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 coughs hard after abdominal surgery, and loops of bowel appear through the opened wound. What does the nurse do first?

  1. AHelp the patient walk to the toilet to relieve abdominal pressure
  2. BLeave the wound uncovered so the surgeon can see it on arrival
  3. CPush the bowel gently back into the abdomen with a gloved hand
  4. DCover the wound with sterile dressings moistened with saline
2.Prioritization & delegationHard

Which patient finding after a total knee replacement needs the nurse’s action first?

  1. APain of 4/10 when the physiotherapist bends the knee during the morning session
  2. BSudden calf pain and swelling in the operated leg, with new breathlessness
  3. CA small amount of dried blood on the dressing
  4. DAsks for an ice pack to help with swelling around the knee
3.Infection control & patient safetyMedium

Why are some patients screened with a nasal swab for MRSA on admission?

  1. ATo measure the patient’s immunity to MRSA
  2. BTo find carriers so precautions or decolonization can be used
  3. CTo diagnose a sinus infection
  4. DTo check whether the patient is allergic to penicillin before surgery
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 half the dose
  2. BWithhold the dose, assess the patient and inform the prescriber
  3. CGive the dose and recheck the respiratory rate tomorrow
  4. DGive the dose because pain was reported earlier
5.Lab values & electrolytesMedium

Which laboratory value best reflects the cause of confusion in a patient with severe liver disease and a flapping tremor?

  1. AA low serum lipase
  2. BA raised troponin
  3. CA low serum potassium only
  4. DA raised serum ammonia
6.Lab values & electrolytesHard

Which pattern of results fits SIADH?

  1. ALow serum sodium, low serum osmolality and concentrated urine
  2. BLow serum sodium, high serum osmolality and dilute urine
  3. CHigh serum sodium, high serum osmolality and very dilute urine
  4. DNormal sodium with very dilute urine
7.Clinical nursingMedium

A patient with heart failure has pink, frothy sputum and crackles throughout both lungs. What is happening?

  1. AUpper gastrointestinal bleeding
  2. BAsthma attack
  3. CAcute pulmonary oedema
  4. DPneumothorax
8.Clinical nursingHard

A patient with a confirmed pulmonary embolism is started on anticoagulation. Which statement best explains its purpose?

  1. AIt stops the clot growing and prevents new clots while the body breaks it down
  2. BIt is mainly given to lower the blood pressure
  3. CIt dissolves the clot completely within minutes of the first dose being given
  4. DIt thins the blood so that the lungs absorb more oxygen
9.Med-surg: cardiovascular & respiratoryMedium

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

  1. AAvoid heavy lifting and pushing up with the arms
  2. BAvoid walking until the stitches are removed
  3. CSleep only on the stomach to protect the wound
  4. DLift the arms above the head often to stretch the chest
10.Med-surg: cardiovascular & respiratoryHard

A patient with obstructive sleep apnoea who uses CPAP at home is having surgery. Which plan is safest after the operation?

  1. AUse their CPAP machine and monitor closely, using opioids with caution
  2. BGive extra opioids so the patient sleeps through the night
  3. CLeave the CPAP machine at home, as it is not needed while in hospital
  4. DNurse the patient lying flat on their back to keep the airway open
11.Med-surg: neuro, endocrine & renalMedium

For which patient would the nurse question an order for pioglitazone?

  1. AA patient with heart failure
  2. BA patient with hypothyroidism
  3. CA patient with an allergy to latex
  4. DA patient with asthma
12.Med-surg: neuro, endocrine & renalHard

The nurse has four urology patients. Which one needs to be seen first?

  1. AA patient after TURP with light pink drainage and mild discomfort
  2. BA patient with a suprapubic catheter due for a routine change
  3. CA patient with a nephrostomy who has rigors and a BP of 86/50 mmHg
  4. DA patient with stress incontinence asking about pelvic floor exercises
13.Med-surg: GI, perioperative & oncologyMedium

Which is a recognised side effect of ondansetron?

  1. ASevere hypoglycaemia
  2. BHearing loss
  3. CConstipation
  4. DHair loss
14.Med-surg: GI, perioperative & oncologyHard

A patient with an ileostomy has had no output for 6 hours, with cramping pain, distension, nausea and a swollen stoma. What should the nurse suspect?

  1. AA minor skin rash around the stoma
  2. BDehydration from very high ileostomy output
  3. CNormal quiet period for a new ileostomy
  4. DA stoma blockage, often from food, needing review

3Solutions

1.Prioritization & delegation

Answer: D · Cover the wound with sterile dressings moistened with saline

Why this is the answer

Evisceration is a surgical emergency. The nurse covers the organs with sterile saline-moistened dressings, stays with the patient, positions them to reduce strain and calls the surgeon at once.

