Mastering Clinical
Judgment: Next
Generation NCLEX-RN
Case Study
Compilation 2025
1. A nurse in the emergency department assesses a client with sudden onset of severe chest pain
radiating to the jaw, diaphoresis, and nausea. The client's vital signs: BP 90/60, HR 120, RR 24, SpO2 94%
on room air. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer sublingual nitroglycerin
,C. Start an IV line with normal saline
D. Apply supplemental oxygen at 2 L/min via nasal cannula
💫RATIONALE✔️✔️: The priority is obtaining an ECG to rule out ST-elevation myocardial infarction
(STEMI) within 10 minutes of arrival, as rapid reperfusion is critical. Nitroglycerin is contraindicated with
hypotension (BP <90 systolic).
💫ANSWER✔️✔️: A. Obtain a 12-lead ECG
---
2. A postpartum client reports a sudden feeling of "heaviness" in the perineum and sees a small amount
of bright red bleeding. The nurse notes the fundus is firm at midline and the perineal pad is half
saturated. What is the nurse's priority action?
A. Assess perineal area for a hematoma
B. Increase the IV oxytocin infusion rate
C. Massage the fundus vigorously
D. Document the finding as normal lochia rubra
💫RATIONALE✔️✔️: A sensation of perineal heaviness with bright red bleeding despite a firm fundus
suggests a developing vaginal or vulvar hematoma from a hidden bleed. Immediate assessment is
needed to prevent further expansion and pain.
💫ANSWER✔️✔️: A. Assess perineal area for a hematoma
---
3. A nurse is caring for a client with major depressive disorder who started taking sertraline 50 mg daily
5 days ago. The client tells the nurse, "I feel worse than before, and I just can't go on anymore." Which
response is most appropriate?
A. "It takes 2-4 weeks for the full effect, so give it more time."
B. "I will contact your provider to increase the dose immediately."
C. "Are you having thoughts of harming yourself right now?"
D. "Let's focus on the small improvements you've made this week."
,💫RATIONALE✔️✔️: The client's statement indicates possible worsening depression or suicidal
ideation, which can occur early in SSRI therapy. Direct assessment of current suicidal intent is the
priority safety action.
💫ANSWER✔️✔️: C. "Are you having thoughts of harming yourself right now?"
---
4. A nurse prepares to administer enoxaparin 40 mg subcutaneously for DVT prophylaxis. The available
vial is 60 mg/0.6 mL. How many mL should the nurse draw up? (Record answer to one decimal place.)
A. 0.4 mL
B. 0.6 mL
C. 0.8 mL
D. 1.0 mL
💫RATIONALE✔️✔️: Use the formula (desired dose / available dose) × volume = (40 mg / 60 mg) × 0.6
mL = 0.6667 × 0.6 = 0.4 mL. Do not round up when using a low-molecular-weight heparin syringe.
💫ANSWER✔️✔️: A. 0.4 mL
---
5. A client with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.1 mEq/L, calcium 7.5
mg/dL, and phosphate 6.0 mg/dL. Which breakfast selection indicates effective teaching?
A. Oatmeal with raisins and a banana
B. Scrambled eggs with white toast and apple slices
C. Bran cereal with orange slices and milk
D. Yogurt parfait with granola and dried apricots
💫RATIONALE✔️✔️: Eggs, white toast, and apples are low in potassium, while bananas, oranges,
dried fruit, bran, and dairy are high in potassium or phosphate. The client needs low-potassium, low-
phosphate foods.
💫ANSWER✔️✔️: B. Scrambled eggs with white toast and apple slices
, ---
6. A nurse in a long-term care facility observes a resident with dementia repeatedly trying to open the
locked door to the garden. Which action best addresses the resident's needs while maintaining safety?
A. Redirect the resident to a seated activity near a window overlooking the garden
B. Firmly tell the resident "No, the door is locked for your safety"
C. Administer a PRN antipsychotic medication to reduce agitation
D. Allow the resident to open and close an unlocked closet door instead
💫RATIONALE✔️✔️: Redirection to a safe, similar sensory experience (viewing the garden) respects
the resident's desire to go outside while preventing elopement risk. Locked doors without redirection
increase frustration.
💫ANSWER✔️✔️: A. Redirect the resident to a seated activity near a window overlooking the garden
---
7. A client receiving a continuous IV heparin infusion has an aPTT of 110 seconds (normal 25-35,
therapeutic goal 60-80). The nurse should anticipate which order from the provider?
A. Decrease the heparin infusion rate by 2 units/kg/hour
B. Administer protamine sulfate 25 mg IV push
C. Increase the heparin infusion rate by 2 units/kg/hour
D. Obtain a stat platelet count and hold the next infusion
💫RATIONALE✔️✔️: An aPTT >100 seconds is supratherapeutic and increases bleeding risk. The
standard protocol is to decrease the infusion rate by a specified amount (e.g., 2 units/kg/hour) and
redraw aPTT in 6 hours.
💫ANSWER✔️✔️: A. Decrease the heparin infusion rate by 2 units/kg/hour
---
8. A nurse is teaching a client with newly diagnosed type 2 diabetes about foot care. Which statement
by the client indicates a need for further teaching?
