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 reports pain of 8/10. Before giving the prescribed as-needed analgesic, what does the nurse do first?

  1. AGive the strongest analgesic on the chart straight away
  2. BAssess the location, character and onset of the pain and the vital signs
  3. CTell the patient to wait until the next scheduled dose is due in two hours
  4. DAsk the nursing assistant to reposition the patient
2.Prioritization & delegationHard

A patient’s serum potassium is 6.1 mEq/L. Which of the patient’s medications should the nurse question first?

  1. ASpironolactone
  2. BOmeprazole
  3. CHydrochlorothiazide
  4. DFurosemide
3.Infection control & patient safetyMedium

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

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

Which approach best prevents catheter-associated urinary tract infection when a urinary catheter is clearly needed?

  1. AKeep the bag on the bed, level with the bladder
  2. BAseptic insertion, a closed system and a daily review of need
  3. CChange the catheter every day to keep it clean and free of crust
  4. DDisconnect the bag regularly to empty it more easily
5.Lab values & electrolytesMedium

A patient with central diabetes insipidus starts desmopressin. Which laboratory result is most important to monitor for an adverse effect?

  1. ASerum potassium, which may rise too high
  2. BSerum sodium, which may fall too low
  3. CSerum calcium, which may rise too high
  4. DSerum glucose, which may rise very high
6.Lab values & electrolytesHard

Four drug levels are reported. Which patient should the nurse assess first?

  1. AValproate 75 mcg/mL with no symptoms
  2. BPhenytoin 15 mcg/mL with no symptoms
  3. CDigoxin 1.0 ng/mL with a pulse of 72/min
  4. DLithium 1.8 mEq/L with a new coarse tremor
7.Clinical nursingMedium

What happens in third-degree (complete) heart block?

  1. AThe ventricles beat very fast and regularly
  2. BNo impulses from the atria reach the ventricles, so they beat independently
  3. CThe atria beat chaotically with no P waves, and the ventricular rate is irregular
  4. DEvery impulse reaches the ventricles, but each one is slightly delayed
8.Clinical nursingHard

A drowsy patient in recovery is making snoring sounds and the SpO2 is falling. What is the first action?

  1. ALie the patient face down
  2. BWait for the patient to wake up fully
  3. CGive sips of oral fluid to clear the throat and wake them
  4. DOpen the airway with a head tilt–chin lift or jaw thrust
9.Med-surg: cardiovascular & respiratoryMedium

A patient with asthma uses their reliever inhaler more than three times a week. What does this suggest?

  1. AThe reliever no longer works and should be stopped
  2. BAsthma control is poor and treatment needs review
  3. CThe preventer inhaler is no longer needed
  4. DAsthma is well controlled with the current plan
10.Med-surg: cardiovascular & respiratoryHard

The stump of a recent below-knee amputation suddenly bleeds heavily through the dressing. What should the nurse do first?

  1. AEncourage the patient to walk on crutches to ease the pressure
  2. BApply a warm compress to the stump
  3. CRemove all the dressings and wait for the bleeding to stop by itself
  4. DApply firm direct pressure and call for urgent surgical help
11.Med-surg: neuro, endocrine & renalMedium

Which picture fits Brown-Séquard syndrome?

  1. AWeakness on the same side and loss of pain on the opposite side
  2. BParalysis of both legs, with normal sensation everywhere in the body
  3. CWeakness of both arms with normal strength in the legs
  4. DLoss of all feeling but normal movement on both sides
12.Med-surg: neuro, endocrine & renalHard

A patient with multiple sclerosis has had worse leg weakness for one day, together with a fever and burning on passing urine. What is the most likely explanation?

  1. AA pseudo-relapse caused by infection
  2. BA side effect of physiotherapy
  3. CA change to progressive MS
  4. DA true relapse that needs high-dose steroids
13.Med-surg: GI, perioperative & oncologyMedium

During the first infusion of a monoclonal antibody such as rituximab, which problem is most important to watch for?

  1. ASudden hair loss during the infusion
  2. BA rise in platelet count above normal
  3. CAn infusion reaction, such as fever, rigors or breathlessness
  4. DSevere constipation within the first hour of starting the infusion
14.Med-surg: GI, perioperative & oncologyHard

Which history should most alert the nurse to a possible latex allergy before surgery?

  1. AFeeling sick after eating shellfish once
  2. BA rash after taking amoxicillin as a child, with a family history of asthma
  3. CHay fever every spring since childhood
  4. DItching with bananas, avocado and kiwi, and many operations

3Solutions

1.Prioritization & delegation

Answer: B · Assess the location, character and onset of the pain and the vital signs

Why this is the answer

Assessment comes first, because severe pain may be a sign of a new complication such as bleeding or a heart attack. The assessment also guides which analgesic is appropriate.

