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Next Generation NCLEX (NGN) Practice Questions

Medically reviewed by Douglas Carollo, MSN, APRN, FNP-BC Updated September 2026 6 practice questions

Quick answer: The Next Generation NCLEX (NGN) tests clinical judgment with items such as bow-tie, matrix/grid, drop-down cloze, highlight, trend, and extended multiple response (select all that apply). Below are six free NGN practice questions, one of each, with the answer and a full rationale. Most NGN items award partial credit, so a partly correct response can still earn points.

Next Generation NCLEX (NGN) items measure clinical judgment through a set of item types NCSBN documents: extended multiple response, extended drag-and-drop, cloze (drop-down), highlight (enhanced hot spot), matrix/grid, and bow-tie. You will also meet trend items, built on one client's record across several time points. NCSBN does not publish trend as a formal item type, so treat it as a way of presenting data rather than a separate format. Unlike traditional single-answer questions, most NGN items use partial-credit scoring, so scoring is not all-or-nothing and a partly correct response can still earn points. The practice set below works through six items (bow-tie, matrix/grid, drop-down cloze, highlight, trend, and extended multiple response), each built on a distinct high-yield clinical scenario, with rationales that follow current US standards (Surviving Sepsis Campaign, AHA, ADA, ACOG). New to these formats? See our complete guide to NGN question types.

Next Generation NCLEX (NGN) Practice Questions

Item 1 · Bow-Tie · Septic Shock (Bow-tie)

A 68-year-old woman is admitted from a long-term care facility with acute pyelonephritis. On assessment: temperature 39.2 C (102.6 F), heart rate 118 beats/min, blood pressure 88/52 mmHg, respiratory rate 26 breaths/min, SpO2 91% on room air. Skin is mottled and cool. She is newly confused and oriented to person only. Point-of-care labs: WBC 18,300/mm3, serum lactate 4.2 mmol/L.

Complete the diagram by selecting the 2 Actions to Take, the 1 Potential Condition the client is most likely experiencing, and the 2 Parameters to Monitor to evaluate the response to treatment.

Actions to Take (select 2)
  • Obtain blood cultures and then administer broad-spectrum IV antibiotics
  • Initiate a 30 mL/kg isotonic crystalloid (0.9% sodium chloride) bolus
  • Restrict IV and oral fluids to 1,000 mL over 24 hours
  • Give a PRN antipyretic and reassess the client in 4 hours
  • Place the client in Trendelenburg position and apply warm blankets
Potential Condition (select 1)
  • Septic shock
  • Cardiogenic shock
  • Anaphylactic shock
  • Neurogenic shock
Parameters to Monitor (select 2)
  • Serum lactate
  • Mean arterial pressure (MAP)
  • Deep tendon reflexes
  • 24-hour dietary intake
  • Serum amylase
Show answer & rationale
Actions to Take (select 2): Obtain blood cultures and then administer broad-spectrum IV antibiotics; Initiate a 30 mL/kg isotonic crystalloid (0.9% sodium chloride) bolus
Potential Condition (select 1): Septic shock
Parameters to Monitor (select 2): Serum lactate; Mean arterial pressure (MAP)
Fever, tachycardia, hypotension, tachypnea, altered mentation, a WBC of 18,300/mm3, and a lactate of 4.2 mmol/L in a client with a known infection identify septic shock: sepsis-induced hypoperfusion with a lactate greater than 2 mmol/L and hypotension. The Surviving Sepsis Campaign Hour-1 bundle drives the actions: obtain blood cultures BEFORE antibiotics, give broad-spectrum antibiotics rapidly, and infuse 30 mL/kg of isotonic crystalloid for hypotension or a lactate of 4 mmol/L or greater. Cultures precede antibiotics to preserve pathogen yield without delaying the drug. Fluid restriction is the opposite of the required aggressive resuscitation; giving only an antipyretic and waiting 4 hours delays life-saving therapy; and Trendelenburg positioning is not evidence-based and can worsen respiratory effort. Cardiogenic shock would show signs of pump failure (crackles, JVD, low output after MI); anaphylactic shock follows an allergen exposure with urticaria/wheezing; neurogenic shock produces hypotension with bradycardia after spinal injury — none fit this infectious picture. Serum lactate and MAP are the key monitoring parameters: a downtrending lactate signals improving perfusion, and MAP is targeted at 65 mmHg or higher (vasopressors are added if fluids do not achieve this). Deep tendon reflexes, dietary intake, and serum amylase do not evaluate perfusion or sepsis resuscitation.
Item 2 · Matrix / Grid · Acute Decompensated Heart Failure (Matrix)

