NCLEX-RN 2026 NGN Case Studies | Next Generation
NCLEX Clinical Judgment Questions | PDF
Welcome to this focused NGN practice exam. This resource contains 150 case study–based questions
designed to test clinical judgment using the Next Generation NCLEX framework. You will encounter bow-tie
items, matrix-style prioritization, drag-and-drop ordering and unfolding client scenarios. Each question is
followed by the correct answer with the full choice text and a concise rationale. Use this exam to sharpen
your clinical reasoning and prepare for the new NGN format.
Key Topics Covered
i. NGN Clinical Judgment – Recognizing cues, analyzing cues, prioritizing hypotheses, generating
solutions, taking action, evaluating outcomes
ii. Bow-Tie Questions – Identifying client problem, related risk factors, and priority actions
iii. Matrix/Grid Questions – Multiple simultaneous findings requiring correct matching
iv. Drag-and-Drop (Ordering) – Prioritizing nursing actions, medication administration steps, discharge
teaching sequences
v. Unfolding Case Studies – Sequential changes in client condition across shifts or visits
vi. Client Scenario Analysis – Emergency, acute care, mental health, maternal-newborn, med-surg
Questions 1–150
Case 1 (Questions 1-5): A 68-year-old male with a history of heart failure is admitted with worsening
dyspnea, orthopnea, and peripheral edema. Vital signs: BP 160/90, HR 110, RR 28, SpO2 89% on 2 L/min.
Lung sounds reveal crackles in bilateral bases.
1. Based on the initial assessment, which finding is the priority cue?
A) Peripheral edema
B) Crackles in bilateral bases
C) Heart rate 110 bpm
D) SpO2 89% on 2 L/min
Answer D: SpO2 89% on 2 L/min
Rationale: Oxygen desaturation despite supplemental oxygen indicates impaired gas exchange, which is an
immediate threat to tissue perfusion. Crackles and tachycardia are important but secondary to hypoxemia.
SpO2 <90% requires rapid intervention to prevent organ damage.
,2. The nurse reviews the medication list. Which medication is most likely to be prescribed first for
acute decompensation?
A) Metoprolol 25 mg orally
B) Furosemide 40 mg IV push
C) Spironolactone 25 mg orally
D) Digoxin 0.125 mg orally
Answer B: Furosemide 40 mg IV push
Rationale: IV loop diuretics rapidly reduce preload and pulmonary congestion in acute heart failure. Beta-
blockers are not started acutely; spironolactone is for chronic management. Digoxin has no role in acute
pulmonary edema.
3. (Bow-Tie) Complete the bow-tie by selecting the client’s most likely problem, one risk factor, and
one priority action. Which problem is most likely?
A) Cardiogenic shock
B) Acute decompensated heart failure with pulmonary edema
C) Pneumonia
D) Pulmonary embolism
Answer B: Acute decompensated heart failure with pulmonary edema
Rationale: History of HF plus crackles, orthopnea, and hypoxia point to acute on chronic heart failure.
Cardiogenic shock would present with hypotension; pneumonia has fever/productive cough. PE causes
sudden pleuritic pain.
4. Which risk factor from the client’s history most contributed to this exacerbation?
A) Non-adherence to low-sodium diet
B) Previous myocardial infarction
C) Chronic kidney disease stage 3
D) Atrial fibrillation
Answer A: Non-adherence to low-sodium diet
Rationale: Dietary sodium excess leads to fluid retention, increasing preload and worsening HF symptoms.
While other factors increase HF risk, acute exacerbation is often triggered by diet non-adherence or
medication non-compliance. Identifying triggers guides discharge teaching.
5. The nurse administers furosemide IV. Which assessment finding indicates a therapeutic response?
,A) Blood pressure decreases to 110/70 mmHg
B) Urine output increases to 200 mL over 2 hours
C) Respiratory rate increases to 32 breaths/min
D) Potassium level rises to 4.5 mEq/L
Answer B: Urine output increases to 200 mL over 2 hours
Rationale: Diuresis reduces fluid overload; expected urine output is ≥100-150 mL/hr after IV furosemide.
BP may drop but not desired; increased RR indicates worsening. Hypokalemia is a side effect.
Case 2 (Questions 6-10): A 24-year-old female presents to the emergency department with sudden onset of
severe right lower quadrant pain, nausea, and vomiting. She is sexually active and her last menstrual period
was 6 weeks ago.
6. Which assessment finding is most concerning for an ectopic pregnancy?
A) Bilateral lower quadrant pain
B) Painless vaginal bleeding
C) Referred shoulder pain
D) Fever and chills
Answer C: Referred shoulder pain
Rationale: Shoulder pain (Kehr’s sign) indicates diaphragmatic irritation from intra-abdominal bleeding in a
ruptured ectopic pregnancy. Painless bleeding is more typical of placenta previa; fever suggests infection.