Answer

B · Assess the location, character and onset of the pain and the vital signs
2.Prioritization & delegation

Answer: A · Spironolactone

Why this is the answer

Spironolactone is a potassium-sparing diuretic and can raise potassium further. Furosemide and thiazides tend to lower potassium, and omeprazole does not usually affect it.

Answer

A · Spironolactone
3.Infection control & patient safety

Answer: D · 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

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

Answer: B · Aseptic insertion, a closed system and a daily review of need

Why this is the answer

CAUTI prevention involves aseptic insertion, a closed system with the bag below the bladder and free flow, and daily review so the catheter is removed as soon as it is no longer needed. Frequent changes and breaking the closed system increase infection risk.

Answer

B · Aseptic insertion, a closed system and a daily review of need
5.Lab values & electrolytes

Answer: B · Serum sodium, which may fall too low

Why this is the answer

Desmopressin acts like ADH, so the kidneys retain water. If the patient drinks too much, water retention can cause hyponatremia, which may lead to confusion and seizures. Sodium, weight and fluid balance are monitored.

Answer

B · Serum sodium, which may fall too low
6.Lab values & electrolytes

Answer: D · Lithium 1.8 mEq/L with a new coarse tremor

Why this is the answer

A lithium level of 1.8 mEq/L with a coarse tremor suggests toxicity, which can progress to confusion and seizures. The digoxin, phenytoin and valproate levels are within commonly cited ranges and the patients are stable.

Answer

D · Lithium 1.8 mEq/L with a new coarse tremor
7.Clinical nursing

Answer: B · No impulses from the atria reach the ventricles, so they beat independently

Why this is the answer

In complete heart block the atria and ventricles are dissociated, and a slow escape rhythm drives the ventricles. Patients may be dizzy or collapse and often need pacing.

Answer

B · No impulses from the atria reach the ventricles, so they beat independently
8.Clinical nursing

Answer: D · Open the airway with a head tilt–chin lift or jaw thrust

Why this is the answer

In a drowsy patient the tongue can fall back and obstruct the airway, causing snoring. Simple airway manoeuvres, oxygen and, if needed, an airway adjunct are used while help is called.

Answer

D · Open the airway with a head tilt–chin lift or jaw thrust
9.Med-surg: cardiovascular & respiratory

Answer: B · Asthma control is poor and treatment needs review

Why this is the answer

Needing a reliever often, waking at night with symptoms or limiting activity indicates poorly controlled asthma. Inhaler technique, adherence and triggers should be checked and the regular preventer treatment stepped up.

Answer

B · Asthma control is poor and treatment needs review
10.Med-surg: cardiovascular & respiratory

Answer: D · Apply firm direct pressure and call for urgent surgical help

Why this is the answer

Haemorrhage from a stump needs immediate direct pressure, elevation if appropriate, and urgent surgical help. A tourniquet should be available as policy directs. Vital signs are monitored for shock.

Answer

D · Apply firm direct pressure and call for urgent surgical help
11.Med-surg: neuro, endocrine & renal

Answer: A · Weakness on the same side and loss of pain on the opposite side

Why this is the answer

Damage to one side of the spinal cord, often from a stab wound, causes motor loss and loss of proprioception on the same side, and loss of pain and temperature on the opposite side. The pain fibres cross soon after entering the cord.

Answer

A · Weakness on the same side and loss of pain on the opposite side
12.Med-surg: neuro, endocrine & renal

Answer: A · A pseudo-relapse caused by infection

Why this is the answer

Infection and fever can temporarily worsen existing MS symptoms without new damage (a pseudo-relapse). The infection, here probably a UTI, is treated first. Steroids for a true relapse are considered only if the infection is excluded.

Answer

A · A pseudo-relapse caused by infection
13.Med-surg: GI, perioperative & oncology

Answer: C · An infusion reaction, such as fever, rigors or breathlessness

Why this is the answer

Infusion-related reactions are most common with the first dose. Premedication, a slow starting rate, close monitoring and readiness to stop the infusion and treat anaphylaxis are standard.

Answer

C · An infusion reaction, such as fever, rigors or breathlessness
14.Med-surg: GI, perioperative & oncology

Answer: D · Itching with bananas, avocado and kiwi, and many operations

Why this is the answer

Latex–fruit syndrome links latex allergy with foods such as banana, avocado, kiwi and chestnut. Repeated exposure, for example through many operations or catheters, also increases risk.

Answer

D · Itching with bananas, avocado and kiwi, and many operations

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