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 nurse asks a nursing assistant to “assess the patient’s pain and decide if the patient needs more medication”. Which right of delegation is violated?

  1. ARight person
  2. BRight circumstance
  3. CRight supervision and evaluation
  4. DRight task
2.Prioritization & delegationHard

During START triage, an adult is not breathing. The airway is repositioned and the victim still does not breathe. What is the correct category?

  1. ARed, and start CPR at once
  2. BYellow, and come back later
  3. CRed, because no breathing is the most urgent finding
  4. DBlack (deceased or expectant)
3.Infection control & patient safetyMedium

Which IV fluid can be given with packed red blood cells in the same line?

  1. ALactated Ringer’s (Hartmann’s) solution
  2. B0.9% sodium chloride
  3. C5% dextrose in water
  4. D5% dextrose in 0.45% sodium chloride
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. BOne careless person makes a mistake that no system could stop
  3. CPatients often do not follow their care instructions
  4. DWeaknesses in several layers of defense line up at the same time
5.Lab values & electrolytesMedium

A conscious patient with a blood glucose of 54 mg/dL (3.0 mmol/L) has taken 15 g of fast-acting carbohydrate. When should the glucose be rechecked?

  1. AThe next morning
  2. BAfter about 2 hours
  3. CAt the next meal
  4. DAfter about 15 minutes
6.Lab values & electrolytesHard

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

  1. APhenytoin 15 mcg/mL with no symptoms
  2. BDigoxin 1.0 ng/mL with a pulse of 72/min
  3. CLithium 1.8 mEq/L with a new coarse tremor
  4. DValproate 75 mcg/mL with no symptoms
7.Clinical nursingMedium

A patient has a continuous stream of bubbles in the water seal chamber of their chest drain. What does this most likely indicate?

  1. AThe lung has fully re-expanded
  2. BThe drain is blocked
  3. CThe drain is working normally for a fluid collection only
  4. DAn air leak, from the lung or from the drainage system
8.Clinical nursingHard

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

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

A patient's blood pressure is high in clinic but normal on home readings. Which step best confirms the diagnosis?

  1. AAmbulatory or structured home blood pressure monitoring
  2. BA single repeat reading in the same clinic visit
  3. CStarting two antihypertensive drugs at once at full dose
  4. DA chest X-ray
10.Med-surg: cardiovascular & respiratoryHard

After chest trauma, a patient is hypotensive with reduced breath sounds on the left. Which finding suggests a haemothorax rather than a tension pneumothorax?

  1. ATrachea pushed away from the affected side
  2. BDistended neck veins
  3. CDullness to percussion on the affected side
  4. DHyper-resonance on the affected side
11.Med-surg: neuro, endocrine & renalMedium

Why is intermittent self-catheterisation often taught after a spinal cord injury?

  1. AIt removes all risk of a urinary tract infection completely
  2. BThe bladder may not empty, and regular emptying protects the kidneys
  3. CIt trains the bladder to grow gradually larger over time
  4. DIt is mainly used to measure the urine output accurately
12.Med-surg: neuro, endocrine & renalHard

A patient with an insulin pump is admitted with nausea, a glucose of 19 mmol/L (342 mg/dL) and blood ketones of 3.1 mmol/L. What is the priority?

  1. AIncrease the pump rate and recheck the ketones in 12 hours
  2. BDisconnect the pump and give no insulin until the ketones clear
  3. CGive an antiemetic only, because nausea is causing the high glucose
  4. DSuspect failed insulin delivery and give insulin by another route
13.Med-surg: GI, perioperative & oncologyMedium

Which long-term effect must be monitored in patients receiving anthracyclines such as doxorubicin?

  1. ADamage to the heart muscle
  2. BPermanent high blood glucose
  3. CExcess growth of body hair
  4. DLoss of the sense of smell
14.Med-surg: GI, perioperative & oncologyHard

On day 2 of severe acute pancreatitis, a patient becomes breathless, with SpO₂ 88% and bilateral infiltrates on chest X-ray. Which complication is most likely?