A 70-year-old man was admitted 6 hours ago with acute decompensated heart failure and received IV furosemide. On admission he had bilateral crackles, jugular venous distention, SpO2 94% on room air, and weight 92 kg. The nurse now reassesses him to evaluate the response to therapy.

For each reassessment finding, mark whether it indicates the client is improving, is worsening, or is unrelated to the heart failure treatment.

Reassessment finding Value / status at 6 hours
Urine output 1,400 mL over 6 hours
Lung sounds Bases now clear to auscultation
Jugular venous distention Resolved
Oxygen saturation Decreased from 94% to 86% on room air
Serum potassium 2.9 mEq/L
Prior appendectomy scar Small, well-healed, nontender
Indicates improvement Indicates worsening Unrelated to heart failure treatment
Urine output 1,400 mL over 6 hours ◯ ◯ ◯
Lung bases now clear to auscultation ◯ ◯ ◯
Jugular venous distention resolved ◯ ◯ ◯
Oxygen saturation decreased from 94% to 86% on room air ◯ ◯ ◯
Serum potassium 2.9 mEq/L ◯ ◯ ◯
Well-healed appendectomy scar ◯ ◯ ◯
Show answer & rationale
Urine output 1,400 mL over 6 hours: Indicates improvement
Lung bases now clear to auscultation: Indicates improvement
Jugular venous distention resolved: Indicates improvement
Oxygen saturation decreased from 94% to 86% on room air: Indicates worsening
Serum potassium 2.9 mEq/L: Indicates worsening
Well-healed appendectomy scar: Unrelated to heart failure treatment
The goal of IV loop diuretic therapy in acute decompensated heart failure is to reduce fluid overload, so improvement is shown by increased diuresis (1,400 mL in 6 hours), clearing of pulmonary crackles as pulmonary congestion resolves, and resolution of jugular venous distention as preload and venous congestion fall. A falling oxygen saturation from 94% to 86% indicates worsening: it signals deteriorating gas exchange from a new complication (because the lung bases are now clear, a cause such as pulmonary embolism must be considered) and requires immediate escalation. A serum potassium of 2.9 mEq/L (normal 3.5 to 5.0 mEq/L) is hypokalemia, a common and dangerous adverse effect of loop diuretics; it increases the risk of lethal dysrhythmias, especially relevant if the client also takes digoxin, and therefore represents worsening that needs potassium replacement. The well-healed appendectomy scar is an incidental, chronic finding with no bearing on the current heart failure treatment, so it is unrelated. Recognizing which reassessment data reflect therapeutic success versus a treatment complication is the core clinical-judgment skill this matrix tests — a nurse must both confirm the diuretic is working and catch its predictable harms.
Item 3 · Cloze (Drop-Down) · Diabetic Ketoacidosis (Cloze / Drop-down)

A 19-year-old with type 1 diabetes is brought to the ED with nausea, vomiting, and abdominal pain after a viral illness. Assessment: deep, rapid respirations, fruity-scented breath, dry mucous membranes. Labs: blood glucose 480 mg/dL, arterial pH 7.22, serum bicarbonate 14 mEq/L, serum ketones positive, serum potassium 5.4 mEq/L.

Choose the option in each drop-down that correctly completes the statements about the priority problem and initial management.

