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 is raising his voice, pacing and clenching his fists. What should the nurse do first?

  1. ASpeak calmly, keep a safe distance and invite him to talk about what is wrong
  2. BStand very close to him and tell him firmly and loudly to sit down and be quiet
  3. CTurn away and ignore the behavior
  4. DApply physical restraints at once
2.Prioritization & delegationHard

After surgery, a patient who has taken long-term steroids becomes hypotensive and weak, and the blood pressure does not rise with IV fluids. Which problem should the nurse suspect?

  1. AAdrenal crisis from steroid withdrawal
  2. BFluid overload from too much IV fluid
  3. CAn allergic reaction to the anesthetic
  4. DNormal tiredness after anesthesia
3.Infection control & patient safetyMedium

A nurse who wears prescription glasses must irrigate a wound where splashing is likely. Which eye protection is suitable?

  1. ANo eye protection, if the nurse stands to one side
  2. BThe glasses with a surgical mask
  3. CGoggles or a face shield worn over the glasses
  4. DThe prescription glasses alone
4.Infection control & patient safetyHard

In a US hospital (CMS rules), a patient keeps pulling at an endotracheal tube, and alternatives have failed. The nurse applies wrist restraints in an emergency. What must happen next?

  1. AAsk the provider for a PRN restraint order to use as needed
  2. BKeep the restraints on without an order until the patient is calm
  3. CAsk the family to sign a consent form instead of an order
  4. DObtain a time-limited order for the restraint promptly, following policy
5.Lab values & electrolytesMedium

A patient taking warfarin for atrial fibrillation has an INR of 5.2 and no bleeding. What is the nurse’s best action?

  1. AGive the usual dose and recheck in a month
  2. BAdvise the patient to stop eating green vegetables from today
  3. CGive a double dose
  4. DHold the warfarin dose and inform the prescriber
6.Lab values & electrolytesHard

A patient with a platelet count of 35 × 10³/µL is prescribed an intramuscular injection. What should the nurse do?

  1. AGive the injection and apply a heat pack
  2. BGive the injection with a longer needle
  3. CAsk the prescriber whether another route can be used
  4. DGive the injection as prescribed and massage the site firmly
7.Clinical nursingMedium

An unconscious patient with diabetes has a blood glucose of 2.1 mmol/L and no IV access. What can be given?

  1. AIntramuscular glucagon
  2. BGlucose tablets by mouth
  3. CSubcutaneous insulin
  4. DOral fruit juice
8.Clinical nursingHard

A healthcare assistant reports four observations. Which one needs the nurse's immediate action?

  1. A"Ms Ali has walked to the bathroom on her own."
  2. B"Mrs Jones would like a cup of tea and her glasses cleaned."
  3. C"Mr Patel's breathing rate is 8 a minute and he's hard to wake."
  4. D"Mr Chen's blood pressure is 128/80 as usual."
9.Med-surg: cardiovascular & respiratoryMedium

A patient with COPD is prescribed long-term oxygen therapy. How many hours a day is it usually needed to improve survival?

  1. AOnly when walking outside
  2. BAbout one hour each morning
  3. CAt least 15 hours a day
  4. DOnly during meals
10.Med-surg: cardiovascular & respiratoryHard

A patient with a mechanical mitral valve replacement on warfarin has an INR of 2.2. What should the nurse consider?

  1. AThe INR should be about 1.0 for mechanical valves
  2. BThe INR may be below this patient's higher target, so check it and report
  3. CThe INR is dangerously high and the dose must be withheld
  4. DThe INR is in range for every warfarin indication, so no action is needed
11.Med-surg: neuro, endocrine & renalMedium

A patient has acute glomerulonephritis with oedema and high blood pressure. Which nursing care is most appropriate?

  1. ACheck the weight once a week
  2. BMonitor BP, fluid balance and daily weight
  3. CGive large amounts of IV fluid
  4. DEncourage a high-salt diet to balance the fluids
12.Med-surg: neuro, endocrine & renalHard

A patient with a long-term catheter has fever and rigors, and a catheter UTI is suspected. Which action is recommended before starting antibiotics?

  1. AReplace the catheter and take a sample from the new one
  2. BTake a sample from the drainage bag and send it to the lab
  3. CFlush the catheter with saline and continue
  4. DRemove the catheter and leave it out permanently
13.Med-surg: GI, perioperative & oncologyMedium

How should a patient with facial burns usually be positioned?

  1. AWith the head of the bed raised to reduce swelling
  2. BIn any position that keeps the face covered
  3. CLying face down on the pillow to protect the airway
  4. DLying flat with the head lower than the feet
14.Med-surg: GI, perioperative & oncologyHard

A sacral wound has heavy exudate, and the surrounding skin is white, soft and wrinkled. What should the nurse do?

  1. AApply a tight plastic film directly over the wound
  2. BLeave the same dressing in place for a week so the wound is not disturbed
  3. CProtect the skin edges and use a more absorbent dressing
  4. DUse a dressing that adds even more moisture

3Solutions

1.Prioritization & delegation

Answer: A · Speak calmly, keep a safe distance and invite him to talk about what is wrong

Why this is the answer

Early verbal de-escalation, with a calm voice and a safe distance, is the first approach for rising agitation. Restraint is a last resort, and crowding the patient can make things worse.

