A highlight item gives you a block of chart text and asks you to click only the findings that answer one specific question. The clickable targets are pre-defined words, phrases, or whole lines from a nurses' note, a history and physical, or a lab report, and you select them inside the passage instead of picking lettered options. What it tests is cue recognition: can you read a realistic chart the way a nurse reads it, separate the data that changes your next action from the data that is simply present, and stay inside the exact question asked. The failure mode this format punishes hardest is over-selecting. Every abnormal value looks clickable, so you grab all of them. Extra clicks are not free. Most prep sources that address highlight scoring assume incorrect selections work against your credit, though NCSBN's current scoring FAQ does not name the format. Read the prompt first, define what makes a finding qualify, then click only what clears that bar. The eight items below drill that discipline across septic shock, DKA, stroke thrombolytic screening, severe preeclampsia, opioid-induced respiratory depression, pediatric dehydration, upper GI bleeding, and worsening heart failure. New to these formats? See our complete guide to NGN question types, practice all six NGN item types, or read how the NGN is scored.
Highlight NCLEX Practice Questions With Rationales
A 68-year-old client, weight 80 kg, is on postoperative day 2 following an emergency sigmoid colectomy with colostomy creation for perforated diverticulitis. History includes type 2 diabetes mellitus and hypertension. The client received the scheduled dose of IV antibiotics at 1000, and the nurse is completing a focused assessment at 1400 after the certified nursing assistant reports that the client "seems off."
Highlight the findings in the nurses’ note that indicate sepsis-induced organ hypoperfusion.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
The acute change in mentation is one of the earliest and most important signs that the brain is not being perfused. A client who was oriented to person, place, and time this morning and is now oriented to person only has an organ failing in front of you. Blood pressure 84/46 mm Hg with a MAP of 59 mm Hg sits below the initial MAP target of 65 mm Hg used in the Surviving Sepsis Campaign guidelines, meaning perfusion pressure to every organ bed is inadequate. Urine output of 15 mL in 2 hours is 7.5 mL/hr, far below the 0.5 mL/kg/hr minimum, which for this 80 kg client is 40 mL/hr, and it reflects renal hypoperfusion. A lactate of 4.2 mmol/L confirms anaerobic metabolism from inadequate oxygen delivery. A lactate above 2 mmol/L can signal sepsis-induced hypoperfusion, and hypotension or a lactate of 4 mmol/L or higher, both present here, drives immediate fluid resuscitation with 30 mL/kg crystalloid, blood cultures, broad-spectrum antibiotics, and vasopressors if hypotension persists, with norepinephrine as first-line.
Several other findings in this note are also abnormal. Fever of 38.9°C, heart rate 118, respirations 24, and a WBC of 16,800/mm3 are the expected inflammatory and compensatory response to infection. They tell you sepsis exists; they do not tell you the client has decompensated, and treating them alone does not restore perfusion. Small serosanguineous drainage on a postoperative day 2 incision is normal healing, not purulence or dehiscence. Oxygen saturation of 96% and a glucose of 118 mg/dL are within acceptable limits.
Clinical pearl: in early septic shock the skin can be warm and flushed because of vasodilation, so the classic cool, clammy shock picture may be absent. Trust mentation, MAP, urine output, and lactate. Hypotension that persists after adequate fluid resuscitation and requires vasopressors, together with a lactate above 2 mmol/L, is what separates septic shock from sepsis.
A 24-year-old woman with type 1 diabetes is brought to the emergency department by her roommate. She ran out of insulin four days ago and has been vomiting since yesterday. Triage point-of-care glucose is 486 mg/dL, point-of-care beta-hydroxybutyrate is 5.4 mmol/L, venous pH is 7.11, and serum bicarbonate is 9 mmol/L. The nurse completes the initial assessment while the provider writes admission orders.
Highlight the findings in the nurses' note that require immediate follow-up.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
Lethargy with orientation to person only signals that acidosis and hyperosmolality are depressing the sensorium. Declining mental status threatens airway protection in a client who is actively vomiting, and alongside a bicarbonate of 9 mmol/L it places this presentation at the severe end of the spectrum.
