NCLEX RN 2026 Next Generation (NGN) Actual
Exam Questions & Answers | Latest Verifi ed
Prep Pack to Pass the NCLEX RN 2026 on First
Attempt
Section 1: Clinical Judgment & Prioritization
(NGN Bow-Tie, Trend, Case Study)
1. Bow-Tie: Acute Respiratory Distress
A nurse assesses a client with sudden shortness of breath, crackles in both lung
bases, SpO₂ 88% on 2L nasal cannula, and BP 100/70 mmHg. Which conditions
belong in the "Risk Factors" (left box) and "Interventions" (right box) of the Bow-
Tie model?
Answer:
Risk Factors: Sepsis, Aspiration, Pancreatitis
Interventions: Intubation with PEEP, Prone positioning, Diuretics
Rationale: ARDS risk factors include direct/indirect lung injury. Interventions focus
on oxygenation (PEEP, prone) and managing pulmonary edema.
2. Trend: Postoperative Hemorrhage
Vital signs: 0800: HR 88, BP 120/80; 0900: HR 110, BP 100/70; 0915: HR 120, BP
90/60, urine output 20 mL/hr. What action?
Answer: Notify provider immediately.
Rationale: Trend shows hypovolemic shock. Decreasing BP + increasing HR +
oliguria = hemorrhage until proven otherwise.
3. Matrix/SATA: DVT Prevention
Which interventions prevent DVT post-hip surgery? (Select 3)
Answer: SCDs, LMWH, Early ambulation.
Rationale: SCDs and LMWH reduce stasis/hypercoagulability. Ambulation promotes
venous return. Aspirin alone is less effective.
4. Case Study: Heart Failure Exacerbation
A client with HF presents with JVD, 3+ pitting edema, crackles, and weight gain of 5
lbs in 3 days. Which is priority?
,Answer: Administer IV furosemide.
Rationale: Pulmonary congestion is life-threatening. Diuresis reduces preload.
5. Cloze (Drop-Down): TBI Management
A client with TBI has ICP 22 mmHg, BP 150/90, CPP = ___ (calculate). Intervention:
___ (mannitol/hyperventilation/fluids).
Answer: CPP = MAP - ICP = (150+90/3) - 22 = (150+30) - 22 = 180-22 = 158? Wait
correction: MAP = diastolic + 1/3 pulse pressure = 90 + (60/3) = 90+20=110. Then
CPP = 110-22=88 mmHg. Mannitol.
Rationale: Target CPP >60 mmHg. Mannitol reduces ICP; hyperventilation only for
herniation.
6. Hot Spot: Chest Tube Air Leak
Where do you look for an air leak in a chest tube system? (Diagram: water seal
chamber)
Answer: Water seal chamber – continuous bubbling indicates air leak.
Rationale: Intermittent bubbling is normal with exhalation/cough; continuous
bubbling = leak.
7. SATA: Sepsis Resuscitation
Which actions within first 3 hours of sepsis recognition? (Select 4)
Answer: Measure lactate, Obtain blood cultures, Start broad-spectrum antibiotics,
Give 30 mL/kg crystalloid.
Rationale: Surviving Sepsis Campaign 3-hour bundle.
8. Bow-Tie: Anaphylaxis
Left box (triggers): penicillin, bee stings, peanuts. Right box (immediate
interventions): epinephrine IM, airway management, IV fluids.
Rationale: Epinephrine is first-line; antihistamines are secondary.
9. Trend: Increasing Oxygen Requirement
Day 1: 2L NC → SpO₂ 94%; Day 2: 4L NC → 90%; Day 3: 6L NC → 86%. Next action?
Answer: Prepare for non-rebreather or BiPAP, notify rapid response.
Rationale: Deteriorating oxygenation despite escalating O₂ indicates impending
respiratory failure.
,10. Cloze: Burn Resuscitation
A 70 kg client with 40% TBSA burn. First 24 hr fluid (Parkland formula) = ___ mL.
Answer: 4 mL × 70 kg × 40% = 11,200 mL (half in first 8 hr).
Rationale: Parkland: 4 mL/kg/%TBSA.
11. SATA: Acute Stroke Management
Which are contraindications for IV alteplase? (Select 3)
Answer: CT showing hemorrhage, SBP >185 mmHg, last known well >4.5 hours.
Rationale: tPA contraindicated for hemorrhagic stroke, uncontrolled hypertension,
or unknown onset >4.5h.
12. Case Study: DKA
Client with DKA: BG 650, pH 7.1, HCO3 12, K+ 5.2. Priority intervention?
Answer: Start IV insulin and fluids (0.9% NS).
Rationale: Fluid resuscitation first, then insulin. Hold potassium if K+ >5.0.
