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

Which infant with gastroenteritis should the nurse see first?

  1. AMild diaper rash, otherwise playful
  2. BAlert, crying with tears, had a wet diaper an hour ago
  3. CLethargic, sunken fontanel, no wet diaper for 8 hours
  4. DTwo loose stools today, feeding well
2.Prioritization & delegationHard

A patient in hypovolemic shock is receiving IV fluids. Which finding best shows that the treatment is working?

  1. ACooler, paler skin on the arms and legs
  2. BA heart rate that keeps rising after each bag of fluid
  3. CNew crackles at both lung bases
  4. DUrine output at least 0.5 mL/kg/h and clearer thinking
3.Infection control & patient safetyMedium

A nurse cleans an IV pump with a disinfectant wipe. What must happen for the disinfectant to work?

  1. AThe wipe is used on many pumps to save product
  2. BThe surface is dried with a clean towel right after wiping
  3. CThe surface is wiped once lightly without pressure
  4. DThe surface stays wet for the contact time on the product label
4.Infection control & patient safetyHard

While preparing an IV medication, a nurse sees that the syringe tip touched the medication tray after the cap came off. What should the nurse do?

  1. ABlow on the tip to remove any dust
  2. BWipe the tip with an alcohol swab and give the dose
  3. CGive the dose anyway, because the medication tray was cleaned this morning
  4. DDiscard the syringe and prepare the dose again with new equipment
5.Lab values & electrolytesMedium

An older adult takes lisinopril and furosemide and recently started daily ibuprofen for knee pain. The creatinine has risen from 1.0 to 1.8 mg/dL (88 to 159 µmol/L). What is the most likely cause?

  1. ANormal aging of the kidneys over a period of a few weeks
  2. BThe NSAID reduces kidney blood flow on top of the other two drugs
  3. CA laboratory error, since ibuprofen has no effect on the kidney
  4. DMore activity has increased the patient's muscle mass quickly
6.Lab values & electrolytesHard

Weeks after neck surgery, a patient has muscle cramps and tingling. Calcium is low, phosphate is high and parathyroid hormone (PTH) is low. Which condition fits best?

  1. APrimary hyperparathyroidism
  2. BHypoparathyroidism
  3. CChronic kidney disease
  4. DVitamin D toxicity
7.Clinical nursingMedium

Which electrolyte disturbance is most dangerous for the heart rhythm?

  1. AHigh or low potassium
  2. BHigh chloride
  3. CLow sodium
  4. DLow phosphate
8.Clinical nursingHard

After a high spinal cord injury, a patient has low blood pressure with a slow heart rate and warm, dry skin. What is most likely?

  1. ACardiac tamponade
  2. BNeurogenic shock
  3. CSeptic shock
  4. DHypovolaemic shock
9.Med-surg: cardiovascular & respiratoryMedium

Shortly after a permanent pacemaker is inserted via the subclavian vein, the patient becomes breathless with reduced breath sounds on that side. What complication should be suspected?

  1. APulmonary oedema
  2. BPericarditis
  3. CAsthma
  4. DPneumothorax
10.Med-surg: cardiovascular & respiratoryHard

A patient has new chest pain at rest. The ECG shows ST depression, but serial troponins remain normal. Which diagnosis fits best?

  1. AUnstable angina
  2. BST-elevation myocardial infarction
  3. CStable angina
  4. DNon-ST-elevation myocardial infarction
11.Med-surg: neuro, endocrine & renalMedium

A week after thyroid surgery, a patient's voice is still hoarse and weak. Which complication is most likely?

  1. ALow calcium from parathyroid injury
  2. BA thyroid storm caused by surgery
  3. CAn allergic reaction to the adhesive dressing tape
  4. DDamage to a recurrent laryngeal nerve
12.Med-surg: neuro, endocrine & renalHard

A nurse is caring for four patients. Which patient needs to be seen first?

  1. AA patient with stable hypothyroidism due for levothyroxine
  2. BA patient after a craniotomy whose right pupil is newly dilated and slow to react
  3. CA patient on peritoneal dialysis with clear effluent
  4. DA patient with CKD asking about their phosphate binder
13.Med-surg: GI, perioperative & oncologyMedium

Why are patients with cirrhosis at increased risk of bleeding?

  1. AHigh arterial blood pressure in cirrhosis makes vessels burst
  2. BThe scarred liver releases anticoagulant substances such as heparin into the blood
  3. CFewer clotting factors, low platelets and varices from portal hypertension
  4. DCirrhosis raises the platelet count, which makes platelets weaker
14.Med-surg: GI, perioperative & oncologyHard

Which patient has the highest risk of postoperative nausea and vomiting?

  1. AA man with no history of nausea having local anaesthetic only
  2. BA smoker who has never had nausea after surgery
  3. CA non-smoking woman with motion sickness who will need opioids
  4. DA male smoker having a short procedure without opioids

3Solutions

1.Prioritization & delegation

Answer: C · Lethargic, sunken fontanel, no wet diaper for 8 hours

Why this is the answer

Lethargy, a sunken fontanel and no urine for hours suggest severe dehydration, which can lead to shock in infants. The other infants are well hydrated.

