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 nasogastric tube has just been placed for feeding. What must happen before the first feed is given?

  1. AThe feed is started slowly to see if the patient coughs
  2. BThe patient is asked if the tube feels comfortable
  3. CThe tube is flushed with a large volume of water
  4. DPlacement is confirmed by an approved method
2.Prioritization & delegationHard

A child with sickle cell disease in a pain crisis develops chest pain, fever and an SpO₂ of 89%. What does this most likely mean?

  1. AAnxiety that will settle with reassurance
  2. BAcute chest syndrome, which needs urgent escalation and oxygen
  3. CA minor chest infection that can safely wait until the morning round
  4. DAn ordinary pain crisis that will improve with rest
3.Infection control & patient safetyMedium

Where should the dispersive (grounding) pad for electrosurgery be placed?

  1. AOn clean, dry skin over a well-perfused muscle, close to the surgical site
  2. BOn skin that is wet with antiseptic prep
  3. COver an area with scar tissue or a tattoo, so that the pad does not slip
  4. DOver a bony prominence such as the hip bone
4.Infection control & patient safetyHard

A patient with pulmonary tuberculosis has been on treatment. Which findings usually allow airborne isolation to end?

  1. AThe cough has stopped, even with no sputum tests
  2. BOne negative chest x-ray after starting treatment
  3. CThree negative sputum smears, clinical improvement and continued therapy
  4. DThe patient has been in hospital for one week and has taken every dose of medicine
5.Lab values & electrolytesMedium

A patient has weight loss, tremor and heat intolerance. Which thyroid test pattern fits Graves disease?

  1. ANormal TSH with a low free T4
  2. BHigh TSH with a low free T4
  3. CHigh TSH with a normal free T4
  4. DLow TSH with a high free T4
6.Lab values & electrolytesHard

A patient has marked generalized edema. Results show heavy proteinuria, serum albumin 1.8 g/dL (18 g/L) and total cholesterol 340 mg/dL (8.8 mmol/L). Which condition fits best?

  1. ALiver cirrhosis only
  2. BNephrotic syndrome
  3. CPrerenal kidney injury
  4. DAcute pyelonephritis
7.Clinical nursingMedium

Which assessment best detects compartment syndrome after a fractured leg is put in a cast?

  1. AMild itching under the cast
  2. BPain out of proportion to the injury, especially on passive stretch
  3. CA strong pulse in the foot
  4. DA warm, pink foot
8.Clinical nursingHard

A patient with suspected meningitis has fever, neck stiffness and a non-blanching rash. What is the priority?

  1. AGive paracetamol for the fever and review the patient tomorrow
  2. BWait for the lumbar puncture result before starting any treatment
  3. CDim the lights, encourage rest and recheck observations in four hours
  4. DUrgent review and immediate antibiotics, without waiting for tests
9.Med-surg: cardiovascular & respiratoryMedium

How is the jugular venous pressure usually assessed?

  1. APatient sitting upright with the arms raised above the head
  2. BPatient standing with the neck flexed forward
  3. CPatient lying completely flat with the head turned to the right
  4. DPatient reclined at 45° with the head turned slightly to the left
10.Med-surg: cardiovascular & respiratoryHard

A patient with COPD is going home on long-term oxygen. Which teaching point is most important for safety?

  1. ATurn the flow up as high as needed when breathless
  2. BNever smoke or allow open flames near the oxygen
  3. CStore spare cylinders next to the cooker
  4. DUse petroleum jelly to soothe dry nostrils
11.Med-surg: neuro, endocrine & renalMedium

A woman who takes the combined contraceptive pill is starting carbamazepine. What should she be taught?

  1. AShe should take both at the same time so they are absorbed together
  2. BThe pill makes carbamazepine toxic, so she must stop the pill
  3. CThere is no interaction between these two medicines
  4. DCarbamazepine can make the pill less effective, so other contraception is needed
12.Med-surg: neuro, endocrine & renalHard

A patient on warfarin starts levothyroxine for hypothyroidism. What should the nurse expect to monitor more closely?

  1. AThe urine output, because it may stop
  2. BThe blood glucose, because it may fall
  3. CThe INR, because it may rise
  4. DThe potassium, because it may rise
13.Med-surg: GI, perioperative & oncologyMedium

A patient on warfarin is booked for elective surgery with a high bleeding risk. What is usual practice?

  1. ASwap to aspirin on the morning of surgery
  2. BTake the usual dose on the morning of surgery
  3. CStop it about 5 days before and check the INR
  4. DDouble the dose for a week so the blood is ready for surgery
14.Med-surg: GI, perioperative & oncologyHard

During burn resuscitation, an 80 kg adult's urine output is 15 mL/h for 2 hours. What does this indicate?

  1. AFluid overload; all IV fluids should be stopped now
  2. BA normal urine output for a patient with burns
  3. CUnder-resuscitation; the fluid rate usually needs increasing
  4. DA blocked catheter that should simply be removed

3Solutions

1.Prioritization & delegation

Answer: D · Placement is confirmed by an approved method

Why this is the answer

A newly placed feeding tube can enter the airway without obvious symptoms, so placement is confirmed before anything is given. Methods differ: US practice usually requires an X-ray for a new feeding tube, while UK guidance uses aspirate pH testing (5.5 or below) first, with X-ray if that fails. Air “whoosh” tests and waiting for coughing are not reliable.

