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 arrives in the recovery room after general anesthesia. What does the nurse assess first?

  1. AUrine output
  2. BAirway patency and breathing
  3. CThe surgical dressing and the drains
  4. DThe pain score
2.Prioritization & delegationHard

Which assignment by the charge nurse should be changed?

  1. AAn LPN/LVN is assigned to give oral medications to stable patients
  2. BAn LPN/LVN is assigned to admit a new patient from the emergency department
  3. CAn RN is assigned to a patient receiving a blood transfusion
  4. DA nursing assistant is assigned to help several stable patients with their meals
3.Infection control & patient safetyMedium

A nurse who never had BCG vaccine has a positive tuberculin skin test for the first time. The chest x-ray is clear and there are no symptoms. What does this most likely mean?

  1. AA failed test that must be repeated next year
  2. BLatent TB infection, which is not contagious
  3. CActive TB, which needs airborne isolation
  4. DImmunity to TB from a past exposure
4.Infection control & patient safetyHard

A nurse floated to an unfamiliar unit is asked to manage a device they have never been trained to use. What should the nurse do?

  1. ALeave the device untouched and not tell anyone
  2. BTell the charge nurse and ask for help or a change of assignment
  3. CDo it anyway, using only the device manual and the instructions on the screen
  4. DAsk the patient or the family to explain how the device works
5.Lab values & electrolytesMedium

How does IV calcium gluconate help a patient with severe hyperkalemia?

  1. AIt binds potassium in the gut so that it is passed in the stool
  2. BIt increases potassium excretion by the kidneys
  3. CIt moves potassium from the blood into the cells
  4. DIt stabilizes heart cell membranes without lowering potassium
6.Lab values & electrolytesHard

A patient on long-term amiodarone has fatigue and weight gain. TSH is 11 mIU/L and the free T4 is low. What is the most likely explanation?

  1. AAmiodarone-induced hypothyroidism
  2. BAmiodarone-induced hyperthyroidism
  3. CSecondary hypothyroidism from pituitary failure
  4. DA normal response to amiodarone needing no action
7.Clinical nursingMedium

A patient with sickle cell disease is admitted with a painful crisis. What is a key early nursing priority?

  1. ARestricting oral fluids
  2. BDelaying pain relief until a diagnosis is confirmed
  3. CApplying cold packs to the painful areas
  4. DGiving prompt, effective analgesia
8.Clinical nursingHard

Why are liquid medicines for nasogastric tubes drawn up in dedicated enteral (oral) syringes rather than IV syringes?

  1. ATo prevent accidental intravenous administration
  2. BEnteral syringes measure doses less accurately
  3. CEnteral syringes keep the medicine sterile
  4. DIV syringes cannot hold liquid medicines
9.Med-surg: cardiovascular & respiratoryMedium

A patient on theophylline develops nausea, vomiting, a fast heart rate and restlessness. What should the nurse suspect?

  1. AA theophylline allergy causing a rash
  2. BTheophylline toxicity
  3. CHypoglycaemia caused by the drug
  4. DAn expected sign that the drug is working
10.Med-surg: cardiovascular & respiratoryHard

A patient on warfarin for atrial fibrillation has an INR of 8.5 but no bleeding. What is the most likely management?

  1. AGive prothrombin complex concentrate and a blood transfusion
  2. BContinue the usual dose and recheck the INR in a month
  3. CGive IV protamine sulfate immediately to reverse it
  4. DWithhold warfarin, inform the prescriber and recheck the INR soon
11.Med-surg: neuro, endocrine & renalMedium

Which headache feature most suggests raised intracranial pressure from a brain tumour?

  1. ABetter in the morning and worse with stress
  2. BA tight band across the forehead that eases with rest
  3. CWorse on waking and on coughing, with vomiting
  4. DOnly present after reading for a long time
12.Med-surg: neuro, endocrine & renalHard

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

  1. AA patient with mild itching from uraemia who wants a cream
  2. BA patient with CKD asking about their phosphate binder
  3. CA patient with a potassium of 6.8 mmol/L who reports palpitations
  4. DA patient with a creatinine slightly above their usual level
13.Med-surg: GI, perioperative & oncologyMedium

Which drug class is commonly used to reduce acid after endoscopic treatment of a bleeding peptic ulcer?

  1. ALoop diuretics
  2. BProton pump inhibitors
  3. CBeta-blockers
  4. DH1 antihistamines such as cetirizine
14.Med-surg: GI, perioperative & oncologyHard

On the day after a Hartmann's procedure, the end colostomy is dark purple to black. What should the nurse do?

  1. ARub the stoma to improve its colour
  2. BCut a smaller hole in the pouch
  3. CRecord it as normal postoperative bruising and recheck it next week
  4. DReport it urgently, as the stoma may be necrotic

3Solutions

1.Prioritization & delegation

Answer: B · Airway patency and breathing

Why this is the answer

After anesthesia, the airway can be blocked by the tongue or secretions, and breathing may be depressed. The airway and breathing are checked first, followed by circulation and the wound.

