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 speaks little English, and the nurse needs to explain a new procedure. What is the best way to communicate?

  1. AAsk the patient’s 10-year-old child to translate
  2. BUse hand gestures and hope the patient understands
  3. CUse a professional medical interpreter
  4. DSpeak loudly and slowly in English
2.Prioritization & delegationHard

A nursing assistant has twice not reported abnormal vital signs to the RN. What is the RN’s best action?

  1. AComplain about the assistant to the patients during care
  2. BSay nothing to the assistant and quietly recheck all of the assistant’s vital signs in secret
  3. CStop delegating any tasks to the assistant for the rest of the year
  4. DTalk to the assistant privately, restate what must be reported and follow up closely
3.Infection control & patient safetyMedium

Which type of white blood cell is most often raised in viral infections?

  1. AEosinophils
  2. BBasophils
  3. CNeutrophils
  4. DLymphocytes
4.Infection control & patient safetyHard

According to the “Swiss cheese” model of error, why do errors reach patients?

  1. ATechnology fails more often than people do
  2. BWeaknesses in several layers of defense line up at the same time
  3. COne careless person makes a mistake that no system could stop
  4. DPatients often do not follow their care instructions
5.Lab values & electrolytesMedium

When should a patient with chronic kidney disease take a phosphate binder such as calcium acetate or sevelamer?

  1. AWith meals
  2. BAt bedtime on an empty stomach
  3. COnly once a week
  4. DOnly when the patient feels unwell
6.Lab values & electrolytesHard

A patient in DKA is receiving IV fluids and insulin. The glucose has fallen to about 220 mg/dL (12.2 mmol/L), but the anion gap is still high. What change would the nurse expect?

  1. AStop the IV fluids and start oral fluids only
  2. BGive an IV bolus of sodium bicarbonate at once
  3. CStop the insulin infusion because the glucose is near normal
  4. DAdd dextrose to the IV fluids and continue the insulin
7.Clinical nursingMedium

How does CPAP help a patient with obstructive sleep apnoea?

  1. AIt keeps the upper airway open during sleep with continuous air pressure
  2. BIt removes excess carbon dioxide from the lungs by gentle suction
  3. CIt strengthens the breathing muscles during the day
  4. DIt delivers bronchodilator drugs deep into the lungs overnight
8.Clinical nursingHard

A patient with long-standing COPD has an arterial blood gas with pH 7.37, a raised PaCO2 and a raised bicarbonate. How is this best described?

  1. ACompensated respiratory acidosis
  2. BUncompensated metabolic alkalosis
  3. CMixed metabolic and respiratory alkalosis
  4. DAcute respiratory acidosis
9.Med-surg: cardiovascular & respiratoryMedium

A patient is starting doxazosin, an alpha-blocker, for hypertension. Which advice is most important?

  1. AAvoid all potassium-containing foods
  2. BTake it with a large glass of grapefruit juice to improve absorption
  3. CStop it suddenly if the heart rate rises after the first few doses
  4. DTake the first dose at bedtime, as dizziness and fainting can occur
10.Med-surg: cardiovascular & respiratoryHard

Three days after an MI, a patient faints on the commode while straining hard to open the bowels. The heart rate was 42/min at the time. What is the most likely mechanism?

  1. AA vagal response to straining
  2. BA new pulmonary embolism
  3. CAn allergic reaction to the commode
  4. DLow blood glucose from fasting
11.Med-surg: neuro, endocrine & renalMedium

Why is an ACE inhibitor often given to a patient with diabetes and albumin in the urine?

  1. AIt raises potassium to protect the heart
  2. BIt lowers the blood glucose to normal
  3. CIt protects the kidneys and reduces albumin loss
  4. DIt stops the kidneys from passing so much urine at night
12.Med-surg: neuro, endocrine & renalHard

A patient with a severe head injury does not open the eyes, and in response to pain the arms extend and rotate inwards with the legs extended. What does this indicate?

  1. AExtensor (decerebrate) posturing: severe brainstem injury
  2. BA focal seizure that will stop without any treatment
  3. CFlexor (decorticate) posturing, a sign of mild cortical injury
  4. DA normal withdrawal response to a painful stimulus
13.Med-surg: GI, perioperative & oncologyMedium

How is the height of an epidural sensory block usually checked?

  1. AChecking the colour of the patient's urine
  2. BTesting sensation to cold with ice or a cold spray
  3. CMeasuring the patient's blood glucose level
  4. DTapping the knee with a reflex hammer and recording the score
14.Med-surg: GI, perioperative & oncologyHard

A bag of parenteral nutrition runs out and the next one will not arrive for several hours. Which risk should the nurse anticipate?