The client's presentation is most consistent with ___.
  • diabetic ketoacidosis
  • hyperosmolar hyperglycemic state
  • hypoglycemia
  • diabetes insipidus
The first-priority IV fluid to initiate is ___.
  • 0.9% sodium chloride
  • 5% dextrose in water
  • 3% sodium chloride
  • 0.45% sodium chloride with 20 mEq bicarbonate
A continuous ___ infusion should be started only after serum potassium is confirmed to be above 3.5 mEq/L.
  • regular insulin
  • glargine insulin
  • dextrose
  • potassium chloride
Show answer & rationale
The client's presentation is most consistent with ___.: diabetic ketoacidosis
The first-priority IV fluid to initiate is ___.: 0.9% sodium chloride
A continuous ___ infusion should be started only after serum potassium is confirmed to be above 3.5 mEq/L.: regular insulin
The combination of hyperglycemia (480 mg/dL), high anion-gap metabolic acidosis (pH 7.22, bicarbonate 14 mEq/L), positive ketones, Kussmaul respirations, and fruity breath in a client with type 1 diabetes defines diabetic ketoacidosis (DKA). Hyperosmolar hyperglycemic state (HHS) typically shows much higher glucose (often greater than 600 mg/dL) with minimal ketosis and a pH above 7.30; hypoglycemia is excluded by the elevated glucose; and diabetes insipidus is a water-balance disorder without hyperglycemia or acidosis. Per ADA management, the first priority is aggressive volume replacement with isotonic 0.9% sodium chloride to correct the profound dehydration and improve perfusion before or alongside insulin. Dextrose (5% to 10%, added to the IV fluids) is started later, once glucose falls below about 250 mg/dL, to prevent hypoglycemia while the insulin infusion continues to clear ketones; 3% saline is for symptomatic hyponatremia, not DKA. A continuous regular insulin infusion is the insulin used for DKA, but it must be withheld until serum potassium is above 3.5 mEq/L (2024 ADA consensus; older references cite 3.3 mEq/L), because insulin drives potassium intracellularly and can precipitate life-threatening hypokalemia and dysrhythmias. This client's potassium of 5.4 mEq/L is above that threshold, but total body potassium is depleted, so potassium is monitored closely and replaced as the level falls. Long-acting glargine is not used for acute DKA correction.
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Item 4 · Highlight · Acute Ischemic Stroke (Highlight)

Nurse's Notes, Emergency Department: Client arrived via EMS. Family reports sudden onset of right-sided facial droop and slurred speech that began 90 minutes ago while the client was eating breakfast. On assessment, right arm drift is noted and the client is unable to lift the right arm against gravity. Speech is garbled and difficult to understand. Blood pressure 182/98 mmHg. Blood glucose 112 mg/dL. Temperature 37.0 C (98.6 F). Client reports a history of mild seasonal allergies. Family states the client ambulated to the bathroom without difficulty last evening. Client denies chest pain and is oriented to person only.

Highlight (select) the findings in the nurse's notes that are relevant and require immediate follow-up for a suspected acute ischemic stroke.

Findings to highlight
  • Right-sided facial droop
  • Garbled, slurred speech
  • Symptom onset 90 minutes ago
  • Right arm drift, unable to lift against gravity
  • Blood pressure 182/98 mmHg
  • Blood glucose 112 mg/dL
  • History of mild seasonal allergies
  • Oriented to person only
Show answer & rationale
Findings to highlight: Right-sided facial droop; Garbled, slurred speech; Symptom onset 90 minutes ago; Right arm drift, unable to lift against gravity; Blood pressure 182/98 mmHg; Oriented to person only
The findings to highlight are the classic focal neurologic deficits of acute ischemic stroke plus the data that drive time-sensitive treatment decisions. Facial droop, slurred/garbled speech, and unilateral arm drift are the core FAST deficits (Face, Arm, Speech) confirming a likely stroke. Symptom onset 90 minutes ago is critical because IV thrombolysis (alteplase/tenecteplase) is generally indicated within a 3- to 4.5-hour window from last known well; documenting an exact onset time governs eligibility, so it must be flagged. A blood pressure of 182/98 mmHg is relevant: before thrombolytics, BP must be below 185/110 mmHg, and it requires close monitoring and possible treatment. Being oriented to person only reflects an altered level of consciousness and a change in neurologic status that warrants immediate follow-up. A blood glucose of 112 mg/dL is a normal value; it is checked to rule out hypoglycemia as a stroke mimic, but because it is normal it is not a concerning finding to highlight. Mild seasonal allergies are chronic and irrelevant to the acute event, and the ability to ambulate normally the previous evening simply helps establish the last-known-well baseline rather than being a current concern. Selecting the true focal deficits and the treatment-window and BP data demonstrates recognition of a stroke emergency and the urgency of the thrombolytic pathway.
Item 5 · Trend · Upper GI Bleed / Hypovolemic Shock (Trend)

