immunoassays, such as troponin or TSH
  4. DBiotin causes a true rise in blood glucose in all patients
6.Lab values & electrolytesHard

A patient with severe sepsis is oozing blood from IV sites. Platelets 40 × 10³/µL, fibrinogen low, D-dimer very high, PT and aPTT both prolonged. Which condition fits best?

  1. ADisseminated intravascular coagulation (DIC)
  2. BImmune thrombocytopenic purpura (ITP)
  3. CHemophilia A (factor VIII deficiency)
  4. DHeparin-induced thrombocytopenia (HIT)
7.Clinical nursingMedium

Which side effects are common after high doses of salbutamol (albuterol)?

  1. ABradycardia and drowsiness
  2. BTremor and a fast heart rate
  3. CHair loss and weight gain
  4. DConstipation and urinary retention
8.Clinical nursingHard

A patient with back pain develops numbness around the anus and genitals and new difficulty passing urine. Which condition should be suspected?

  1. AKidney stones
  2. BSimple muscle strain
  3. CConstipation
  4. DCauda equina syndrome
9.Med-surg: cardiovascular & respiratoryMedium

Rheumatic heart disease most often follows which infection?

  1. AA viral infection of the upper airway
  2. BStaphylococcal infection of the skin
  3. CA group A streptococcal throat infection
  4. DA fungal infection of the lungs
10.Med-surg: cardiovascular & respiratoryHard

A patient receiving noradrenaline (norepinephrine) through a peripheral cannula has pale, cold skin around the site. What should the nurse do?

  1. AContinue the infusion, as this is expected
  2. BStop it at that site, inform the team and follow the extravasation policy
  3. CIncrease the rate so the drug enters the vein faster and leaks less
  4. DMassage the area firmly to spread the drug out into the surrounding tissue
11.Med-surg: neuro, endocrine & renalMedium

Which statement about giving IV potassium is correct?

  1. AIt needs no monitoring at all once the infusion is running
  2. BIt is safest given through a small vein in the hand at a fast rate
  3. CIt can be given quickly as a push to correct the level fast
  4. DIt is diluted and given through an infusion pump, never as a bolus
12.Med-surg: neuro, endocrine & renalHard

A patient received IV insulin and glucose for hyperkalaemia an hour ago. What must the nurse monitor over the next few hours?

  1. ASkin, for a drug rash
  2. BCapillary glucose, for hypoglycaemia
  3. CPupils, for raised intracranial pressure
  4. DUrine colour, for blood in the urine
13.Med-surg: GI, perioperative & oncologyMedium

A patient with a new colostomy asks what to eat at home. Which advice is most appropriate?

  1. ADrink as little fluid as possible to reduce output
  2. BEat only liquids until the stoma is removed
  3. CAvoid all fruit and vegetables for the rest of their life
  4. DEat a normal, balanced diet and introduce foods gradually
14.Med-surg: GI, perioperative & oncologyHard

A patient with a platelet count of 8 × 109/L (8,000/µL) develops a sudden severe headache and confusion. What should the nurse suspect?

  1. AIntracranial bleeding
  2. BDehydration from poor intake
  3. CA tension headache from stress
  4. DNormal effects of chemotherapy

3Solutions

1.Prioritization & delegation

Answer: A · A voice that is getting hoarser, with new noisy breathing

Why this is the answer

Increasing hoarseness and noisy breathing can mean swelling, bleeding or nerve injury affecting the airway. This must be assessed at once and escalated. Mild pain and a small amount of serous drainage are expected.

Answer

A · A voice that is getting hoarser, with new noisy breathing
2.Prioritization & delegation

Answer: D · Respiratory muscle fatigue with possible impending respiratory failure

Why this is the answer

Early in an asthma attack, fast breathing lowers the PaCO₂. A rising, “normal” value in a tiring patient means they can no longer move enough air, which is a warning sign of respiratory failure.

Answer

D · Respiratory muscle fatigue with possible impending respiratory failure
3.Infection control & patient safety

Answer: C · Confirm identity with two identifiers and apply a new wristband first

Why this is the answer

Every medication requires a confirmed identity. The nurse replaces the wristband after confirming the patient’s identity with two identifiers. Familiarity and room numbers are not acceptable identifiers.