  1. AAcute urinary retention
  2. BRaised intracranial pressure
  3. CSevere hyperkalaemia
  4. DRebound hypoglycaemia

3Solutions

1.Prioritization & delegation

Answer: C · Use a professional medical interpreter

Why this is the answer

Professional interpreters give accurate, confidential translation of medical information. Family members, especially children, may leave things out and should not be used for important explanations.

Answer

C · Use a professional medical interpreter
2.Prioritization & delegation

Answer: D · Talk to the assistant privately, restate what must be reported and follow up closely

Why this is the answer

The RN gives direct, private feedback, restates the reporting limits and increases supervision. If the problem continues, it is escalated to the manager according to policy.

Answer

D · Talk to the assistant privately, restate what must be reported and follow up closely
3.Infection control & patient safety

Answer: D · Lymphocytes

Why this is the answer

Lymphocytes increase in many viral infections. Neutrophils rise mainly with bacterial infections, and eosinophils with allergies and parasites.

Answer

D · Lymphocytes
4.Infection control & patient safety

Answer: B · Weaknesses in several layers of defense line up at the same time

Why this is the answer

Reason’s Swiss cheese model shows that each safety layer, such as prescribing, dispensing, checking and scanning, has weaknesses. Harm happens when the holes in several layers line up, so safety improvement focuses on strengthening the system.

Answer

B · Weaknesses in several layers of defense line up at the same time
5.Lab values & electrolytes

Answer: A · With meals

Why this is the answer

Phosphate binders work in the gut by binding phosphate from food, so they are taken with meals. Taken between meals, they have little effect.

Answer

A · With meals
6.Lab values & electrolytes

Answer: D · Add dextrose to the IV fluids and continue the insulin

Why this is the answer

The glucose usually falls before the ketoacidosis resolves. Dextrose is added so insulin can continue, clearing ketones without causing hypoglycemia, until the anion gap closes. Stopping insulin too early lets ketoacidosis return.

Answer

D · Add dextrose to the IV fluids and continue the insulin
7.Clinical nursing

Answer: A · It keeps the upper airway open during sleep with continuous air pressure

Why this is the answer

Continuous positive airway pressure acts as a splint for the upper airway, preventing collapse and apnoeas. Patients should bring their CPAP machine into hospital.

Answer

A · It keeps the upper airway open during sleep with continuous air pressure
8.Clinical nursing

Answer: A · Compensated respiratory acidosis

Why this is the answer

Chronic CO2 retention is offset by the kidneys retaining bicarbonate, bringing the pH back to normal. A normal pH with high PaCO2 and high bicarbonate is a compensated respiratory acidosis.

Answer

A · Compensated respiratory acidosis
9.Med-surg: cardiovascular & respiratory

Answer: D · Take the first dose at bedtime, as dizziness and fainting can occur

Why this is the answer

Alpha-blockers can cause marked first-dose postural hypotension. Taking the first dose at bedtime and rising slowly reduces the risk of falls. They are also used for symptoms of an enlarged prostate.

Answer

D · Take the first dose at bedtime, as dizziness and fainting can occur
10.Med-surg: cardiovascular & respiratory

Answer: A · A vagal response to straining

Why this is the answer

Straining (the Valsalva manoeuvre) can cause a vagal bradycardia and a fall in cardiac output, leading to syncope. After an MI, stool softeners, adequate fluids and avoiding straining are advised. The event is still reported and the patient assessed for arrhythmia or ischaemia.

Answer

A · A vagal response to straining
11.Med-surg: neuro, endocrine & renal

Answer: C · It protects the kidneys and reduces albumin loss

Why this is the answer

ACE inhibitors and ARBs reduce glomerular pressure, lower albuminuria and slow the progression of diabetic kidney disease, as well as treating blood pressure. Potassium and creatinine are checked after starting them.

Answer

C · It protects the kidneys and reduces albumin loss
12.Med-surg: neuro, endocrine & renal

Answer: A · Extensor (decerebrate) posturing: severe brainstem injury

Why this is the answer

Abnormal extension to pain (GCS motor score 2) indicates severe injury at or near the brainstem and carries a worse prognosis than abnormal flexion (decorticate posturing, motor score 3). Any new abnormal posturing needs immediate escalation.

Answer

A · Extensor (decerebrate) posturing: severe brainstem injury
13.Med-surg: GI, perioperative & oncology

Answer: B · Testing sensation to cold with ice or a cold spray

Why this is the answer

The level at which the patient no longer feels cold shows the upper extent of the sensory block. Motor block is assessed with a scale such as Bromage. A rising block or new weakness is reported.

Answer

B · Testing sensation to cold with ice or a cold spray
14.Med-surg: GI, perioperative & oncology

Answer: D · Rebound hypoglycaemia

Why this is the answer

Stopping PN suddenly can cause hypoglycaemia because insulin levels stay high for a while. Glucose is monitored, and a glucose infusion may be given according to local policy.

Answer

D · Rebound hypoglycaemia

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