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 taking lithium has vomiting, diarrhea and a new coarse tremor. What should the nurse do?

  1. AReassure the patient that a coarse tremor is expected at first
  2. BHold the next dose and report for an urgent lithium level
  3. CEncourage the patient to cut down on salt and fluids
  4. DGive the dose with food to reduce the stomach upset
2.Prioritization & delegationHard

An adult choking on food is coughing forcefully and can speak a little. What should the nurse do?

  1. AGive the patient water to wash the food down
  2. BGive abdominal thrusts straight away until the food comes out
  3. CEncourage the patient to keep coughing and stay with them
  4. DSweep the mouth blindly with a finger
3.Infection control & patient safetyMedium

A patient with a respiratory infection has a raised procalcitonin level. What does this most suggest?

  1. ADehydration from poor intake
  2. BA purely viral illness
  3. CAn allergic reaction to a recent medication
  4. DA bacterial rather than a viral infection
4.Infection control & patient safetyHard

A nurse teaches new parents about safe infant sleep. Which statement shows a need for further teaching?

  1. A“We will not smoke near the baby.”
  2. B“We will lay the baby on the back for every sleep, including naps.”
  3. C“We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
  4. D“We will keep the crib in our room, next to our bed, for the first months.”
5.Lab values & electrolytesMedium

A patient with sickle cell disease takes hydroxyurea. Which laboratory test is monitored regularly for an adverse effect?

  1. AUrine ketone level
  2. BSerum lithium level
  3. CSerum amylase level
  4. DComplete blood count
6.Lab values & electrolytesHard

A patient arrives 30 minutes after vomiting a large amount of blood. The heart rate is 125/min, but the first hemoglobin is 13.0 g/dL (130 g/L). Why is the hemoglobin misleading?

  1. AWhole blood is lost, so the level falls only hours later
  2. BThe test is never accurate in emergency situations
  3. CHemoglobin rises during bleeding, which hides the loss
  4. DThe value proves there is no significant bleeding
7.Clinical nursingMedium

A patient is having a 12-lead ECG. Where are the chest electrodes placed?

  1. AIn standard numbered positions across the front and left of the chest
  2. BAnywhere on the chest where the skin is clear
  3. COn both shoulders and both hips only
  4. DIn a straight line down the centre of the sternum from top to bottom
8.Clinical nursingHard

After a head injury, a patient passes very large volumes of dilute urine and the serum sodium is rising. What is most likely?

  1. ADiabetes mellitus
  2. BSyndrome of inappropriate ADH secretion
  3. CAcute kidney injury
  4. DDiabetes insipidus
9.Med-surg: cardiovascular & respiratoryMedium

What is the main problem in heart failure with preserved ejection fraction?

  1. AA blocked pulmonary artery
  2. BA stiff ventricle that fills poorly in diastole
  3. CA leaking aortic valve
  4. DA dilated ventricle that cannot contract strongly
10.Med-surg: cardiovascular & respiratoryHard

Which approach to chest drain removal is commonly taught?

  1. ARemove it during a held breath or expiration, then seal the site
  2. BRemove it with the suction still running at full power
  3. CRemove it and leave the site open to drain for a day
  4. DRemove it slowly while the patient takes a long, deep breath in
11.Med-surg: neuro, endocrine & renalMedium

A patient on insulin asks about drinking alcohol. Which advice is correct?

  1. AAlcohol raises glucose, so extra insulin should be taken first
  2. BAlcohol can cause hypos, even the next day, so eat carbs with it
  3. CAlcohol has no effect on blood glucose in people with diabetes
  4. DAlcohol should replace a meal on the days it is drunk
12.Med-surg: neuro, endocrine & renalHard

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

  1. AA patient with Graves' disease asking about radioactive iodine
  2. BA patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)
  3. CA patient after thyroidectomy with mild pain on swallowing
  4. DA patient with hypothyroidism who has been constipated for three days
13.Med-surg: GI, perioperative & oncologyMedium

For which stoma can colostomy irrigation be considered?

  1. AAn established descending or sigmoid colostomy
  2. BA new ileostomy in the first week
  3. CAny stoma that has liquid or very loose output
  4. DAn ileal conduit draining urine
14.Med-surg: GI, perioperative & oncologyHard

On day 5 after a major burn, a patient is confused, with a temperature of 39.2 °C, tachycardia, and an offensive, discoloured wound. What should the nurse suspect?

  1. AThe normal hypermetabolic response alone
  2. BAn allergy to the dressing only
  3. CBurn wound infection with sepsis
  4. DDelirium from boredom on the ward

3Solutions

1.Prioritization & delegation

Answer: B · Hold the next dose and report for an urgent lithium level

Why this is the answer

Vomiting, diarrhea and a coarse tremor suggest lithium toxicity. The nurse holds the dose and reports so a serum level can be checked; low salt or fluid intake raises lithium levels further.