Respirations of 28 breaths/min, deep and sighing with a fruity odor, are Kussmaul respirations. Their rate and depth quantify how severe the acidosis is, track the response to fluids and insulin, and warn of impending respiratory fatigue. That respiratory effort is what is holding the pH up; when it tires in a client who is already lethargic and vomiting, the pH falls quickly and airway support is needed, so the pattern must be monitored continuously.
A blood pressure of 86/52 mm Hg with a heart rate of 126 beats/min reflects the volume deficit produced by osmotic diuresis. Isotonic fluid resuscitation is the first treatment priority.
Potassium of 3.1 mmol/L is the most time-critical laboratory value. Total-body potassium is depleted even when the serum level looks normal, and insulin drives potassium intracellularly. The 2024 consensus directs replacement at about 10 mmol/hour with insulin withheld until the potassium exceeds 3.5 mmol/L, because starting insulin at this level can precipitate a fatal arrhythmia.
The remaining abnormalities are real but do not alter immediate management. Sodium of 132 mmol/L is dilutional hyponatremia from the osmotic pull of hyperglycemia; corrected for a glucose of 486 mg/dL it is roughly 138 mmol/L, and it rises as glucose falls. Creatinine of 1.3 mg/dL is a prerenal rise that improves with the fluids already indicated. Dry membranes, polyuria, thirst, and the weight loss document the same dehydration the vital signs already flagged. Temperature and oxygen saturation are normal.
Clinical pearl: in DKA, check the potassium before hanging the insulin.
A 68-year-old client with hypertension and atrial fibrillation is brought to the emergency department by family for difficulty speaking and right-sided weakness noticed this morning. The stroke team is activated and the client is screened for intravenous thrombolytic therapy. The nurse reviews the record before the neurologist makes the treatment decision.
Highlight the findings in the nurses' note that make this client ineligible for intravenous thrombolytic therapy.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
Last known well was 2130 and the client was discovered at 0615, so the treatable interval is measured from 2130, not from discovery. That is far outside the 4.5-hour window the AHA/ASA guideline sets for standard intravenous thrombolysis, and this client has not been selected by advanced imaging, so time alone disqualifies. Blood pressure of 196/114 mm Hg after two labetalol doses exceeds the 185/110 mm Hg ceiling; a pressure that cannot be safely brought below that threshold is an exclusion, because thrombolysis in a hypertensive brain markedly raises hemorrhagic transformation risk. A platelet count of 74,000/mm3 (reference 150,000-450,000/mm3) is below the 100,000/mm3 floor, and an international normalized ratio of 2.4 on warfarin is above the 1.7 cutoff. Both values sit on the exclusion side of the standard screen: a platelet count below 100,000/mm3 and an INR above 1.7 are each grounds to withhold intravenous thrombolysis. Both results mean hemostasis is already impaired before adding a drug that lyses clot systemically.
The remaining findings do not close the door on thrombolysis. An NIHSS of 14 with aphasia and arm drift is the reason to treat, not a reason to withhold; disabling deficits argue for thrombolysis. Atrial fibrillation with a rate of 118 explains the likely cardioembolic mechanism but is not a contraindication. A temperature of 37.9 C is a low-grade elevation to treat supportively. Glucose of 168 mg/dL is mildly high and does not exclude anyone. The CT showing no hemorrhage and the normal respiratory findings are reassuring data that support proceeding.
Clinical pearl: build the screen around three buckets, clock, pressure, and bleeding risk. Ask when the client was last seen normal, whether the pressure can be brought under 185/110 mm Hg, and whether platelets, INR, anticoagulants, or recent bleeding or head trauma leave the client unable to hold a clot. Everything else is context.
A 29-year-old client at 33 weeks and 2 days gestation is admitted to the antepartum unit for evaluation of new-onset hypertension detected at a prenatal visit. Her pregnancy has been otherwise uncomplicated, and she takes only a prenatal vitamin. The nurse completes an assessment two hours after admission and reviews the admission laboratory results.
Highlight the findings that require immediate follow-up.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
The initial reading of 168/112 mm Hg, repeated at 172/114 mm Hg 15 minutes later, confirms severe-range hypertension. ACOG allows confirmation within minutes rather than waiting four hours precisely so treatment is not delayed, because sustained severe-range pressures carry stroke risk. The unrelieved headache and the flashing lights with blurred vision are cerebral and visual manifestations of the endothelial dysfunction, vasospasm, and cerebral hyperperfusion that precede eclamptic seizure. The platelet count of 74,000/mm3 signals platelet consumption from endothelial injury and raises concern for HELLP syndrome.
