NGN Case Study Examples — 5 Full Walkthroughs

What's "new" about NGN

The 2023+ NCLEX-RN added two structural changes to the test:

• Unfolding case studies. A patient scenario evolves over 6 questions, each tied to a clinical-judgment step (recognize cues → analyze cues → prioritize hypotheses → generate solutions → take action → evaluate outcomes).
• 5 new item types beyond classic multiple-choice: bow-tie, matrix multiple-response, drag-and-drop, highlight, and cloze.

Scoring on these items is partial-credit in many cases, which means a "+1 right, −0 wrong" strategy is incomplete — you need to be confident on every checkbox, not just the easy ones.

Case 1 — Postpartum hemorrhage (bow-tie)

Scenario: A 28-year-old G2P2 was admitted at 1400 for spontaneous vaginal delivery of a 9-lb 2-oz infant. EBL 600 mL at delivery. At 1530 the nurse documents BP 88/52, HR 118, fundus boggy 2 cm above umbilicus, lochia rubra heavy with clots, oxygen saturation 95%. The patient reports feeling "really lightheaded."

Bow-tie task: Select the priority condition the client is experiencing, the two priority actions to address it, and two parameters to monitor.

Reasoning: The clinical pattern — boggy fundus + heavy lochia + tachycardia + hypotension — is uterine atony with progressing hypovolemic shock. That's the priority condition. The two priority actions are fundal massage (mechanical control) and establish a second large-bore IV with bolus and oxytocin per protocol (volume + uterotonic). The two monitor parameters are vital signs (BP, HR) and uterine tone + lochia. Distractors will include "antibiotics" (premature, no infection signs) and "pain medication" (not the priority).

Case 2 — DKA (matrix multiple-response)

Scenario: A 17-year-old presents with 2 days of polyuria, polydipsia, vomiting, and abdominal pain. VS: T 37.8°C, HR 124, BP 96/60, RR 28 deep and labored, SpO2 98% on RA. Glucose 482, pH 7.21, HCO₃ 12, K 5.4, Na 132, ketones large. Patient is alert but lethargic.

Matrix task: For each finding, mark whether it is consistent with DKA, suggests resolving DKA, or is unrelated.

Reasoning by row: Kussmaul breathing → consistent (compensatory respiratory alkalosis attempting to correct metabolic acidosis). Hyperglycemia 482 → consistent. Potassium 5.4 → consistent (extracellular shift in acidosis; total-body K is depleted despite the elevated lab). pH 7.21 → consistent. Polyuria → consistent. Once treatment begins, K will drop as insulin pushes it intracellularly — that's the trap question that asks "what happens after starting insulin?"

Case 3 — Stroke door-to-needle (drag-and-drop ordered)

Scenario: A 67-year-old presents to the ED at 0905 with sudden-onset right-sided facial droop, slurred speech, and right-arm weakness. Onset witnessed by family at 0820. NIHSS 11.

Drag-and-drop task: Place these actions in the order the nurse should perform them.

1. Assess airway, breathing, circulation.
2. Obtain IV access and draw labs (CBC, BMP, coags, glucose).
3. Send patient to CT (rule out hemorrhage).
4. If non-hemorrhagic and within window, prepare tPA per protocol.
5. Establish neuro baseline and monitor q15min during infusion.

Reasoning: ABCs always first. Then the head-CT-before-tPA rule — you must rule out hemorrhagic stroke before giving thrombolytics. IV access happens early because tPA needs a dedicated line. Door-to-needle target is <60 minutes.

Case 4 — Sepsis bundle (highlight)

Scenario: A 74-year-old in the ED with 2 days of cough and confusion. T 38.9°C, HR 124, BP 86/50, RR 28, lactate 4.2, WBC 18.4. The provider has placed orders.

Highlight task: Highlight the elements of the order set that should be completed within the first hour ("hour-1 sepsis bundle").

Reasoning: The hour-1 bundle is: blood cultures before antibiotics, broad-spectrum antibiotic, lactate measurement, 30 mL/kg crystalloid bolus for hypotension or lactate ≥4, vasopressors if MAP <65 after fluids. Elements that are NOT hour-1: foley placement, dietary consult, chest CT (warranted but not hour-1).

Case 5 — Lithium teaching (cloze)

Scenario: A client newly prescribed lithium 600 mg PO BID for bipolar I disorder is being discharged. The nurse is reinforcing teaching.

Cloze task: Complete the sentence: "The client should maintain a consistent intake of [____1____] daily, avoid [____2____], and seek care for early signs of toxicity such as [____3____]."

Answers: (1) fluid (about 2.5 L) and sodium — both affect lithium clearance; dehydration concentrates lithium and causes toxicity. (2) NSAIDs and ACE inhibitors / thiazides — all raise lithium levels. (3) tremor, GI upset, lethargy, confusion — early lithium toxicity. (Mnemonic LITH from the pharm guide.)

How to actually prep for NGN

• Practice partial-credit pacing. Each row of a matrix has to be right; one wrong row reduces the partial credit. Don't speed-click.
• Use the clinical-judgment frame. Identify which step the question is testing (recognize / analyze / prioritize / generate / act / evaluate). The right answer fits the step — "monitor lactate" doesn't fit a "take action" step.
• Drill the 5 item types specifically. Most general Q-banks dilute NGN with classic multiple-choice. NGN-native banks (Archer, Nursing Ready) keep the format ratio realistic.
• Read the chart slowly the first time. Once you've internalized the cues (vitals, labs, history), the 6 questions in the case go fast.