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

After a hip replacement, a patient has sudden severe hip pain, and the operated leg looks shorter and turned. What should the nurse suspect?

  1. ADislocation of the new hip
  2. BA pressure injury on the heel
  3. CNormal pain after surgery
  4. DA urinary tract infection
2.Prioritization & delegationHard

A patient has a heart rate of 38/min, feels dizzy and has a blood pressure of 80/50 mmHg. Which drug is usually given first, as prescribed?

  1. ADigoxin
  2. BDiltiazem
  3. CMetoprolol
  4. DAtropine
3.Infection control & patient safetyMedium

Which practice makes shift handoff safer?

  1. ALeaving written notes only, without a chance for questions
  2. BGiving handoff from memory without any structure
  3. CGiving handoff in a busy corridor so that the outgoing nurse can leave on time
  4. DUsing a standard format such as SBAR or I-PASS, with time for questions
4.Infection control & patient safetyHard

A patient after heart surgery has temporary epicardial pacing wires. Why do staff take special care with electrical safety?

  1. APacing wires can only carry current coming from the pacemaker box itself
  2. BSmall currents can travel along the wires straight to the heart and cause arrhythmias
  3. CThe wires make the patient immune to electric shock
  4. DElectrical safety only matters for patients who have permanent implanted pacemakers
5.Lab values & electrolytesMedium

On the first day after major surgery, a patient's white cell count is 12.5 × 10³/µL, with no fever or wound signs. What is the best interpretation?

  1. ADefinite wound infection that needs antibiotics now
  2. BA laboratory error, since surgery lowers white cells
  3. CA sign of leukemia that needs bone marrow testing
  4. DA common stress response to surgery that is monitored
6.Lab values & electrolytesHard

A patient has taken metformin for 8 years and now has numbness in the feet, a hemoglobin of 10.2 g/dL (102 g/L) and an MCV of 108 fL. Which deficiency is most likely?

  1. AIron deficiency from gut loss
  2. BVitamin K deficiency
  3. CVitamin B12 deficiency
  4. DVitamin D (calciferol) deficiency
7.Clinical nursingMedium

A patient is started on spironolactone while already taking an ACE inhibitor. Which blood result should be watched most closely?

  1. ASodium, because both drugs raise it sharply
  2. BCalcium, because both drugs lower it
  3. CGlucose, because both drugs cause hyperglycaemia
  4. DPotassium, because both drugs can raise it
8.Clinical nursingHard

A patient has a painful, punched-out ulcer on the toes, with a cold, pale foot and weak foot pulses. Which type of ulcer is most likely?

  1. AA venous ulcer
  2. BA burn
  3. CA pressure ulcer from bed rest
  4. DAn arterial ulcer
9.Med-surg: cardiovascular & respiratoryMedium

Why is a raised serum lactate concerning in a patient with shock?

  1. AIt suggests tissues are short of oxygen and using anaerobic metabolism
  2. BIt means the kidneys are working harder than normal to clear fluid
  3. CIt shows only that the patient has eaten a large meal in the past hour
  4. DIt confirms a bacterial infection is present
10.Med-surg: cardiovascular & respiratoryHard

After cardiac catheterisation via the radial artery, which assessment is most important?

  1. ABowel sounds and abdominal girth every hour after the test
  2. BUrine specific gravity every four hours
  3. CPupil size and reaction to light every 15 minutes
  4. DCirculation, sensation and movement of the hand, and the site
11.Med-surg: neuro, endocrine & renalMedium

An 85-year-old care home resident becomes newly confused and is falling more often. A UTI is one possibility. Why?

  1. AOlder adults often show infection as confusion
  2. BA UTI cannot occur in people over 80
  3. CUrinary infections always cause a high fever in older adults
  4. DConfusion is the only symptom of a UTI at any age
12.Med-surg: neuro, endocrine & renalHard

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

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

Why is pethidine (meperidine) generally avoided for regular pain relief?

  1. AIt can only be given by mouth
  2. BIt has no pain-relieving effect at all in adults
  3. CIt always causes severe diarrhoea
  4. DA metabolite can build up and cause seizures
14.Med-surg: GI, perioperative & oncologyHard

After signing the consent form, a patient tells the nurse, "I don't really understand what they are going to do." What should the nurse do?

  1. AExplain the surgical risks in detail without involving the surgeon
  2. BIgnore the comment because the form is already signed
  3. CReassure the patient that the surgeon knows best
  4. DInform the surgeon so that the procedure can be explained again

3Solutions

1.Prioritization & delegation

Answer: A · Dislocation of the new hip

Why this is the answer

Sudden pain with shortening and rotation of the leg suggests prosthetic hip dislocation. The nurse keeps the leg still, checks circulation and informs the surgeon.