A 58-year-old man is admitted with an upper gastrointestinal bleed after several episodes of hematemesis and melena. He has a history of chronic NSAID use for arthritis. The nurse records serial assessments over 4 hours.

Review the trend of the client's data and select all findings that indicate the client is deteriorating and developing hypovolemic (hemorrhagic) shock.

Assessment 0800 1000 1200
Heart rate (beats/min) 92 108 126
Blood pressure (mmHg) 118/72 104/66 86/54
Respiratory rate (breaths/min) 18 22 26
Level of consciousness Alert Alert, anxious Lethargic
Skin Warm, pink Cool Cool, clammy, pale
Urine output (mL/hr) 45 30 15
Findings indicating deterioration (select all that apply)
  • Rising heart rate from 92 to 126 beats/min
  • Falling blood pressure to 86/54 mmHg
  • Decreasing urine output to 15 mL/hr
  • Progression to cool, clammy, pale skin
  • Declining level of consciousness to lethargic
  • Respiratory rate remaining stable within normal limits
  • Rising blood pressure indicating fluid overload
Show answer & rationale
Findings indicating deterioration (select all that apply): Rising heart rate from 92 to 126 beats/min; Falling blood pressure to 86/54 mmHg; Decreasing urine output to 15 mL/hr; Progression to cool, clammy, pale skin; Declining level of consciousness to lethargic
The trend shows classic progressive hypovolemic (hemorrhagic) shock from ongoing GI blood loss. Early compensation is reflected in the rising heart rate (92 to 126 beats/min) and rising respiratory rate as the body tries to maintain cardiac output and oxygen delivery; tachycardia is often the earliest sign of hypovolemia. As blood loss continues and compensation fails, the blood pressure falls to a frankly hypotensive 86/54 mmHg. Urine output drops from 45 to 15 mL/hr; output below 30 mL/hr (or less than 0.5 mL/kg/hr) signals inadequate renal perfusion from falling circulating volume. The skin becomes cool, clammy, and pale as peripheral vasoconstriction shunts blood to vital organs, and the level of consciousness deteriorates from alert to lethargic as cerebral perfusion declines — a critical late warning sign. Two options are incorrect: the respiratory rate is NOT stable within normal limits — it climbs from 18 to 26 breaths/min, which is itself a deterioration sign, so the statement misrepresents the data. The blood pressure is falling, not rising, so there is no evidence of fluid overload; the concern here is volume depletion, not excess. Recognizing this downward trend should prompt immediate action: large-bore IV access, isotonic fluid resuscitation, type and crossmatch for blood products, and notification of the provider.
Item 6 · Extended Multiple Response · Preeclampsia with Severe Features (Extended Multiple Response)

A 28-year-old woman at 33 weeks gestation is admitted with blood pressure 168/112 mmHg on two readings 15 minutes apart. She reports a severe headache and blurred vision and has epigastric pain. Assessment: 3+ proteinuria, deep tendon reflexes 4+ with clonus, platelet count 88,000/mm3. The provider diagnoses preeclampsia with severe features.

Select all the appropriate nursing actions for this client.