Unilateral pain is classic for ectopic; bilateral is less specific.
7. The nurse obtains a urine pregnancy test which is positive. Which diagnostic test should the nurse
anticipate?
A) Abdominal X-ray
B) Transvaginal ultrasound
C) MRI of the pelvis
D) Hysterosalpingography
Answer B: Transvaginal ultrasound
Rationale: Transvaginal ultrasound is the gold standard to visualize an intrauterine pregnancy or adnexal
mass. Absence of intrauterine pregnancy with positive β-hCG suggests ectopic. X-ray and MRI are not first-
line.
, 8. The client’s vital signs are BP 90/60, HR 120, RR 22. The nurse notes the client is pale and
diaphoretic. Which action should the nurse take first?
A) Administer IV morphine for pain
B) Obtain consent for surgery
C) Start two large-bore IV lines with normal saline bolus
D) Place the client in Trendelenburg position
Answer C: Start two large-bore IV lines with normal saline bolus
Rationale: Hypovolemic shock from ruptured ectopic requires aggressive fluid resuscitation before surgery.
Pain medication may lower BP further; Trendelenburg is not recommended. Surgery is definitive but fluid
first.
9. (Matrix) Match each finding to the most likely cause in suspected ruptured ectopic pregnancy.
Finding: Hypotension → ?
A) Anxiety
B) Hemorrhage
C) Vasovagal response
D) Infection
Answer B: Hemorrhage
Rationale: Hypovolemia from intra-abdominal bleeding is the direct cause of hypotension in ruptured
ectopic. Infection would cause fever; anxiety may cause tachycardia but not hypotension. Hemorrhage
requires immediate fluid and blood products.
10. After stabilization, the client undergoes laparoscopic salpingectomy. Which discharge instruction
is most important?
A) “You may resume sexual intercourse in 1 week”
B) “Report any shoulder pain or heavy bleeding immediately”
C) “Take iron supplements for 1 month”
D) “Your future fertility will not be affected”
Answer B: “Report any shoulder pain or heavy bleeding immediately”
Rationale: Shoulder pain may indicate ongoing bleeding (irritation of diaphragm) and requires re-
evaluation. Resuming intercourse too early risks infection; fertility may be reduced but not the priority.
Heavy bleeding is a danger sign.
NCLEX Clinical Judgment Questions | PDF
Welcome to this focused NGN practice exam. This resource contains 150 case study–based questions
designed to test clinical judgment using the Next Generation NCLEX framework. You will encounter bow-tie
items, matrix-style prioritization, drag-and-drop ordering and unfolding client scenarios. Each question is
followed by the correct answer with the full choice text and a concise rationale. Use this exam to sharpen
your clinical reasoning and prepare for the new NGN format.
Key Topics Covered
i. NGN Clinical Judgment – Recognizing cues, analyzing cues, prioritizing hypotheses, generating
solutions, taking action, evaluating outcomes
ii. Bow-Tie Questions – Identifying client problem, related risk factors, and priority actions
iii. Matrix/Grid Questions – Multiple simultaneous findings requiring correct matching
iv. Drag-and-Drop (Ordering) – Prioritizing nursing actions, medication administration steps, discharge
teaching sequences
v. Unfolding Case Studies – Sequential changes in client condition across shifts or visits
vi. Client Scenario Analysis – Emergency, acute care, mental health, maternal-newborn, med-surg
Questions 1–150
Case 1 (Questions 1-5): A 68-year-old male with a history of heart failure is admitted with worsening
dyspnea, orthopnea, and peripheral edema. Vital signs: BP 160/90, HR 110, RR 28, SpO2 89% on 2 L/min.
Lung sounds reveal crackles in bilateral bases.
1. Based on the initial assessment, which finding is the priority cue?
A) Peripheral edema
B) Crackles in bilateral bases
C) Heart rate 110 bpm
D) SpO2 89% on 2 L/min
Answer D: SpO2 89% on 2 L/min
Rationale: Oxygen desaturation despite supplemental oxygen indicates impaired gas exchange, which is an
immediate threat to tissue perfusion. Crackles and tachycardia are important but secondary to hypoxemia.
SpO2 <90% requires rapid intervention to prevent organ damage.
,2. The nurse reviews the medication list. Which medication is most likely to be prescribed first for
acute decompensation?
A) Metoprolol 25 mg orally
B) Furosemide 40 mg IV push
C) Spironolactone 25 mg orally
D) Digoxin 0.125 mg orally
Answer B: Furosemide 40 mg IV push
Rationale: IV loop diuretics rapidly reduce preload and pulmonary congestion in acute heart failure. Beta-
blockers are not started acutely; spironolactone is for chronic management. Digoxin has no role in acute
pulmonary edema.
