NCLEX-RN • NEXT GENERATION (NGN)
Clinical Judgment Case Studies
Practice Exam 2026/2027
50 Original NGN-Style Questions with Correct Answers
& Detailed Rationales | 6 Unfolding Case Studies
50 6 8 100%
Original questions Unfolding case studies Item formats Rationales included
WHAT'S INSIDE
✓ 6 unfolding case studies (6 items each) that walk through the clinical judgment steps: recognize cues, analyze cues,
prioritize hypotheses, generate solutions, take action, evaluate outcomes
✓ Case topics: heart failure, septic shock, diabetic ketoacidosis, acute ischemic stroke, cirrhosis with variceal
bleeding, pediatric asthma
✓ 14 stand-alone items: prioritization, delegation, infection control, dosage calculation, communication, and safety
✓ NGN formats: bow-tie, matrix, drop-down cloze, highlight / select all that apply, plus multiple choice, ordered
response, and fill-in-the-blank
✓ A correct answer and a detailed rationale (including why the other options are wrong) for every question
✓ Quick-reference answer key for fast self-scoring
Disclaimer: Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. Content reflects
current standard nursing references at the time of writing; always follow your program's materials, facility protocols, and
prescriber orders in clinical practice.
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
Table of Contents
Sections, question numbers, and page locations
# Section Questions Page
1 Case Study 1: Heart Failure with Fluid Overload Q1–Q6 (6) 3
2 Case Study 2: Septic Shock from Urinary Source Q7–Q12 (6) 7
3 Case Study 3: Diabetic Ketoacidosis Q13–Q18 (6) 10
4 Case Study 4: Acute Ischemic Stroke Q19–Q24 (6) 13
5 Case Study 5: Cirrhosis with Variceal Bleeding Q25–Q30 (6) 16
6 Case Study 6: Pediatric Asthma Exacerbation Q31–Q36 (6) 20
7 Prioritization, Delegation & Safety Q37–Q43 (7) 23
8 Rapid-Fire Clinical Judgment: Communication, Procedures & Ethics Q44–Q50 (7) 27
Quick-Reference Answer Key Q1–Q50 31
How to Use This Exam
• Read the whole client scenario first, then answer the six items in order: each step builds on the one before it.
• Cover the answer box beneath each question and commit to an answer before reading the rationale.
• Select-all-that-apply, highlight, and matrix items are scored per option: judge every option as true or false on
its own.
• For bow-tie items choose one condition, two actions, and two monitoring parameters that match each other.
• Read every rationale, including why the wrong options are wrong; this is where most of the learning happens.
• Use the answer key at the end to self-score a timed attempt (aim for about 1 to 1.5 minutes per item).
Disclaimer: Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. All questions were
written from scratch and are not reproduced from any exam, publisher, or question bank. This document is an
educational study aid and is not a substitute for clinical judgment, institutional protocols, or professional references.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 2
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
SECTION 1
Case Study 1: Heart Failure with Fluid Overload
Questions 1–6
Client Scenario
Client: A 72-year-old man with heart failure with reduced ejection fraction, hypertension, and type 2 diabetes
is admitted with 3 days of worsening shortness of breath, a 6-lb (2.7-kg) weight gain over 4 days, and needing
3 pillows to sleep.
Home medications: Lisinopril, carvedilol, furosemide 40 mg PO daily, metformin.
Assessment: BP 148/92, HR 112, RR 28, SpO₂ 89% on room air, T 37.0 °C (98.6 °F). Bilateral crackles to the
mid-lung fields, jugular vein distention, S3 gallop, 3+ pitting edema to the knees.
Labs: BNP 1,450 pg/mL (elevated); K⁺ 3.4 mEq/L; Na⁺ 133 mEq/L; creatinine 1.4 mg/dL.
Question 1 NGN Highlight / Select All • Recognize Cues
Which findings indicate fluid volume overload? Select all that apply.