Answer

B · Airway patency and breathing
2.Prioritization & delegation

Answer: B · An LPN/LVN is assigned to admit a new patient from the emergency department

Why this is the answer

Admitting a new patient includes the initial assessment and plan of care, which belong to the RN. The other assignments match each staff member’s role.

Answer

B · An LPN/LVN is assigned to admit a new patient from the emergency department
3.Infection control & patient safety

Answer: B · Latent TB infection, which is not contagious

Why this is the answer

A positive skin test with no symptoms and a normal chest x-ray suggests latent TB infection. The person cannot spread TB but should be evaluated for treatment to prevent active disease later.

Answer

B · Latent TB infection, which is not contagious
4.Infection control & patient safety

Answer: B · Tell the charge nurse and ask for help or a change of assignment

Why this is the answer

Accepting a task beyond one’s competence puts the patient at risk. The nurse explains the limit to the charge nurse, who can arrange help, training or reassignment.

Answer

B · Tell the charge nurse and ask for help or a change of assignment
5.Lab values & electrolytes

Answer: D · It stabilizes heart cell membranes without lowering potassium

Why this is the answer

Calcium counteracts the effect of high potassium on the heart’s electrical activity within minutes. The potassium must still be lowered by shifting it into cells (insulin with glucose) and removing it (binders, diuretics or dialysis).

Answer

D · It stabilizes heart cell membranes without lowering potassium
6.Lab values & electrolytes

Answer: A · Amiodarone-induced hypothyroidism

Why this is the answer

Amiodarone is rich in iodine and can cause either hypothyroidism or hyperthyroidism. A high TSH with a low free T4 shows primary hypothyroidism, so thyroid function is monitored before and during therapy; liver tests are monitored too.

Answer

A · Amiodarone-induced hypothyroidism
7.Clinical nursing

Answer: D · Giving prompt, effective analgesia

Why this is the answer

A sickle cell crisis needs rapid analgesia, often opioids, within a short target time, plus hydration, oxygen if hypoxic, warmth and monitoring for complications. Cold can trigger more sickling.

Answer

D · Giving prompt, effective analgesia
8.Clinical nursing

Answer: A · To prevent accidental intravenous administration

Why this is the answer

Giving an oral or enteral medicine intravenously can be fatal. Enteral syringes with non-IV connectors, such as ENFit, make this wrong-route error much less likely.

Answer

A · To prevent accidental intravenous administration
9.Med-surg: cardiovascular & respiratory

Answer: B · Theophylline toxicity

Why this is the answer

Theophylline has a narrow therapeutic window. Toxicity causes nausea, vomiting, tachycardia, arrhythmias, agitation and seizures. Levels are monitored, and many drugs and smoking status change its clearance. The nurse should hold the dose and report.

Answer

B · Theophylline toxicity
10.Med-surg: cardiovascular & respiratory

Answer: D · Withhold warfarin, inform the prescriber and recheck the INR soon

Why this is the answer

A very high INR without bleeding is usually managed by withholding warfarin, informing the prescriber and repeating the INR. Low-dose oral vitamin K may also be prescribed depending on the INR and local protocol (UK guidance gives it above an INR of 8; US guidance mainly above 10 or with high bleeding risk). Prothrombin complex concentrate and IV vitamin K are used for major bleeding. Protamine reverses heparin. The reason for the rise (new drugs, illness, diet) should be explored.

Answer

D · Withhold warfarin, inform the prescriber and recheck the INR soon
11.Med-surg: neuro, endocrine & renal

Answer: C · Worse on waking and on coughing, with vomiting

Why this is the answer

Headaches from raised ICP are often worse on waking, when coughing, sneezing or bending, and may come with vomiting or visual changes. A new headache with these features needs prompt assessment.

Answer

C · Worse on waking and on coughing, with vomiting
12.Med-surg: neuro, endocrine & renal

Answer: C · A patient with a potassium of 6.8 mmol/L who reports palpitations

Why this is the answer

Severe hyperkalaemia with palpitations may lead to life-threatening arrhythmias and needs an urgent ECG, cardiac monitoring and treatment. The other problems are stable or less urgent.

Answer

C · A patient with a potassium of 6.8 mmol/L who reports palpitations
13.Med-surg: GI, perioperative & oncology

Answer: B · Proton pump inhibitors

Why this is the answer

PPIs raise gastric pH, stabilising clots and reducing rebleeding after endoscopic treatment of ulcer bleeding. H. pylori is tested for and eradicated, and NSAIDs are stopped where possible.

Answer

B · Proton pump inhibitors
14.Med-surg: GI, perioperative & oncology

Answer: D · Report it urgently, as the stoma may be necrotic

Why this is the answer

A dark or black stoma suggests poor blood supply and necrosis, which can extend below the skin. The surgical team must assess it urgently, as further surgery may be needed.

Answer

D · Report it urgently, as the stoma may be necrotic

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