  1. AAcute severe asthma attack
  2. BSpontaneous tension pneumothorax
  3. CAcute respiratory distress syndrome (ARDS)
  4. DAspiration of a foreign body

3Solutions

1.Prioritization & delegation

Answer: D · Right task

Why this is the answer

Assessing a patient and deciding on treatment need nursing judgement, so the task itself cannot be delegated to assistive personnel. An assistant can report what the patient says, but the RN assesses and decides.

Answer

D · Right task
2.Prioritization & delegation

Answer: D · Black (deceased or expectant)

Why this is the answer

In START, a victim who does not breathe after the airway is repositioned is tagged black. CPR for one person would take rescuers away from many others who could survive. If breathing starts after repositioning, the victim is red.

Answer

D · Black (deceased or expectant)
3.Infection control & patient safety

Answer: B · 0.9% sodium chloride

Why this is the answer

Only 0.9% sodium chloride is compatible with blood. Dextrose (glucose) solutions can cause red cells to clump and break down, and the calcium in lactated Ringer’s (Hartmann’s) can cause clotting.

Answer

B · 0.9% sodium chloride
4.Infection control & patient safety

Answer: D · 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

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

Answer: D · After about 15 minutes

Why this is the answer

The rule of 15 is 15 g of fast-acting carbohydrate, a recheck after 15 minutes, and a repeat if the glucose is still below 70 mg/dL (3.9 mmol/L). A snack or meal then helps prevent a recurrence.

Answer

D · After about 15 minutes
6.Lab values & electrolytes

Answer: C · 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

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

Answer: D · An air leak, from the lung or from the drainage system

Why this is the answer

Bubbling with breathing in a drain for pneumothorax shows air is leaving the pleural space. Continuous bubbling can also mean a leak in the connections, so the system is checked and the finding reported.

Answer

D · An air leak, from the lung or from the drainage system
8.Clinical nursing

Answer: C · 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

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

Answer: A · Ambulatory or structured home blood pressure monitoring

Why this is the answer

"White-coat" hypertension means raised readings only in clinical settings. Ambulatory monitoring over 24 hours or a structured series of home readings gives a truer picture and is widely recommended before diagnosing hypertension.

Answer

A · Ambulatory or structured home blood pressure monitoring
10.Med-surg: cardiovascular & respiratory

Answer: C · Dullness to percussion on the affected side

Why this is the answer

Blood in the pleural space gives a dull percussion note, whereas air gives hyper-resonance. In haemothorax the neck veins are often flat because of blood loss; in tension pneumothorax they are distended. A massive haemothorax needs a large chest drain, blood replacement and surgical review.

Answer

C · Dullness to percussion on the affected side
11.Med-surg: neuro, endocrine & renal

Answer: B · The bladder may not empty, and regular emptying protects the kidneys

Why this is the answer

Spinal cord injury often causes neurogenic bladder. Clean intermittent catheterisation at regular intervals empties the bladder, prevents high pressures, reduces infection and kidney damage and avoids triggering autonomic dysreflexia.

Answer

B · The bladder may not empty, and regular emptying protects the kidneys
12.Med-surg: neuro, endocrine & renal

Answer: D · Suspect failed insulin delivery and give insulin by another route

Why this is the answer

Rising ketones in a pump user suggest that insulin delivery has failed, for example from a kinked cannula or an empty reservoir. Insulin must be given by pen or IV, and DKA treatment started if criteria are met. The site and pump are checked.

Answer

D · Suspect failed insulin delivery and give insulin by another route
13.Med-surg: GI, perioperative & oncology

Answer: A · Damage to the heart muscle

Why this is the answer

Anthracyclines can cause cumulative, dose-related cardiomyopathy and heart failure. Cardiac function is checked before and during treatment, and a lifetime dose limit is applied.

Answer

A · Damage to the heart muscle
14.Med-surg: GI, perioperative & oncology

Answer: C · Acute respiratory distress syndrome (ARDS)

Why this is the answer

Severe pancreatitis triggers a systemic inflammatory response that can cause ARDS, AKI and shock. Hypoxaemia with bilateral infiltrates is typical. Escalation to critical care for respiratory support is needed.

Answer

C · Acute respiratory distress syndrome (ARDS)

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