The remaining findings are either expected or supportive rather than severe features. Dependent edema with a 2 lb gain over a week is common in late pregnancy, and edema was removed from the diagnostic criteria long ago. Proteinuria of 2+ supports the diagnosis of preeclampsia, but the amount of protein is not a severe feature and does not grade severity. A creatinine of 0.7 mg/dL is normal and actually reassuring, since pregnancy lowers baseline creatinine. Vital signs other than blood pressure are unremarkable, and the fetal heart rate tracing is category I. Heartburn is the trap paired with right upper quadrant or epigastric pain from hepatic capsule distention. Food-related burning relieved by an antacid is reflux, not hepatic involvement.
Clinical pearl: absent clonus does not rule out severe disease. Reflex changes are supportive data, never the deciding criterion. Act on the blood pressure, the headache, the visual changes, and the low platelet count.
A 68-year-old client is on the surgical unit following an open sigmoid colectomy earlier today. History includes obesity, obstructive sleep apnea treated with nightly CPAP at home, and stage 3 chronic kidney disease. A hydromorphone patient-controlled analgesia (PCA) pump was started in the post-anesthesia care unit, and the nurse is completing the 3-hour post-transfer assessment.
Highlight the findings in the nurses' note that require immediate follow-up for opioid-induced respiratory depression.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
A rate of 7 breaths per minute that is shallow and irregular is frank bradypnea. Opioids blunt the medullary chemoreceptor response to rising carbon dioxide, so ventilation falls before oxygenation does. That is exactly what the capnography shows: an end-tidal carbon dioxide of 58 mm Hg (normal 35 to 45) rising from a baseline of 41 confirms hypoventilation in real time.
Increasing sedation is the earliest and most reliable warning sign, which is why the ASPMN and the Joint Commission direct you to monitor sedation level (POSS or RASS) alongside respiratory rate rather than relying on pain scores. A client who cannot stay awake through a sentence is already over-sedated; respiratory depression follows sedation, not the other way around.
PCA by proxy, meaning anyone other than the client pressing the button, defeats the built-in safety feature of the device. The client must be awake enough to self-dose. The spouse's dosing is the mechanism driving everything else in this note, so it requires immediate correction and re-education.
A saturation of 93% on supplemental oxygen looks reassuring, but it is not the finding that drives action here. Supplemental oxygen masks hypoventilation by keeping the saturation acceptable while carbon dioxide climbs. Pulse oximetry lags; capnography does not. A heart rate of 58 and a blood pressure of 138/84 are not opioid respiratory toxicity. Urinary retention of 420 mL and hypoactive bowel sounds are genuine opioid and postoperative effects that need intervention, but neither threatens the airway tonight.
Act by stopping the PCA, stimulating the client, supporting ventilation, and preparing naloxone per protocol with the provider notified.
Clinical pearl: obesity, obstructive sleep apnea, and reduced renal clearance stack risk. Reduced renal clearance prolongs hydromorphone exposure, and its neuroexcitatory metabolite accumulates as well, so this client was primed for trouble before the first proxy dose.
A 14-month-old boy is brought to the pediatric emergency department by his mother. He has had watery diarrhea and vomiting for three days following a viral illness that spread through his daycare, and he has refused nearly all oral fluids since yesterday. His mother says his breathing "looks different" this morning and that he is not acting like himself. He has no chronic medical conditions and is up to date on immunizations.
Highlight the findings in the nurses' note that require immediate follow-up.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
A heart rate of 186 with weak, thready pulses sits well above the awake range for a 12- to 24-month-old (roughly 98-140 beats/minute) and reflects the sympathetic surge holding cardiac output together as stroke volume falls. Capillary refill of 4 seconds with cool, mottled extremities is the perfusion half of that same picture — peripheral vasoconstriction shunting blood centrally. Lethargy and failure to engage with his mother tell you the brain is now underperfused; in AHA PALS teaching, altered mental status plus delayed capillary refill and tachycardia defines compensated shock and drives an immediate isotonic fluid bolus (20 mL/kg normal saline or lactated Ringer's) with reassessment. Respiratory rate 62 with retractions and grunting completes the picture. Tachypnea by itself can be respiratory compensation for the metabolic acidosis of bicarbonate loss in stool and lactate from poor perfusion, but retractions and grunting mean real work of breathing and require evaluation for a pulmonary cause layered on top of that acidosis.