3. (Bow-Tie) Complete the bow-tie by selecting the client’s most likely problem, one risk factor, and
one priority action. Which problem is most likely?
A) Cardiogenic shock
B) Acute decompensated heart failure with pulmonary edema
C) Pneumonia
D) Pulmonary embolism
Answer B: Acute decompensated heart failure with pulmonary edema
Rationale: History of HF plus crackles, orthopnea, and hypoxia point to acute on chronic heart failure.
Cardiogenic shock would present with hypotension; pneumonia has fever/productive cough. PE causes
sudden pleuritic pain.
4. Which risk factor from the client’s history most contributed to this exacerbation?
A) Non-adherence to low-sodium diet
B) Previous myocardial infarction
C) Chronic kidney disease stage 3
D) Atrial fibrillation
Answer A: Non-adherence to low-sodium diet
Rationale: Dietary sodium excess leads to fluid retention, increasing preload and worsening HF symptoms.
While other factors increase HF risk, acute exacerbation is often triggered by diet non-adherence or
medication non-compliance. Identifying triggers guides discharge teaching.
5. The nurse administers furosemide IV. Which assessment finding indicates a therapeutic response?
,A) Blood pressure decreases to 110/70 mmHg
B) Urine output increases to 200 mL over 2 hours
C) Respiratory rate increases to 32 breaths/min
D) Potassium level rises to 4.5 mEq/L
Answer B: Urine output increases to 200 mL over 2 hours
Rationale: Diuresis reduces fluid overload; expected urine output is ≥100-150 mL/hr after IV furosemide.
BP may drop but not desired; increased RR indicates worsening. Hypokalemia is a side effect.
Case 2 (Questions 6-10): A 24-year-old female presents to the emergency department with sudden onset of
severe right lower quadrant pain, nausea, and vomiting. She is sexually active and her last menstrual period
was 6 weeks ago.
6. Which assessment finding is most concerning for an ectopic pregnancy?
A) Bilateral lower quadrant pain
B) Painless vaginal bleeding
C) Referred shoulder pain
D) Fever and chills
Answer C: Referred shoulder pain
Rationale: Shoulder pain (Kehr’s sign) indicates diaphragmatic irritation from intra-abdominal bleeding in a
ruptured ectopic pregnancy. Painless bleeding is more typical of placenta previa; fever suggests infection.
Unilateral pain is classic for ectopic; bilateral is less specific.
7. The nurse obtains a urine pregnancy test which is positive. Which diagnostic test should the nurse
anticipate?
A) Abdominal X-ray
B) Transvaginal ultrasound
C) MRI of the pelvis
D) Hysterosalpingography
Answer B: Transvaginal ultrasound
Rationale: Transvaginal ultrasound is the gold standard to visualize an intrauterine pregnancy or adnexal
mass. Absence of intrauterine pregnancy with positive β-hCG suggests ectopic. X-ray and MRI are not first-
line.
, 8. The client’s vital signs are BP 90/60, HR 120, RR 22. The nurse notes the client is pale and
diaphoretic. Which action should the nurse take first?
A) Administer IV morphine for pain
B) Obtain consent for surgery
C) Start two large-bore IV lines with normal saline bolus
D) Place the client in Trendelenburg position
Answer C: Start two large-bore IV lines with normal saline bolus
Rationale: Hypovolemic shock from ruptured ectopic requires aggressive fluid resuscitation before surgery.
Pain medication may lower BP further; Trendelenburg is not recommended. Surgery is definitive but fluid
first.
9. (Matrix) Match each finding to the most likely cause in suspected ruptured ectopic pregnancy.
Finding: Hypotension → ?
A) Anxiety
B) Hemorrhage
C) Vasovagal response
D) Infection
Answer B: Hemorrhage
Rationale: Hypovolemia from intra-abdominal bleeding is the direct cause of hypotension in ruptured
ectopic. Infection would cause fever; anxiety may cause tachycardia but not hypotension. Hemorrhage
requires immediate fluid and blood products.
10. After stabilization, the client undergoes laparoscopic salpingectomy. Which discharge instruction
is most important?
A) “You may resume sexual intercourse in 1 week”
B) “Report any shoulder pain or heavy bleeding immediately”
C) “Take iron supplements for 1 month”
D) “Your future fertility will not be affected”
Answer B: “Report any shoulder pain or heavy bleeding immediately”
Rationale: Shoulder pain may indicate ongoing bleeding (irritation of diaphragm) and requires re-
evaluation. Resuming intercourse too early risks infection; fertility may be reduced but not the priority.
Heavy bleeding is a danger sign.