Answer

C · Confirm identity with two identifiers and apply a new wristband first
4.Infection control & patient safety

Answer: B · Withhold the dose, assess the patient and inform the prescriber

Why this is the answer

Slow breathing and sedation suggest opioid excess, so another dose could cause respiratory arrest. The nurse holds the dose, stimulates and assesses the patient, prepares naloxone per order and escalates.

Answer

B · Withhold the dose, assess the patient and inform the prescriber
5.Lab values & electrolytes

Answer: C · Biotin can distort some immunoassays, such as troponin or TSH

Why this is the answer

Many immunoassays use biotin-streptavidin binding, and high blood biotin levels can give falsely high or low results, for example a falsely low troponin or abnormal thyroid tests. The laboratory and prescriber should know about biotin use.Checked against: Troponin Test · MedlinePlus (NIH) (2023); Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference · U.S. FDA (2022)

Answer

C · Biotin can distort some immunoassays, such as troponin or TSH
6.Lab values & electrolytes

Answer: A · Disseminated intravascular coagulation (DIC)

Why this is the answer

In DIC, widespread clotting consumes platelets and clotting factors, so PT and aPTT are prolonged and fibrinogen falls, while clot breakdown raises the D-dimer. ITP lowers platelets only, and hemophilia A prolongs only the aPTT.Checked against: Fibrinogen blood test · MedlinePlus (NIH) (2025); Prothrombin time (PT) · MedlinePlus (NIH) (2025); D-Dimer Test · MedlinePlus (NIH) (2024)

Answer

A · Disseminated intravascular coagulation (DIC)
7.Clinical nursing

Answer: B · Tremor and a fast heart rate

Why this is the answer

Salbutamol is a beta2-agonist and can cause tremor, tachycardia and palpitations. High doses can also lower serum potassium.

Answer

B · Tremor and a fast heart rate
8.Clinical nursing

Answer: D · Cauda equina syndrome

Why this is the answer

Saddle anaesthesia, bladder or bowel dysfunction and leg symptoms with back pain suggest cauda equina syndrome. It needs an emergency MRI and surgical review to prevent permanent loss of function.

Answer

D · Cauda equina syndrome
9.Med-surg: cardiovascular & respiratory

Answer: C · A group A streptococcal throat infection

Why this is the answer

Rheumatic fever is an autoimmune reaction weeks after group A streptococcal pharyngitis. It can permanently damage heart valves, most often the mitral valve. Prompt antibiotic treatment of strep throat prevents it.

Answer

C · A group A streptococcal throat infection
10.Med-surg: cardiovascular & respiratory

Answer: B · Stop it at that site, inform the team and follow the extravasation policy

Why this is the answer

Extravasated noradrenaline causes intense local vasoconstriction and tissue necrosis. The infusion is stopped at that site (with a plan to continue elsewhere, since the patient depends on it), the team is informed and the local extravasation protocol is followed. Vasopressors are given through a central line where possible.

Answer

B · Stop it at that site, inform the team and follow the extravasation policy
11.Med-surg: neuro, endocrine & renal

Answer: D · It is diluted and given through an infusion pump, never as a bolus

Why this is the answer

Concentrated potassium given quickly can cause fatal arrhythmias. IV potassium is given in a diluted, ready-made solution through an infusion pump at a controlled rate, with monitoring of potassium and, at higher rates, the ECG.

Answer

D · It is diluted and given through an infusion pump, never as a bolus
12.Med-surg: neuro, endocrine & renal

Answer: B · Capillary glucose, for hypoglycaemia

Why this is the answer

Hypoglycaemia is a common complication of insulin–glucose treatment and can occur several hours later, especially in kidney failure. Glucose is checked regularly according to protocol, and potassium is rechecked.

Answer

B · Capillary glucose, for hypoglycaemia
13.Med-surg: GI, perioperative & oncology

Answer: D · Eat a normal, balanced diet and introduce foods gradually

Why this is the answer

People with a colostomy can usually eat a normal diet. Foods are reintroduced gradually to see how each one affects gas, odour and output, and regular meals and fluids help.

Answer

D · Eat a normal, balanced diet and introduce foods gradually
14.Med-surg: GI, perioperative & oncology

Answer: A · Intracranial bleeding

Why this is the answer

Severe thrombocytopenia carries a risk of spontaneous intracranial haemorrhage. Sudden headache, confusion or neurological change need emergency review, neurological observations and usually urgent imaging and platelet transfusion.

Answer

A · Intracranial bleeding

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