Now the findings that do not make the cut. Dry mucous membranes and absent tears are genuine dehydration signs, but they explain why he is here — they are not what escalates care in the next five minutes. Blood pressure 92/54 mm Hg is normal for his age, and that is the trap: children maintain blood pressure until they are nearly decompensated, so a normal reading never reassures you out of the findings above. The 9-hour dry diaper and the 0.7 kg loss (about 6.6% of body weight) document moderate volume depletion and support the shock picture, but neither adds anything the perfusion findings above have not already told you — oliguria here is a consequence of the hypoperfusion you are already treating. Temperature 38.1°C and hyperactive bowel sounds fit acute gastroenteritis. The SpO2 of 94% is only marginally low and is already captured by the respiratory finding above — the retractions and grunting, not the saturation, are what signal the distress.
Pearl: in a child, hypotension is the last domino, not the first. Grade perfusion by heart rate, capillary refill, and mental status — when all three are off, treat the shock before the blood pressure agrees with you.
A 58-year-old man comes to the emergency department after two days of black, tarry stools. He has osteoarthritis and takes naproxen twice daily, and he has no known liver disease. He was triaged as stable 40 minutes ago and has now been moved to a treatment bay for evaluation.
Highlight the findings in the nurses' note that require immediate follow-up.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
Repeated large-volume emesis totaling about 800 mL over 3 hours tells you blood is still entering the stomach; the coffee-ground appearance means it has been in contact with gastric acid rather than arriving as fresh brisk bleeding. A blood pressure that fell from 128/76 to 86/48 mm Hg within 40 minutes, a heart rate of 122 beats/min, and skin that is cool, pale, and diaphoretic with 4-second capillary refill are the classic picture of hypovolemic shock: catecholamine-driven tachycardia and peripheral vasoconstriction shunt blood centrally, and once roughly 30 percent of volume is lost, compensation fails and pressure drops. A hemoglobin of 6.4 g/dL sits below the restrictive transfusion threshold of 7 g/dL that the American College of Gastroenterology recommends for acute upper GI bleeding, so packed red cells are indicated now. These findings drive the same actions: large-bore IV access, type and crossmatch, crystalloid and blood resuscitation, IV proton pump inhibitor, and endoscopy within 24 hours of presentation once resuscitation is under way.
Several other findings are abnormal but not urgent. Three weeks of epigastric burning treated with antacids explains the NSAID-induced ulcer and belongs in the history, but it is not the finding that changes your next 10 minutes. Holding naproxen is appropriate, not a problem. A potassium of 3.4 mEq/L is mildly low and will be replaced, but it is not causing the instability. A respiratory rate of 20 breaths/min with a saturation of 96 percent and a temperature of 37.1 C are within expected limits.
Clinical pearl: calculate the shock index, heart rate divided by systolic blood pressure. Here 122 divided by 86 equals 1.4. Normal is about 0.5 to 0.7, and a value of 0.9 or higher signals significant volume loss even before the blood pressure fully collapses. Also expect a disproportionately elevated BUN with a normal creatinine, a hallmark of digested blood in an upper GI bleed.
A 72-year-old woman with heart failure with reduced ejection fraction (EF 35%) and long-standing hypertension is seen by the home health nurse two weeks after discharge for a heart failure exacerbation. Her regimen includes furosemide, lisinopril, metoprolol succinate, and spironolactone. The visit is a scheduled post-discharge follow-up, and her daughter is present.
Highlight the findings in the nurses' note that require immediate follow-up.
On the exam you click the segments directly in the note. Here they are marked with a dotted underline.
Show answer & rationale
Rapid weight gain is the earliest objective marker of fluid retention. The 2022 AHA/ACC/HFSA heart failure guideline builds self-care teaching around daily weights, and the standard trigger to contact the clinician is more than 2 to 3 lb in a day or about 5 lb in a week. Five pounds in three days is fluid, not fat.
