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Next Generation NCLEX-RN® (NGN) Comprehensive
Advanced Practice Examination 180 Multiple-Choice &
NGN-Style Questions | Advanced Difficulty | With Detailed
Rationales
EXAM TITLE: Next Generation NCLEX-RN® Comprehensive Advanced Clinical Judgment
Assessment — A Systems-Based, High-Acuity Review for the National Council Licensure
Examination for Registered Nurses (Effective 2025–2026 NCSBN Test Plan)
SECTION 1: BOW-TIE QUESTIONS (Questions 1–10)
Instructions for Bow-Tie Questions: For each scenario, identify the center (most likely
condition/clinical problem), the left (two priority nursing actions), and the right (two potential
complications to prevent).
Question 1
A 68-year-old client with a history of heart failure presents with shortness of breath, crackles in
both lung bases, jugular venous distention, and 3+ pitting edema in the lower extremities.
Oxygen saturation is 88% on room air. The client reports worsening dyspnea over the past 2
days and a 5-pound weight gain in 1 week.
,2
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Acute pulmonary edema, Cardiogenic shock, Pneumonia, Place in high-Fowler's
position, Administer furosemide, Apply oxygen, Monitor potassium levels, Assess for
arrhythmias, Administer digoxin
CorreCt Answer:
• Center: Acute pulmonary edema
• Left: Place in high-Fowler's position, Administer furosemide
• Right: Monitor potassium levels, Assess for arrhythmias
Rationale: Acute pulmonary edema is a life-threatening complication of heart failure. High-
Fowler's position reduces venous return and preload. Furosemide is a loop diuretic that reduces
fluid volume. Potassium monitoring is essential due to hypokalemia risk from diuresis.
Arrhythmias can occur from electrolyte imbalances and cardiac strain.
Question 2
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A 45-year-old client with type 1 diabetes reports nausea, abdominal pain, and vomiting for 24
hours. Respirations are deep and rapid (Kussmaul). Lab results: blood glucose 480 mg/dL, pH
7.18, serum ketones elevated, potassium 5.2 mEq/L.
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Diabetic ketoacidosis, Hyperosmolar hyperglycemic state, Start IV regular insulin,
Administer 1L normal saline, Monitor for hypokalemia, Assess risk for dysrhythmias, Administer
sodium bicarbonate, Insert NG tube
CorreCt Answer:
• Center: Diabetic ketoacidosis
• Left: Start IV regular insulin, Administer 1L normal saline
• Right: Monitor for hypokalemia, Assess risk for dysrhythmias
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis. Insulin
therapy addresses the underlying cause. Fluid resuscitation corrects dehydration and improves
, 4
perfusion. As potassium shifts intracellularly with insulin therapy, hypokalemia can develop
rapidly. Cardiac dysrhythmias are a major risk of electrolyte disturbances.
Question 3
A 72-year-old client with liver cirrhosis presents with confusion, asterixis (liver flap), and
lethargy. Ammonia level is elevated at 112 mcg/dL. Family reports the client has been
consuming a high-protein diet and has had recent constipation.
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Hepatic encephalopathy, Portosystemic shunt, Acute liver failure, Administer lactulose,
Administer rifaximin, Restrict dietary protein temporarily, Monitor for GI bleeding, Assess for
infection, Monitor for aspiration
CorreCt Answer:
• Center: Hepatic encephalopathy
• Left: Administer lactulose, Administer rifaximin
Next Generation NCLEX-RN® (NGN) Comprehensive
Advanced Practice Examination 180 Multiple-Choice &
NGN-Style Questions | Advanced Difficulty | With Detailed
Rationales
EXAM TITLE: Next Generation NCLEX-RN® Comprehensive Advanced Clinical Judgment
Assessment — A Systems-Based, High-Acuity Review for the National Council Licensure
Examination for Registered Nurses (Effective 2025–2026 NCSBN Test Plan)
SECTION 1: BOW-TIE QUESTIONS (Questions 1–10)
Instructions for Bow-Tie Questions: For each scenario, identify the center (most likely
condition/clinical problem), the left (two priority nursing actions), and the right (two potential
complications to prevent).
Question 1
A 68-year-old client with a history of heart failure presents with shortness of breath, crackles in
both lung bases, jugular venous distention, and 3+ pitting edema in the lower extremities.
Oxygen saturation is 88% on room air. The client reports worsening dyspnea over the past 2
days and a 5-pound weight gain in 1 week.
,2
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Acute pulmonary edema, Cardiogenic shock, Pneumonia, Place in high-Fowler's
position, Administer furosemide, Apply oxygen, Monitor potassium levels, Assess for
arrhythmias, Administer digoxin
CorreCt Answer:
• Center: Acute pulmonary edema
• Left: Place in high-Fowler's position, Administer furosemide
• Right: Monitor potassium levels, Assess for arrhythmias
Rationale: Acute pulmonary edema is a life-threatening complication of heart failure. High-
Fowler's position reduces venous return and preload. Furosemide is a loop diuretic that reduces
fluid volume. Potassium monitoring is essential due to hypokalemia risk from diuresis.
Arrhythmias can occur from electrolyte imbalances and cardiac strain.
Question 2
,3
A 45-year-old client with type 1 diabetes reports nausea, abdominal pain, and vomiting for 24
hours. Respirations are deep and rapid (Kussmaul). Lab results: blood glucose 480 mg/dL, pH
7.18, serum ketones elevated, potassium 5.2 mEq/L.
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Diabetic ketoacidosis, Hyperosmolar hyperglycemic state, Start IV regular insulin,
Administer 1L normal saline, Monitor for hypokalemia, Assess risk for dysrhythmias, Administer
sodium bicarbonate, Insert NG tube
CorreCt Answer:
• Center: Diabetic ketoacidosis
• Left: Start IV regular insulin, Administer 1L normal saline
• Right: Monitor for hypokalemia, Assess risk for dysrhythmias
Rationale: DKA is characterized by hyperglycemia, ketosis, and metabolic acidosis. Insulin
therapy addresses the underlying cause. Fluid resuscitation corrects dehydration and improves
, 4
perfusion. As potassium shifts intracellularly with insulin therapy, hypokalemia can develop
rapidly. Cardiac dysrhythmias are a major risk of electrolyte disturbances.
Question 3
A 72-year-old client with liver cirrhosis presents with confusion, asterixis (liver flap), and
lethargy. Ammonia level is elevated at 112 mcg/dL. Family reports the client has been
consuming a high-protein diet and has had recent constipation.
Center (Condition): ____________________
Left (Two Priority Actions): ____________________
Right (Two Complications to Prevent): ____________________
Options: Hepatic encephalopathy, Portosystemic shunt, Acute liver failure, Administer lactulose,
Administer rifaximin, Restrict dietary protein temporarily, Monitor for GI bleeding, Assess for
infection, Monitor for aspiration
CorreCt Answer:
• Center: Hepatic encephalopathy
• Left: Administer lactulose, Administer rifaximin