☐ A. Serum potassium 3.4 mEq/L
☐ B. Bilateral crackles to the mid-lung fields
☐ C. Temperature 37.0 °C (98.6 °F)
☐ D. Weight gain of 6 lb in 4 days
☐ E. Jugular vein distention
☐ F. 3+ pitting edema to the knees
Correct Answer: B, D, E, F
Rationale: Rapid weight gain (about 2.2 lb or 1 kg of fluid per day above baseline is concerning), crackles from
pulmonary congestion, JVD, and dependent pitting edema all reflect retained fluid and elevated filling
pressures. The temperature is normal and does not point to volume overload. A low potassium level is a
separate finding (likely from diuretic therapy) that matters for treatment but is not itself a sign of fluid
overload.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 3
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
Question 2 NGN Matrix • Analyze Cues
For each finding, indicate whether it is more characteristic of LEFT-sided or RIGHT-sided heart failure.
Finding Left-sided Right-sided
1. Bilateral crackles and dyspnea ☐ ☐
2. Jugular vein distention ☐ ☐
3. Orthopnea (needs 3 pillows) ☐ ☐
4. 3+ peripheral edema to the knees ☐ ☐
5. Hepatomegaly with right upper ☐ ☐
quadrant tenderness
Correct Answer: 1: Left-sided; 2: Right-sided; 3: Left-sided; 4: Right-sided; 5: Right-sided
Rationale: Left ventricular failure backs blood into the lungs, causing crackles, dyspnea, orthopnea, and
pulmonary edema. Right ventricular failure backs blood into the systemic venous system, causing JVD,
dependent peripheral edema, hepatomegaly, and ascites. This client shows signs of both, which is common
because left-sided failure is the usual cause of right-sided failure.
Question 3 Multiple Choice • Prioritize Hypotheses
Which client problem is the highest priority at this time?
A. Excess fluid volume related to sodium and water retention
B. Impaired gas exchange related to pulmonary congestion (SpO₂ 89%, RR 28)
C. Deficient knowledge related to medication adherence
D. Activity intolerance related to decreased cardiac output
Correct Answer: B
Rationale: Hypoxemia and tachypnea from pulmonary edema threaten oxygenation, so airway, breathing, and
circulation order applies. Fluid excess, activity intolerance, and teaching needs are all real problems, but they
are addressed after oxygenation is improved.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 4
Clinical Judgment Case Studies
Practice Exam 2026/2027
50 Original NGN-Style Questions with Correct Answers
& Detailed Rationales | 6 Unfolding Case Studies
50 6 8 100%
Original questions Unfolding case studies Item formats Rationales included
WHAT'S INSIDE
✓ 6 unfolding case studies (6 items each) that walk through the clinical judgment steps: recognize cues, analyze cues,
prioritize hypotheses, generate solutions, take action, evaluate outcomes
✓ Case topics: heart failure, septic shock, diabetic ketoacidosis, acute ischemic stroke, cirrhosis with variceal
bleeding, pediatric asthma
✓ 14 stand-alone items: prioritization, delegation, infection control, dosage calculation, communication, and safety
✓ NGN formats: bow-tie, matrix, drop-down cloze, highlight / select all that apply, plus multiple choice, ordered
response, and fill-in-the-blank
✓ A correct answer and a detailed rationale (including why the other options are wrong) for every question
✓ Quick-reference answer key for fast self-scoring
Disclaimer: Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. Content reflects
current standard nursing references at the time of writing; always follow your program's materials, facility protocols, and
prescriber orders in clinical practice.
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
Table of Contents
Sections, question numbers, and page locations
# Section Questions Page
1 Case Study 1: Heart Failure with Fluid Overload Q1–Q6 (6) 3
2 Case Study 2: Septic Shock from Urinary Source Q7–Q12 (6) 7
3 Case Study 3: Diabetic Ketoacidosis Q13–Q18 (6) 10
4 Case Study 4: Acute Ischemic Stroke Q19–Q24 (6) 13
5 Case Study 5: Cirrhosis with Variceal Bleeding Q25–Q30 (6) 16
6 Case Study 6: Pediatric Asthma Exacerbation Q31–Q36 (6) 20
7 Prioritization, Delegation & Safety Q37–Q43 (7) 23
8 Rapid-Fire Clinical Judgment: Communication, Procedures & Ethics Q44–Q50 (7) 27
Quick-Reference Answer Key Q1–Q50 31
How to Use This Exam
• Read the whole client scenario first, then answer the six items in order: each step builds on the one before it.