Stopping the furosemide four days ago is the mechanism. Without the loop diuretic blocking reabsorption at the thick ascending limb, sodium and water are retained, plasma volume climbs, and left ventricular filling pressures rise. Nocturia is a real and common complaint, and the fix is moving the dose earlier in the day, not discontinuing it.
Escalating orthopnea, one pillow to three, means that when she lies flat, blood redistributes from the splanchnic and lower-extremity beds into the thorax faster than the failing ventricle can move it forward, so pulmonary capillary pressure rises. New bilateral crackles, absent at the previous visit, are that same pressure pushing fluid into the alveoli. Together, those two say the fluid is already in her lungs.
Now the findings that stay unselected. A blood pressure of 148/86 mm Hg is abnormal, but it reflects chronic hypertension plus a heart rate at the upper end of normal: relevant background, not the finding driving action today. The dry cough is a classic ACE inhibitor effect, unchanged for six months. Trace ankle edema that has not changed is her baseline, and note that peripheral edema is a late, insensitive marker that lags pulmonary congestion, so stable trace edema does not rule out acute volume overload. Morning knee stiffness, a normal temperature, and an organized pill system are noise. Highlight items test relevance, not abnormality.
Clinical pearl: in heart failure, "unchanged" downgrades a finding and "new or worse" upgrades it. Scan the note for change words first, new, increased, up from, stopped, before you scan for abnormal numbers.
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Frequently Asked Questions
What is a highlight question on the Next Generation NCLEX?
A highlight item presents client information as a chart tab or a short case, and the prompt asks you to click the findings that meet one condition, such as findings requiring immediate follow-up or findings consistent with a specific complication. Only certain words, phrases, sentences, or table rows are clickable; the rest of the passage is context. NCSBN describes highlight items as a sentence or several sentences forming a paragraph, with selection of pre-defined words or phrases. Many prep platforms also present a table-style variation where you select rows or cells from a flowsheet or lab report; treat that as a practice convention rather than a documented NCSBN format.
How are highlight items scored?
Treat this carefully. NCSBN's current scoring FAQ does not document a scoring model for highlight items by name, so any confident rule you see quoted online is an inference rather than published fact. Most sources that address it place highlight items under partial credit scoring, where correct selections earn credit and incorrect selections work against you, which is why blanket-clicking every abnormal finding is a losing strategy. For what NCSBN actually publishes about scoring models, see our guide to how the Next Generation NCLEX is scored rather than relying on secondhand point values.
How many findings am I supposed to highlight?
The prompt almost never tells you a number, and that is intentional. Instead of guessing a count, convert the prompt into a test you can apply line by line. If it asks for findings requiring immediate follow-up, the test is whether that finding would change what you do in the next few minutes. A lactate of 4.2 mmol/L with a mean arterial pressure under 65 mmHg passes that test. A remote appendectomy or a mildly elevated cholesterol does not, even though both are technically abnormal.
Can I unselect a finding after I click it?
Yes. Highlight selections toggle, so clicking a highlighted segment again removes the highlight, and you can revise as many times as you want before you submit the item. Use that. A workable approach is to make a first pass clicking anything that might qualify, then make a deliberate second pass and remove every selection that does not clearly satisfy the prompt. Once you move past the item you cannot return to it, so do the pruning before you advance.
Why do I keep over-highlighting?
Because nursing school trains you to notice everything abnormal, and highlight items reward noticing only what is relevant to the question asked. The fix is procedural. Read the prompt before you read the chart so you know what you are hunting for. Then read the chart once for comprehension and a second time for selection. When a finding is abnormal but stable, chronic, or already addressed in the scenario, leave it alone. The skill being measured is prioritization, not abnormality detection, and the two are not the same thing.
Sources
- NCSBN Help Center: What should a candidate expect when they see an NCLEX Highlight item? — Highlight items are sentence(s)/a paragraph; only enabled text is selectable
- NCSBN Help Center: What is the current format and item types for the NCLEX? — Enhanced Hot Spot = pre-defined words/phrases from the chart; candidates can select and deselect
- NCSBN Help Center: What are the current scoring models? — Scoring FAQ gives +/- only for SATA and Matrix MR; highlight is not named
- Society of Critical Care Medicine: Surviving Sepsis Campaign Adult Guidelines — SSC: initial MAP target 65, norepinephrine first-line, >=30 mL/kg crystalloid
Sources checked September 2026.