A. "I will use a mirror to check the bottoms of my feet every day."
Judgment: Next
Generation NCLEX-RN
Case Study
Compilation 2025
1. A nurse in the emergency department assesses a client with sudden onset of severe chest pain
radiating to the jaw, diaphoresis, and nausea. The client's vital signs: BP 90/60, HR 120, RR 24, SpO2 94%
on room air. Which action should the nurse take first?
A. Obtain a 12-lead ECG
B. Administer sublingual nitroglycerin
,C. Start an IV line with normal saline
D. Apply supplemental oxygen at 2 L/min via nasal cannula
💫RATIONALE✔️✔️: The priority is obtaining an ECG to rule out ST-elevation myocardial infarction
(STEMI) within 10 minutes of arrival, as rapid reperfusion is critical. Nitroglycerin is contraindicated with
hypotension (BP <90 systolic).
💫ANSWER✔️✔️: A. Obtain a 12-lead ECG
---
2. A postpartum client reports a sudden feeling of "heaviness" in the perineum and sees a small amount
of bright red bleeding. The nurse notes the fundus is firm at midline and the perineal pad is half
saturated. What is the nurse's priority action?
A. Assess perineal area for a hematoma
B. Increase the IV oxytocin infusion rate
C. Massage the fundus vigorously
D. Document the finding as normal lochia rubra
💫RATIONALE✔️✔️: A sensation of perineal heaviness with bright red bleeding despite a firm fundus
suggests a developing vaginal or vulvar hematoma from a hidden bleed. Immediate assessment is
needed to prevent further expansion and pain.
💫ANSWER✔️✔️: A. Assess perineal area for a hematoma
---
3. A nurse is caring for a client with major depressive disorder who started taking sertraline 50 mg daily
5 days ago. The client tells the nurse, "I feel worse than before, and I just can't go on anymore." Which
response is most appropriate?
A. "It takes 2-4 weeks for the full effect, so give it more time."
B. "I will contact your provider to increase the dose immediately."
C. "Are you having thoughts of harming yourself right now?"
D. "Let's focus on the small improvements you've made this week."
,💫RATIONALE✔️✔️: The client's statement indicates possible worsening depression or suicidal
ideation, which can occur early in SSRI therapy. Direct assessment of current suicidal intent is the
priority safety action.
💫ANSWER✔️✔️: C. "Are you having thoughts of harming yourself right now?"
---
4. A nurse prepares to administer enoxaparin 40 mg subcutaneously for DVT prophylaxis. The available
vial is 60 mg/0.6 mL. How many mL should the nurse draw up? (Record answer to one decimal place.)
A. 0.4 mL
B. 0.6 mL
C. 0.8 mL
D. 1.0 mL
💫RATIONALE✔️✔️: Use the formula (desired dose / available dose) × volume = (40 mg / 60 mg) × 0.6
mL = 0.6667 × 0.6 = 0.4 mL. Do not round up when using a low-molecular-weight heparin syringe.
💫ANSWER✔️✔️: A. 0.4 mL
---
5. A client with chronic kidney disease (CKD) stage 4 has a serum potassium of 6.1 mEq/L, calcium 7.5
mg/dL, and phosphate 6.0 mg/dL. Which breakfast selection indicates effective teaching?
A. Oatmeal with raisins and a banana
B. Scrambled eggs with white toast and apple slices
C. Bran cereal with orange slices and milk
D. Yogurt parfait with granola and dried apricots
💫RATIONALE✔️✔️: Eggs, white toast, and apples are low in potassium, while bananas, oranges,
dried fruit, bran, and dairy are high in potassium or phosphate. The client needs low-potassium, low-
phosphate foods.
💫ANSWER✔️✔️: B. Scrambled eggs with white toast and apple slices
, ---
6. A nurse in a long-term care facility observes a resident with dementia repeatedly trying to open the
locked door to the garden. Which action best addresses the resident's needs while maintaining safety?
A. Redirect the resident to a seated activity near a window overlooking the garden
B. Firmly tell the resident "No, the door is locked for your safety"
C. Administer a PRN antipsychotic medication to reduce agitation
D. Allow the resident to open and close an unlocked closet door instead
💫RATIONALE✔️✔️: Redirection to a safe, similar sensory experience (viewing the garden) respects
the resident's desire to go outside while preventing elopement risk. Locked doors without redirection
increase frustration.
💫ANSWER✔️✔️: A. Redirect the resident to a seated activity near a window overlooking the garden
---
7. A client receiving a continuous IV heparin infusion has an aPTT of 110 seconds (normal 25-35,
therapeutic goal 60-80). The nurse should anticipate which order from the provider?
A. Decrease the heparin infusion rate by 2 units/kg/hour
B. Administer protamine sulfate 25 mg IV push
C. Increase the heparin infusion rate by 2 units/kg/hour
D. Obtain a stat platelet count and hold the next infusion
💫RATIONALE✔️✔️: An aPTT >100 seconds is supratherapeutic and increases bleeding risk. The
standard protocol is to decrease the infusion rate by a specified amount (e.g., 2 units/kg/hour) and
redraw aPTT in 6 hours.
💫ANSWER✔️✔️: A. Decrease the heparin infusion rate by 2 units/kg/hour
---
8. A nurse is teaching a client with newly diagnosed type 2 diabetes about foot care. Which statement
by the client indicates a need for further teaching?
A. "I will use a mirror to check the bottoms of my feet every day."