Appropriate nursing actions (select all that apply)
  • Administer IV magnesium sulfate as prescribed
  • Initiate seizure precautions and reduce environmental stimuli
  • Prepare to administer an antihypertensive such as IV labetalol for blood pressure at or above 160/110 mmHg
  • Keep calcium gluconate readily available as the antidote for magnesium toxicity
  • Encourage the client to ambulate in the hallway to promote circulation
  • Place the client in a brightly lit room and encourage frequent visitors
  • Monitor deep tendon reflexes, respiratory rate, and hourly urine output
Show answer & rationale
Appropriate nursing actions (select all that apply): Administer IV magnesium sulfate as prescribed; Initiate seizure precautions and reduce environmental stimuli; Prepare to administer an antihypertensive such as IV labetalol for blood pressure at or above 160/110 mmHg; Keep calcium gluconate readily available as the antidote for magnesium toxicity; Monitor deep tendon reflexes, respiratory rate, and hourly urine output
This client has preeclampsia with severe features — severe-range blood pressure (at or above 160/110 mmHg), headache, visual changes, epigastric pain, hyperreflexia with clonus, and thrombocytopenia (platelets 88,000/mm3) — placing her at high risk for eclamptic seizure and HELLP syndrome. IV magnesium sulfate is the standard therapy for seizure prophylaxis and is the priority pharmacologic intervention. Because she is at seizure risk, the nurse initiates seizure precautions and reduces stimulation. Severe-range hypertension (systolic 160 mmHg or higher, or diastolic 110 mmHg or higher) is treated with a first-line IV antihypertensive such as labetalol or hydralazine to prevent maternal stroke. Calcium gluconate must be at the bedside as the antidote for magnesium sulfate toxicity, which is recognized by loss of deep tendon reflexes, respiratory rate below 12 breaths/min, and urine output below 30 mL/hr — so ongoing monitoring of DTRs, respiratory rate, and hourly urine output is essential to catch toxicity early. Two options are wrong: encouraging ambulation is unsafe — the client needs bed rest with limited activity given her seizure risk and severe hypertension. Placing her in a brightly lit room with frequent visitors directly contradicts seizure-precaution management, which calls for a quiet, dimly lit, low-stimulation environment to avoid provoking a seizure. Selecting the five correct actions reflects the priorities of preventing seizure, controlling dangerous blood pressure, and monitoring for treatment complications.

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Next Generation NCLEX FAQ

What are the 6 NGN question types on the NCLEX?

The Next Generation NCLEX uses six item types: extended multiple response, extended drag-and-drop/cloze (drop-down), matrix/grid, highlight (text or table), bow-tie, and trend. Most appear inside stand-alone items or six-part unfolding case studies that walk you through the Clinical Judgment Measurement Model (recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes).

How are NGN questions scored?

Unlike traditional all-or-nothing questions, most NGN items use partial-credit scoring. NCSBN uses three models: zero/one scoring (a point for each correct response, nothing subtracted; used for items such as drop-down cloze, matrix multiple choice, and bow-tie, which is worth up to 5 points), +/- scoring (a point for each correct choice, minus a point for each incorrect one, never below zero; used for select-all-that-apply and matrix multiple response), and rationale scoring, where both parts of a linked pair must be right. This means a partially correct answer can still earn points: fill every blank and target on zero/one items, but on +/- items select only options you can defend, because a wrong choice cancels a correct one.

How many NGN questions will I see on my NCLEX?

Every NCLEX-RN and NCLEX-PN candidate can expect NGN content. The exam runs 85 to 150 items, and every exam includes three clinical judgment case studies (six items each, 18 items total) plus stand-alone clinical judgment items (about 10 percent, depending on exam length), alongside traditional multiple-choice and select-all-that-apply items. The exact number varies because the test is computer-adaptive.

How do I answer a bow-tie question?

A bow-tie item asks you to fill a central Potential Condition (the client's likely problem) flanked by Actions to Take on one side and Parameters to Monitor on the other. Identify the condition first by analyzing the cues, then choose the actions that treat that specific condition and the parameters that let you evaluate whether treatment is working. Each correct placement earns points, so reason through the whole diagram rather than guessing.

Sources

Sources checked September 2026.

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