Answer

A · Dislocation of the new hip
2.Prioritization & delegation

Answer: D · Atropine

Why this is the answer

Atropine is the first-line drug for symptomatic bradycardia. Metoprolol, digoxin and diltiazem slow the heart and would make things worse; pacing may be needed if atropine does not work.

Answer

D · Atropine
3.Infection control & patient safety

Answer: D · Using a standard format such as SBAR or I-PASS, with time for questions

Why this is the answer

Many errors happen at transitions of care. A structured handoff with an opportunity to ask questions, ideally at the bedside, reduces missed information.

Answer

D · Using a standard format such as SBAR or I-PASS, with time for questions
4.Infection control & patient safety

Answer: B · Small currents can travel along the wires straight to the heart and cause arrhythmias

Why this is the answer

Wires that lead directly to the heart allow tiny currents (microshock) to reach the myocardium and cause ventricular fibrillation. Staff wear gloves when handling them, cover exposed ends and use properly grounded equipment.

Answer

B · Small currents can travel along the wires straight to the heart and cause arrhythmias
5.Lab values & electrolytes

Answer: D · A common stress response to surgery that is monitored

Why this is the answer

A mild leukocytosis is common after surgery because of tissue injury and the stress response. It is monitored along with temperature and wound assessment. A rising count after several days, or fever, suggests infection.Checked against: WBC count · MedlinePlus (NIH) (2025)

Answer

D · A common stress response to surgery that is monitored
6.Lab values & electrolytes

Answer: C · Vitamin B12 deficiency

Why this is the answer

Long-term metformin reduces vitamin B12 absorption in the gut. B12 deficiency causes macrocytic anemia and peripheral neuropathy, which can be mistaken for diabetic neuropathy. Periodic B12 testing is recommended for long-term users.Checked against: Vitamin B Test · MedlinePlus (NIH) (2026)

Answer

C · Vitamin B12 deficiency
7.Clinical nursing

Answer: D · Potassium, because both drugs can raise it

Why this is the answer

Spironolactone and ACE inhibitors both reduce potassium excretion, so the combination can cause dangerous hyperkalaemia. Potassium and renal function should be checked regularly.

Answer

D · Potassium, because both drugs can raise it
8.Clinical nursing

Answer: D · An arterial ulcer

Why this is the answer

Arterial ulcers are usually on the feet or toes, painful and punched-out, with signs of poor perfusion. Venous ulcers are usually around the ankle, shallow and associated with swelling and skin staining.

Answer

D · An arterial ulcer
9.Med-surg: cardiovascular & respiratory

Answer: A · It suggests tissues are short of oxygen and using anaerobic metabolism

Why this is the answer

When tissues are poorly perfused, cells switch to anaerobic metabolism and produce lactate. A raised lactate is a marker of tissue hypoperfusion and severity in sepsis and shock. Repeated measurements show whether treatment is working.

Answer

A · It suggests tissues are short of oxygen and using anaerobic metabolism
10.Med-surg: cardiovascular & respiratory

Answer: D · Circulation, sensation and movement of the hand, and the site

Why this is the answer

After radial access, the compression device and puncture site are checked for bleeding or haematoma, and the hand for colour, warmth, capillary refill, sensation and movement. Radial artery occlusion and forearm compartment syndrome are possible complications.

Answer

D · Circulation, sensation and movement of the hand, and the site
11.Med-surg: neuro, endocrine & renal

Answer: A · Older adults often show infection as confusion

Why this is the answer

In older adults, infections such as UTI may present with delirium, falls or reduced mobility rather than dysuria or fever. Other causes of delirium must also be considered, and urine tests alone can mislead.

Answer

A · Older adults often show infection as confusion
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: D · A metabolite can build up and cause seizures

Why this is the answer

Pethidine's metabolite norpethidine accumulates with repeated doses or kidney impairment and can cause agitation, tremor and seizures. Other opioids are preferred.

Answer

D · A metabolite can build up and cause seizures
14.Med-surg: GI, perioperative & oncology

Answer: D · Inform the surgeon so that the procedure can be explained again

Why this is the answer

Valid consent requires understanding. The nurse advocates for the patient and asks the surgeon (who obtains consent) to explain again before surgery goes ahead. The conversation is documented.

Answer

D · Inform the surgeon so that the procedure can be explained again

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