Answer

D · Placement is confirmed by an approved method
2.Prioritization & delegation

Answer: B · Acute chest syndrome, which needs urgent escalation and oxygen

Why this is the answer

Chest pain, fever and low oxygen in sickle cell disease suggest acute chest syndrome. It can worsen quickly, so oxygen, urgent review and prescribed treatment are needed.

Answer

B · Acute chest syndrome, which needs urgent escalation and oxygen
3.Infection control & patient safety

Answer: A · On clean, dry skin over a well-perfused muscle, close to the surgical site

Why this is the answer

The pad returns the current safely. Good contact over a well-perfused muscle prevents burns, while bony areas, scars, hair and moisture reduce contact and can cause burns at the pad site.

Answer

A · On clean, dry skin over a well-perfused muscle, close to the surgical site
4.Infection control & patient safety

Answer: C · Three negative sputum smears, clinical improvement and continued therapy

Why this is the answer

Airborne precautions usually continue until the patient is on effective therapy, is improving clinically and has three negative sputum smears for acid-fast bacilli, according to policy.

Answer

C · Three negative sputum smears, clinical improvement and continued therapy
5.Lab values & electrolytes

Answer: D · Low TSH with a high free T4

Why this is the answer

In Graves disease, antibodies stimulate the thyroid to make too much hormone. The high free T4 suppresses TSH from the pituitary through negative feedback, so TSH is low. A high TSH with a low T4 fits primary hypothyroidism.Checked against: TSH test · MedlinePlus (NIH) (2026); Thyroxine (T4) Test · MedlinePlus (NIH) (2024); Graves disease · MedlinePlus (NIH) (2026)

Answer

D · Low TSH with a high free T4
6.Lab values & electrolytes

Answer: B · Nephrotic syndrome

Why this is the answer

Nephrotic syndrome is heavy proteinuria with low albumin, edema and high lipids. Low albumin reduces oncotic pressure, causing edema, and the liver increases lipoprotein production. There is also a higher risk of clots and infection.Checked against: Nephrotic syndrome · MedlinePlus (NIH) (2025)

Answer

B · Nephrotic syndrome
7.Clinical nursing

Answer: B · Pain out of proportion to the injury, especially on passive stretch

Why this is the answer

Increasing pain that is not relieved by analgesia and worsens with passive stretching is the earliest sign. Pallor, numbness and absent pulses are late signs.

Answer

B · Pain out of proportion to the injury, especially on passive stretch
8.Clinical nursing

Answer: D · Urgent review and immediate antibiotics, without waiting for tests

Why this is the answer

Bacterial meningitis and meningococcal sepsis progress rapidly. Antibiotics should not be delayed for tests such as lumbar puncture.

Answer

D · Urgent review and immediate antibiotics, without waiting for tests
9.Med-surg: cardiovascular & respiratory

Answer: D · Patient reclined at 45° with the head turned slightly to the left

Why this is the answer

With the patient at 45°, the vertical height of the pulsation in the right internal jugular vein above the sternal angle is estimated. A height above about 3–4 cm suggests raised right-sided pressure, as in right heart failure or fluid overload.

Answer

D · Patient reclined at 45° with the head turned slightly to the left
10.Med-surg: cardiovascular & respiratory

Answer: B · Never smoke or allow open flames near the oxygen

Why this is the answer

Smoking while using oxygen is a major cause of burns and fatal fires. Patients must keep oxygen away from flames and heat sources, use water-based (not oil-based) lubricants and follow the prescribed flow, because unsupervised increases can worsen CO₂ retention.

Answer

B · Never smoke or allow open flames near the oxygen
11.Med-surg: neuro, endocrine & renal

Answer: D · Carbamazepine can make the pill less effective, so other contraception is needed

Why this is the answer

Carbamazepine is a strong liver enzyme inducer, so it lowers hormone levels from the pill and can lead to an unplanned pregnancy. Contraception that is not affected, such as an IUD, is usually advised.

Answer

D · Carbamazepine can make the pill less effective, so other contraception is needed
12.Med-surg: neuro, endocrine & renal

Answer: C · The INR, because it may rise

Why this is the answer

As thyroid function returns to normal, clotting factors are broken down faster, which increases the effect of warfarin. The INR is checked more often and the warfarin dose may need to be reduced.

Answer

C · The INR, because it may rise
13.Med-surg: GI, perioperative & oncology

Answer: C · Stop it about 5 days before and check the INR

Why this is the answer

Warfarin is usually stopped about 5 days before such surgery, and the INR is checked beforehand. Patients at high clotting risk may be given bridging therapy with a heparin, as planned by the team.

Answer

C · Stop it about 5 days before and check the INR
14.Med-surg: GI, perioperative & oncology

Answer: C · Under-resuscitation; the fluid rate usually needs increasing

Why this is the answer

The usual adult target is about 0.5 mL/kg/h (here 40 mL/h). An output of 15 mL/h suggests inadequate kidney perfusion, and the fluid rate is increased as prescribed after checking the catheter. Excessive fluid is also harmful, causing oedema and compartment syndromes, so the formula is only a starting point.

Answer

C · Under-resuscitation; the fluid rate usually needs increasing

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