Answer

D · Cover the wound with sterile dressings moistened with saline
2.Prioritization & delegation

Answer: B · Sudden calf pain and swelling in the operated leg, with new breathlessness

Why this is the answer

Calf pain and swelling suggest deep vein thrombosis, and new breathlessness raises concern for a pulmonary embolism. This needs immediate assessment and escalation; the other findings are expected.

Answer

B · Sudden calf pain and swelling in the operated leg, with new breathlessness
3.Infection control & patient safety

Answer: B · To find carriers so precautions or decolonization can be used

Why this is the answer

Screening identifies people who are colonized with MRSA, often in the nose. Precautions and, in some cases, decolonization reduce spread and the risk of the patient’s own infection after surgery.

Answer

B · To find carriers so precautions or decolonization can be used
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: D · A raised serum ammonia

Why this is the answer

A failing liver cannot convert ammonia into urea, so ammonia builds up and contributes to hepatic encephalopathy. Lactulose is commonly used to lower ammonia absorption from the gut.Checked against: Ammonia Levels · MedlinePlus (NIH) (2026); Loss of brain function - liver disease · MedlinePlus (NIH) (2025)

Answer

D · A raised serum ammonia
6.Lab values & electrolytes

Answer: A · Low serum sodium, low serum osmolality and concentrated urine

Why this is the answer

Excess antidiuretic hormone causes water retention, diluting the blood (low sodium and osmolality), while the urine is inappropriately concentrated. High sodium with very dilute urine is the pattern of diabetes insipidus.Checked against: Syndrome of inappropriate antidiuretic hormone secretion · MedlinePlus (NIH) (2025)

Answer

A · Low serum sodium, low serum osmolality and concentrated urine
7.Clinical nursing

Answer: C · Acute pulmonary oedema

Why this is the answer

Acute pulmonary oedema causes severe breathlessness, crackles and frothy sputum. Sit the patient up, give oxygen and call urgently for medical help; diuretics are commonly given.

Answer

C · Acute pulmonary oedema
8.Clinical nursing

Answer: A · It stops the clot growing and prevents new clots while the body breaks it down

Why this is the answer

Anticoagulants prevent clot extension and new clots; the body's own fibrinolysis gradually breaks down the existing clot. Thrombolysis, which actively dissolves clots, is reserved for massive PE with shock.

Answer

A · It stops the clot growing and prevents new clots while the body breaks it down
9.Med-surg: cardiovascular & respiratory

Answer: A · Avoid heavy lifting and pushing up with the arms

Why this is the answer

The sternum is wired and takes weeks to heal. Patients are advised to avoid heavy lifting, pulling and pushing with the arms, and to support the chest with a pillow when coughing. Walking is encouraged as part of cardiac rehabilitation.

Answer

A · Avoid heavy lifting and pushing up with the arms
10.Med-surg: cardiovascular & respiratory

Answer: A · Use their CPAP machine and monitor closely, using opioids with caution

Why this is the answer

Sedatives and opioids worsen airway collapse in OSA. Patients should bring and use their CPAP after surgery, be monitored with pulse oximetry, have opioid-sparing analgesia where possible and be nursed semi-upright or on their side.

Answer

A · Use their CPAP machine and monitor closely, using opioids with caution
11.Med-surg: neuro, endocrine & renal

Answer: A · A patient with heart failure

Why this is the answer

Pioglitazone can cause fluid retention and oedema, which can worsen heart failure. It is contraindicated in patients with heart failure. Weight gain and an increased fracture risk are other effects.

Answer

A · A patient with heart failure
12.Med-surg: neuro, endocrine & renal

Answer: C · A patient with a nephrostomy who has rigors and a BP of 86/50 mmHg

Why this is the answer

Rigors and hypotension in a patient with a nephrostomy suggest urosepsis, which needs immediate assessment and treatment. Light pink drainage after TURP is expected. The other patients are stable.

Answer

C · A patient with a nephrostomy who has rigors and a BP of 86/50 mmHg
13.Med-surg: GI, perioperative & oncology

Answer: C · Constipation

Why this is the answer

Common side effects of ondansetron include constipation and headache. It can also prolong the QT interval, so caution is needed with other QT-prolonging drugs and electrolyte imbalance.

Answer

C · Constipation
14.Med-surg: GI, perioperative & oncology

Answer: D · A stoma blockage, often from food, needing review

Why this is the answer

Absent output with cramps, distension, nausea or vomiting and a swollen stoma suggests obstruction, often from fibrous food. The patient needs assessment; fluids may be given and specialist advice sought. Laxatives are not given without medical advice.

Answer

D · A stoma blockage, often from food, needing review

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