13. Hot Spot: PICC Line Dressing
When is PICC dressing change needed? (Select all that apply)
Answer: Every 7 days, if damp/loose, if bloody drainage.
Rationale: CDC: change transparent dressing q7 days or sooner if compromised.
14. Bow-Tie: Pulmonary Embolism
Risk factors (left): prolonged immobility, cancer, oral contraceptives. Interventions
(right): anticoagulation, oxygen, hemodynamic support.
Rationale: PE management: heparin, monitor for right heart strain.
15. Trend: Post-Cardiac Arrest
ROSC at 1000. At 1015: HR 110, BP 90/60, cool extremities. Next?
Answer: Targeted temperature management (32-36°C).
Rationale: Hypothermia improves neurologic outcomes after cardiac arrest.
, 16. SATA: Epidural Hematoma
Which findings suggest epidural hematoma post-head injury? (Select 2)
Answer: Lucid interval then sudden deterioration, ipsilateral fixed dilated pupil.
Rationale: Classic triad: head injury → lucid interval → rapid decline with herniation.
17. Cloze: Heparin Drip Adjustment
Client on heparin drip with aPTT 45 sec (target 60-80). Action: ___
(increase/decrease/hold).
Answer: Increase infusion rate.
Rationale: Subtherapeutic aPTT requires rate increase per protocol.
18. Case Study: GI Bleed
Melena, orthostatic hypotension, Hgb 7.2. Which action first?
Answer: Insert two large-bore IVs, start NS bolus.
Rationale: Volume resuscitation before blood transfusion.
19. Bow-Tie: Thyroid Storm
Left box (precipitants): infection, surgery, radioactive iodine. Right box
(interventions): beta-blocker, propylthiouracil, cooling, hydrocortisone.
Rationale: Thyroid storm: decrease thyroid hormone synthesis (PTU) and block
peripheral effects (beta-blocker).
20. Trend: Liver Failure
AST/ALT rising, INR 1.5 → 2.2 → 2.8, ammonia 80. Priority?
Answer: Lactulose, monitor for asterixis.
Rationale: Rising INR indicates worsening synthetic function; lactulose for hepatic
encephalopathy.
21. SATA: Meningitis
Which findings in bacterial meningitis? (Select 4)
Answer: Nuchal rigidity, Kernig sign, Brudzinski sign, photophobia.
Rationale: Classic meningeal signs; rash in meningococcal.
Exam Questions & Answers | Latest Verifi ed
Prep Pack to Pass the NCLEX RN 2026 on First
Attempt
Section 1: Clinical Judgment & Prioritization
(NGN Bow-Tie, Trend, Case Study)
1. Bow-Tie: Acute Respiratory Distress
A nurse assesses a client with sudden shortness of breath, crackles in both lung
bases, SpO₂ 88% on 2L nasal cannula, and BP 100/70 mmHg. Which conditions
belong in the "Risk Factors" (left box) and "Interventions" (right box) of the Bow-
Tie model?
Answer:
Risk Factors: Sepsis, Aspiration, Pancreatitis
Interventions: Intubation with PEEP, Prone positioning, Diuretics
Rationale: ARDS risk factors include direct/indirect lung injury. Interventions focus
on oxygenation (PEEP, prone) and managing pulmonary edema.
2. Trend: Postoperative Hemorrhage
Vital signs: 0800: HR 88, BP 120/80; 0900: HR 110, BP 100/70; 0915: HR 120, BP
90/60, urine output 20 mL/hr. What action?
Answer: Notify provider immediately.
Rationale: Trend shows hypovolemic shock. Decreasing BP + increasing HR +
oliguria = hemorrhage until proven otherwise.
3. Matrix/SATA: DVT Prevention
Which interventions prevent DVT post-hip surgery? (Select 3)
Answer: SCDs, LMWH, Early ambulation.
Rationale: SCDs and LMWH reduce stasis/hypercoagulability. Ambulation promotes
venous return. Aspirin alone is less effective.
4. Case Study: Heart Failure Exacerbation
A client with HF presents with JVD, 3+ pitting edema, crackles, and weight gain of 5
lbs in 3 days. Which is priority?
,Answer: Administer IV furosemide.
Rationale: Pulmonary congestion is life-threatening. Diuresis reduces preload.
5. Cloze (Drop-Down): TBI Management
A client with TBI has ICP 22 mmHg, BP 150/90, CPP = ___ (calculate). Intervention:
___ (mannitol/hyperventilation/fluids).
Answer: CPP = MAP - ICP = (150+90/3) - 22 = (150+30) - 22 = 180-22 = 158? Wait
correction: MAP = diastolic + 1/3 pulse pressure = 90 + (60/3) = 90+20=110. Then
CPP = 110-22=88 mmHg. Mannitol.