Answer

B · Hold the next dose and report for an urgent lithium level
2.Prioritization & delegation

Answer: C · Encourage the patient to keep coughing and stay with them

Why this is the answer

A partial obstruction with a forceful cough is best cleared by the patient’s own coughing. The nurse stays and is ready to act if the cough becomes weak or the patient cannot speak or breathe.

Answer

C · Encourage the patient to keep coughing and stay with them
3.Infection control & patient safety

Answer: D · A bacterial rather than a viral infection

Why this is the answer

Procalcitonin rises mainly in bacterial infections and much less in viral ones. It is used with clinical judgement to help decide when antibiotics are needed or can be stopped.

Answer

D · A bacterial rather than a viral infection
4.Infection control & patient safety

Answer: C · “We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”

Why this is the answer

Soft bedding, bumpers and loose blankets increase the risk of suffocation and sudden infant death. The crib should hold only a firm mattress with a fitted sheet.

Answer

C · “We will put a soft bumper pad and a blanket in the crib so the baby is cozy.”
5.Lab values & electrolytes

Answer: D · Complete blood count

Why this is the answer

Hydroxyurea increases fetal hemoglobin and reduces sickling crises, but it can suppress the bone marrow. The CBC, including neutrophils and platelets, is monitored regularly, and doses are adjusted if counts fall.Checked against: Sickle cell disease · MedlinePlus (NIH) (2026)

Answer

D · Complete blood count
6.Lab values & electrolytes

Answer: A · Whole blood is lost, so the level falls only hours later

Why this is the answer

Early in hemorrhage, red cells and plasma are lost together, so the concentration stays normal at first. The heart rate and blood pressure are better guides to blood loss in the first hours.

Answer

A · Whole blood is lost, so the level falls only hours later
7.Clinical nursing

Answer: A · In standard numbered positions across the front and left of the chest

Why this is the answer

The six chest leads (V1–V6) have standard anatomical positions, from the 4th intercostal space beside the sternum to the mid-axillary line. Wrong placement can change the ECG and lead to misinterpretation.

Answer

A · In standard numbered positions across the front and left of the chest
8.Clinical nursing

Answer: D · Diabetes insipidus

Why this is the answer

Cranial diabetes insipidus is a lack of ADH, so the kidneys cannot concentrate urine. Water loss raises sodium; strict fluid balance and replacement are needed.

Answer

D · Diabetes insipidus
9.Med-surg: cardiovascular & respiratory

Answer: B · A stiff ventricle that fills poorly in diastole

Why this is the answer

In HFpEF, the left ventricle is stiff and relaxes poorly, so filling pressures rise and cause congestion even though the ejection fraction is normal. It is common in older people with hypertension, diabetes and obesity. HFrEF is mainly a problem of contraction.

Answer

B · A stiff ventricle that fills poorly in diastole
10.Med-surg: cardiovascular & respiratory

Answer: A · Remove it during a held breath or expiration, then seal the site

Why this is the answer

Many guidelines suggest removing the tube at the end of a deep breath held (Valsalva) or during expiration, so that the pressure in the chest is positive. The wound is closed with a suture or occlusive dressing, the patient monitored for recurrent pneumothorax and a chest X-ray done if indicated. Analgesia beforehand is good practice.

Answer

A · Remove it during a held breath or expiration, then seal the site
11.Med-surg: neuro, endocrine & renal

Answer: B · Alcohol can cause hypos, even the next day, so eat carbs with it

Why this is the answer

Alcohol reduces the liver's release of glucose, so it increases the risk of hypoglycaemia, which may be delayed for many hours. Patients should eat carbohydrate, check glucose before bed and tell friends that a hypo can look like drunkenness.

Answer

B · Alcohol can cause hypos, even the next day, so eat carbs with it
12.Med-surg: neuro, endocrine & renal

Answer: B · A patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)

Why this is the answer

Fever and confusion in a patient with hyperthyroidism suggest thyroid storm, which can be fatal without urgent treatment. The other problems are expected or non-urgent.

Answer

B · A patient with hyperthyroidism who is confused, with a temperature of 39.5 °C (103.1 °F)
13.Med-surg: GI, perioperative & oncology

Answer: A · An established descending or sigmoid colostomy

Why this is the answer

Irrigation instils water into a sigmoid or descending colostomy to empty the bowel at set times. It is not used for ileostomies or urostomies and needs specialist teaching.

Answer

A · An established descending or sigmoid colostomy
14.Med-surg: GI, perioperative & oncology

Answer: C · Burn wound infection with sepsis

Why this is the answer

Burn patients are at high risk of infection. Wound changes with systemic deterioration suggest sepsis, needing urgent escalation, cultures, IV antibiotics and wound review. The hypermetabolic state causes mild fever, but not these wound changes.

Answer

C · Burn wound infection with sepsis

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