Answer

C · Lethargic, sunken fontanel, no wet diaper for 8 hours
2.Prioritization & delegation

Answer: D · Urine output at least 0.5 mL/kg/h and clearer thinking

Why this is the answer

Improving urine output, mental state and heart rate show better tissue perfusion. A rising heart rate and cool skin suggest ongoing shock, and new crackles may mean fluid overload.

Answer

D · Urine output at least 0.5 mL/kg/h and clearer thinking
3.Infection control & patient safety

Answer: D · The surface stays wet for the contact time on the product label

Why this is the answer

Each disinfectant has a contact (dwell) time during which the surface must stay visibly wet. Drying it early or spreading one wipe over many items reduces its effect.

Answer

D · The surface stays wet for the contact time on the product label
4.Infection control & patient safety

Answer: D · Discard the syringe and prepare the dose again with new equipment

Why this is the answer

In aseptic non-touch technique, key parts such as syringe tips and IV hubs must not touch any non-sterile surface. A contaminated key part is not cleaned and reused. It is replaced.

Answer

D · Discard the syringe and prepare the dose again with new equipment
5.Lab values & electrolytes

Answer: B · The NSAID reduces kidney blood flow on top of the other two drugs

Why this is the answer

NSAIDs reduce prostaglandin-driven blood flow to the kidney. Combined with an ACE inhibitor and a diuretic, this can cause acute kidney injury, especially in older adults. The nurse reports the result and the NSAID is usually stopped.Checked against: Creatinine blood test · MedlinePlus (NIH) (2025)

Answer

B · The NSAID reduces kidney blood flow on top of the other two drugs
6.Lab values & electrolytes

Answer: B · Hypoparathyroidism

Why this is the answer

Without enough PTH, calcium is not released from bone or kept by the kidney, and phosphate is not excreted, so calcium falls and phosphate rises. It can follow injury or removal of the parathyroid glands during thyroid or neck surgery.Checked against: Hypoparathyroidism · MedlinePlus (NIH) (2026); Hypocalcemia · StatPearls (NCBI Bookshelf) (2026)

Answer

B · Hypoparathyroidism
7.Clinical nursing

Answer: A · High or low potassium

Why this is the answer

Both hyperkalaemia and hypokalaemia can cause life-threatening arrhythmias. Potassium must never be given as an undiluted rapid IV bolus.

Answer

A · High or low potassium
8.Clinical nursing

Answer: B · Neurogenic shock

Why this is the answer

Neurogenic shock from cervical or high thoracic injury causes vasodilation and bradycardia because sympathetic outflow is lost. Hypovolaemic shock usually causes tachycardia and cool, pale skin.

Answer

B · Neurogenic shock
9.Med-surg: cardiovascular & respiratory

Answer: D · Pneumothorax

Why this is the answer

Subclavian puncture can injure the pleura and cause a pneumothorax. A chest X-ray is usually taken after implantation. Other complications include haematoma, lead displacement and infection.

Answer

D · Pneumothorax
10.Med-surg: cardiovascular & respiratory

Answer: A · Unstable angina

Why this is the answer

Unstable angina is new, worsening or rest angina without a troponin rise. It is an acute coronary syndrome and is managed urgently because it can progress to infarction. Stable angina is predictable and exertional. NSTEMI has a rising troponin.

Answer

A · Unstable angina
11.Med-surg: neuro, endocrine & renal

Answer: D · Damage to a recurrent laryngeal nerve

Why this is the answer

The recurrent laryngeal nerves run close to the thyroid and supply most of the laryngeal muscles. Injury causes hoarseness; bilateral injury can cause stridor and airway obstruction. Mild hoarseness from intubation usually settles within days. Parathyroid injury causes hypocalcaemia with tingling and cramps.

Answer

D · Damage to a recurrent laryngeal nerve
12.Med-surg: neuro, endocrine & renal

Answer: B · A patient after a craniotomy whose right pupil is newly dilated and slow to react

Why this is the answer

A new, one-sided dilated and sluggish pupil after brain surgery suggests rising intracranial pressure pressing on the oculomotor nerve, a possible sign of brain herniation. It needs immediate assessment, including the GCS and vital signs, and urgent escalation. The other patients are stable, and their needs can be met shortly afterwards.

Answer

B · A patient after a craniotomy whose right pupil is newly dilated and slow to react
13.Med-surg: GI, perioperative & oncology

Answer: C · Fewer clotting factors, low platelets and varices from portal hypertension

Why this is the answer

Reduced synthesis of clotting factors raises the INR. Portal hypertension causes splenomegaly with platelet sequestration and varices that can bleed. Patients can also have an increased clotting tendency, so the balance is complex.

Answer

C · Fewer clotting factors, low platelets and varices from portal hypertension
14.Med-surg: GI, perioperative & oncology

Answer: C · A non-smoking woman with motion sickness who will need opioids

Why this is the answer

Apfel risk factors are female sex, non-smoking status, a history of PONV or motion sickness, and postoperative opioids. Patients with more factors receive more preventive antiemetics.

Answer

C · A non-smoking woman with motion sickness who will need opioids

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