Answer

A · Speak calmly, keep a safe distance and invite him to talk about what is wrong
2.Prioritization & delegation

Answer: A · Adrenal crisis from steroid withdrawal

Why this is the answer

Patients on long-term steroids may not make enough cortisol to cope with surgical stress. Refractory hypotension suggests adrenal crisis, which needs urgent IV hydrocortisone as prescribed.

Answer

A · Adrenal crisis from steroid withdrawal
3.Infection control & patient safety

Answer: C · Goggles or a face shield worn over the glasses

Why this is the answer

Prescription glasses do not protect against splashes from the sides, top or bottom. Goggles or a face shield that fit over them are worn when splashes are likely.

Answer

C · Goggles or a face shield worn over the glasses
4.Infection control & patient safety

Answer: D · Obtain a time-limited order for the restraint promptly, following policy

Why this is the answer

Under US CMS rules, a nurse may apply a restraint first in an emergency, but an order from a licensed provider must be obtained promptly according to policy. PRN restraint orders are not allowed, and family consent does not replace an order. Other countries use different legal frameworks, but restraint is always a last resort that must be authorized, reviewed and documented.

Answer

D · Obtain a time-limited order for the restraint promptly, following policy
5.Lab values & electrolytes

Answer: D · Hold the warfarin dose and inform the prescriber

Why this is the answer

An INR of 5.2 is far above the target and increases the bleeding risk. The nurse holds the dose, checks for signs of bleeding and informs the prescriber, who may prescribe a lower dose or vitamin K.Checked against: Prothrombin Time Test and INR (PT/INR) · MedlinePlus (NIH) (2024); Warfarin · MedlinePlus (NIH) (2026)

Answer

D · Hold the warfarin dose and inform the prescriber
6.Lab values & electrolytes

Answer: C · Ask the prescriber whether another route can be used

Why this is the answer

IM injections can cause bleeding into the muscle when platelets are low. The nurse asks for another route, such as oral or IV. If an injection is unavoidable, firm pressure without massage is applied afterwards.Checked against: Bleeding and Bruising (Thrombocytopenia) and Cancer Treatment · National Cancer Institute (NIH) (2022)

Answer

C · Ask the prescriber whether another route can be used
7.Clinical nursing

Answer: A · Intramuscular glucagon

Why this is the answer

In unconscious hypoglycaemia, oral treatment risks aspiration. IM glucagon releases liver glycogen; IV glucose is used if access is available.

Answer

A · Intramuscular glucagon
8.Clinical nursing

Answer: C · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."

Why this is the answer

A low respiratory rate with reduced consciousness suggests respiratory depression, for example from opioids. It needs immediate assessment and escalation.

Answer

C · "Mr Patel's breathing rate is 8 a minute and he's hard to wake."
9.Med-surg: cardiovascular & respiratory

Answer: C · At least 15 hours a day

Why this is the answer

Long-term oxygen therapy improves survival in COPD with chronic hypoxaemia when used for at least 15 hours a day, including overnight. Patients must not smoke, because of the fire risk. Ambulatory oxygen for exercise is a separate assessment.

Answer

C · At least 15 hours a day
10.Med-surg: cardiovascular & respiratory

Answer: B · The INR may be below this patient's higher target, so check it and report

Why this is the answer

Mechanical heart valves, especially in the mitral position, often need a higher INR target (for example 2.5–3.5, depending on valve type and risk factors). An INR of 2.2 may be subtherapeutic, increasing the risk of valve thrombosis and stroke. The nurse checks the documented target and informs the prescriber. DOACs are not used for mechanical valves.

Answer

B · The INR may be below this patient's higher target, so check it and report
11.Med-surg: neuro, endocrine & renal

Answer: B · Monitor BP, fluid balance and daily weight

Why this is the answer

In acute glomerulonephritis, salt and water retention cause oedema and hypertension. Close monitoring of BP, input and output and daily weights is needed, often with salt and fluid restriction and antihypertensives.

Answer

B · Monitor BP, fluid balance and daily weight
12.Med-surg: neuro, endocrine & renal

Answer: A · Replace the catheter and take a sample from the new one

Why this is the answer

Long-term catheters develop a biofilm that contaminates samples. Guidance usually advises replacing the catheter, collecting a sample from the new one and then starting antibiotics. Bag samples are not used.

Answer

A · Replace the catheter and take a sample from the new one
13.Med-surg: GI, perioperative & oncology

Answer: A · With the head of the bed raised to reduce swelling

Why this is the answer

Raising the head reduces facial and airway swelling. The airway is monitored closely because swelling can increase over the first 24–48 hours.

Answer

A · With the head of the bed raised to reduce swelling
14.Med-surg: GI, perioperative & oncology

Answer: C · Protect the skin edges and use a more absorbent dressing

Why this is the answer

Maceration shows that exudate is not being managed. A barrier film or cream protects the surrounding skin, and a more absorbent dressing or more frequent changes are used. The cause of high exudate is reviewed.

Answer

C · Protect the skin edges and use a more absorbent dressing

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