• Cover the answer box beneath each question and commit to an answer before reading the rationale.
• Select-all-that-apply, highlight, and matrix items are scored per option: judge every option as true or false on
its own.
• For bow-tie items choose one condition, two actions, and two monitoring parameters that match each other.
• Read every rationale, including why the wrong options are wrong; this is where most of the learning happens.
• Use the answer key at the end to self-score a timed attempt (aim for about 1 to 1.5 minutes per item).
Disclaimer: Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. All questions were
written from scratch and are not reproduced from any exam, publisher, or question bank. This document is an
educational study aid and is not a substitute for clinical judgment, institutional protocols, or professional references.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 2
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
SECTION 1
Case Study 1: Heart Failure with Fluid Overload
Questions 1–6
Client Scenario
Client: A 72-year-old man with heart failure with reduced ejection fraction, hypertension, and type 2 diabetes
is admitted with 3 days of worsening shortness of breath, a 6-lb (2.7-kg) weight gain over 4 days, and needing
3 pillows to sleep.
Home medications: Lisinopril, carvedilol, furosemide 40 mg PO daily, metformin.
Assessment: BP 148/92, HR 112, RR 28, SpO₂ 89% on room air, T 37.0 °C (98.6 °F). Bilateral crackles to the
mid-lung fields, jugular vein distention, S3 gallop, 3+ pitting edema to the knees.
Labs: BNP 1,450 pg/mL (elevated); K⁺ 3.4 mEq/L; Na⁺ 133 mEq/L; creatinine 1.4 mg/dL.
Question 1 NGN Highlight / Select All • Recognize Cues
Which findings indicate fluid volume overload? Select all that apply.
☐ A. Serum potassium 3.4 mEq/L
☐ B. Bilateral crackles to the mid-lung fields
☐ C. Temperature 37.0 °C (98.6 °F)
☐ D. Weight gain of 6 lb in 4 days
☐ E. Jugular vein distention
☐ F. 3+ pitting edema to the knees
Correct Answer: B, D, E, F
Rationale: Rapid weight gain (about 2.2 lb or 1 kg of fluid per day above baseline is concerning), crackles from
pulmonary congestion, JVD, and dependent pitting edema all reflect retained fluid and elevated filling
pressures. The temperature is normal and does not point to volume overload. A low potassium level is a
separate finding (likely from diuretic therapy) that matters for treatment but is not itself a sign of fluid
overload.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 3
, NCLEX-RN 2026/2027 Next Gen Clinical Judgment Case Studies Practice Exam | 50 Original Questions with Rationales
Question 2 NGN Matrix • Analyze Cues
For each finding, indicate whether it is more characteristic of LEFT-sided or RIGHT-sided heart failure.
Finding Left-sided Right-sided
1. Bilateral crackles and dyspnea ☐ ☐
2. Jugular vein distention ☐ ☐
3. Orthopnea (needs 3 pillows) ☐ ☐
4. 3+ peripheral edema to the knees ☐ ☐
5. Hepatomegaly with right upper ☐ ☐
quadrant tenderness
Correct Answer: 1: Left-sided; 2: Right-sided; 3: Left-sided; 4: Right-sided; 5: Right-sided
Rationale: Left ventricular failure backs blood into the lungs, causing crackles, dyspnea, orthopnea, and
pulmonary edema. Right ventricular failure backs blood into the systemic venous system, causing JVD,
dependent peripheral edema, hepatomegaly, and ascites. This client shows signs of both, which is common
because left-sided failure is the usual cause of right-sided failure.
Question 3 Multiple Choice • Prioritize Hypotheses
Which client problem is the highest priority at this time?
A. Excess fluid volume related to sodium and water retention
B. Impaired gas exchange related to pulmonary congestion (SpO₂ 89%, RR 28)
C. Deficient knowledge related to medication adherence
D. Activity intolerance related to decreased cardiac output
Correct Answer: B
Rationale: Hypoxemia and tachypnea from pulmonary edema threaten oxygenation, so airway, breathing, and
circulation order applies. Fluid excess, activity intolerance, and teaching needs are all real problems, but they
are addressed after oxygenation is improved.
Original practice questions for study purposes; not affiliated with ATI, HESI, or NCSBN. • Page 4