Rationale: Target CPP >60 mmHg. Mannitol reduces ICP; hyperventilation only for
herniation.
6. Hot Spot: Chest Tube Air Leak
Where do you look for an air leak in a chest tube system? (Diagram: water seal
chamber)
Answer: Water seal chamber – continuous bubbling indicates air leak.
Rationale: Intermittent bubbling is normal with exhalation/cough; continuous
bubbling = leak.
7. SATA: Sepsis Resuscitation
Which actions within first 3 hours of sepsis recognition? (Select 4)
Answer: Measure lactate, Obtain blood cultures, Start broad-spectrum antibiotics,
Give 30 mL/kg crystalloid.
Rationale: Surviving Sepsis Campaign 3-hour bundle.
8. Bow-Tie: Anaphylaxis
Left box (triggers): penicillin, bee stings, peanuts. Right box (immediate
interventions): epinephrine IM, airway management, IV fluids.
Rationale: Epinephrine is first-line; antihistamines are secondary.
9. Trend: Increasing Oxygen Requirement
Day 1: 2L NC → SpO₂ 94%; Day 2: 4L NC → 90%; Day 3: 6L NC → 86%. Next action?
Answer: Prepare for non-rebreather or BiPAP, notify rapid response.
Rationale: Deteriorating oxygenation despite escalating O₂ indicates impending
respiratory failure.
,10. Cloze: Burn Resuscitation
A 70 kg client with 40% TBSA burn. First 24 hr fluid (Parkland formula) = ___ mL.
Answer: 4 mL × 70 kg × 40% = 11,200 mL (half in first 8 hr).
Rationale: Parkland: 4 mL/kg/%TBSA.
11. SATA: Acute Stroke Management
Which are contraindications for IV alteplase? (Select 3)
Answer: CT showing hemorrhage, SBP >185 mmHg, last known well >4.5 hours.
Rationale: tPA contraindicated for hemorrhagic stroke, uncontrolled hypertension,
or unknown onset >4.5h.
12. Case Study: DKA
Client with DKA: BG 650, pH 7.1, HCO3 12, K+ 5.2. Priority intervention?
Answer: Start IV insulin and fluids (0.9% NS).
Rationale: Fluid resuscitation first, then insulin. Hold potassium if K+ >5.0.
13. Hot Spot: PICC Line Dressing
When is PICC dressing change needed? (Select all that apply)
Answer: Every 7 days, if damp/loose, if bloody drainage.
Rationale: CDC: change transparent dressing q7 days or sooner if compromised.
14. Bow-Tie: Pulmonary Embolism
Risk factors (left): prolonged immobility, cancer, oral contraceptives. Interventions
(right): anticoagulation, oxygen, hemodynamic support.
Rationale: PE management: heparin, monitor for right heart strain.
15. Trend: Post-Cardiac Arrest
ROSC at 1000. At 1015: HR 110, BP 90/60, cool extremities. Next?
Answer: Targeted temperature management (32-36°C).
Rationale: Hypothermia improves neurologic outcomes after cardiac arrest.
, 16. SATA: Epidural Hematoma
Which findings suggest epidural hematoma post-head injury? (Select 2)
Answer: Lucid interval then sudden deterioration, ipsilateral fixed dilated pupil.
Rationale: Classic triad: head injury → lucid interval → rapid decline with herniation.
17. Cloze: Heparin Drip Adjustment
Client on heparin drip with aPTT 45 sec (target 60-80). Action: ___
(increase/decrease/hold).
Answer: Increase infusion rate.
Rationale: Subtherapeutic aPTT requires rate increase per protocol.
18. Case Study: GI Bleed
Melena, orthostatic hypotension, Hgb 7.2. Which action first?
Answer: Insert two large-bore IVs, start NS bolus.
Rationale: Volume resuscitation before blood transfusion.
19. Bow-Tie: Thyroid Storm
Left box (precipitants): infection, surgery, radioactive iodine. Right box
(interventions): beta-blocker, propylthiouracil, cooling, hydrocortisone.
Rationale: Thyroid storm: decrease thyroid hormone synthesis (PTU) and block
peripheral effects (beta-blocker).
20. Trend: Liver Failure
AST/ALT rising, INR 1.5 → 2.2 → 2.8, ammonia 80. Priority?
Answer: Lactulose, monitor for asterixis.
Rationale: Rising INR indicates worsening synthetic function; lactulose for hepatic
encephalopathy.
21. SATA: Meningitis
Which findings in bacterial meningitis? (Select 4)
Answer: Nuchal rigidity, Kernig sign, Brudzinski sign, photophobia.
Rationale: Classic meningeal signs; rash in meningococcal.
