Guide 6 of 8
NCLEX-RN® NGN Case Studies
NGN case studies present an evolving patient scenario across 6 connected items and multiple chart tabs. This guide explains all 6 item types, how to approach each case systematically, and what students consistently miss.
Case studies on this site are original content created for rnclarity.com and are not reproductions of official NCLEX® exam items.
What is NGN and why it matters
Next Generation NCLEX® (NGN) introduced six new item types in April 2023 to measure clinical judgment more directly. Traditional multiple-choice items can test whether a candidate knows what to do; NGN items measure whether a candidate can apply clinical reasoning across a real, unfolding patient scenario.
The most intensive NGN format is the unfolding case study: a single client scenario presented across six items, each connected to shared chart data. Information is revealed progressively — meaning earlier chart data may become relevant to a later item. This mirrors how clinical thinking actually works at the bedside.
3 minimum
Case studies per exam
6
Items per case study
18+
Case-study items total
6 types
NGN item formats
All 6 NGN item types — explained with exam tips
Each of these six formats appears both in standalone questions and within unfolding case studies. Understanding the mechanics of each format before exam day removes one layer of cognitive friction when you encounter them under pressure.
Extended Multiple Response
Format
Select all that apply — or select a specific number (e.g., 'select 3')
Exam tip
Read all options before selecting. Only choose options you are confident about — depending on the scoring model, incorrect selections can work against partial credit.
Example prompt: Which assessment findings require immediate follow-up? Select all that apply.
Drag-and-drop
Format
Drag text labels, actions, or data items into a target — a table column, a priority sequence, or a categorized list
Exam tip
Read the target area labels carefully before dragging. Some items ask for sequence (first → last); others ask for categorization (e.g., indicated / contraindicated / not indicated).
Example prompt: Drag and drop the nursing actions in the order they should be performed when a client returns from surgery with SpO₂ of 89%.
Cloze / Drop Down
Format
A sentence, table, or care plan contains blank dropdown menus. Select the correct option for each blank independently.
Exam tip
Complete all blanks — leaving one empty typically marks the item incorrect. Read the full sentence with your selections filled in before confirming.
Example prompt: The priority nursing action is to [dropdown] and notify the [dropdown] of the change in condition.
Highlight
Format
Click on specific words, phrases, or image regions that answer the question; or highlight relevant text within a chart
Exam tip
Only highlight what directly and specifically answers the question. Over-selecting findings that are expected for the diagnosis (and not clinically concerning) is a common error.
Example prompt: In the nurse's notes below, click on the findings that indicate the client may be developing fluid overload.
Matrix / Grid
Format
A table with rows (findings, medications, or actions) and columns (e.g., Indicated / Contraindicated, Yes / No). Select one answer per row.
Exam tip
Complete every row. Each row is an independent clinical judgment. Apply the specific client's context to every row individually rather than applying a blanket rule across all rows.
Example prompt: For each nursing action listed, indicate whether it is Indicated or Not Indicated based on the client's current presentation.
Bow-tie
Format
A linked clinical-judgment chain: select the most likely condition, actions to take, and parameters to monitor.
Exam tip
Keep every selection connected to the same client problem. The condition, actions, and monitoring parameters should form one coherent clinical plan.
Example prompt: Select the most likely condition, the actions to take, and the parameters to monitor.
A 6-step approach to every case study
Students who perform best on case studies use a consistent reading and reasoning process. These six steps take less than 2 minutes and prevent the most common errors.
Read all chart tabs before the first item
Build a complete clinical picture first — read nurse's notes, vitals, labs, medications. Do not begin answering until you understand the full opening scenario.
Identify the baseline, then track what changes
The opening scenario establishes the baseline. Each subsequent item introduces new data. Ask: what is new? what worsened? what was not present before?
Name the clinical judgment step being tested
Is this item asking you to recognize cues, analyze a pattern, prioritize, generate options, take action, or evaluate an outcome? Naming the step directs your reasoning.
Use the item format as a hint
A matrix item tests categorization. A bow-tie links a condition, actions, and monitoring. A cloze item often tests the correct term in context. The format tells you what kind of thinking is required.
Return to the chart with each new item
New data may appear between items — a new lab result, a provider order, an updated nurse's note with a new time stamp. Recheck all tabs with each item before answering.
Debrief after every case with five review questions
What changed across the scenario? Which cue drove urgency? Did my action match the priority? What objective finding shows improvement? What would I do differently?
What students get wrong most — and the fix
Reading too fast and missing key details in chart tabs
✓ Before answering each item, scan all available tabs. New data may appear in a tab you previously dismissed.
Treating all assessment findings as equally urgent
✓ Look for what is new, what changed, and what deviates from the baseline established in the opening scenario.
Missing changes in vital signs or lab values
✓ Across a case, compare each new value to the previous reading — not just to 'normal.' A worsening trajectory is the signal.
Choosing a teaching/educating action when immediate assessment or intervention is needed
✓ If the client is unstable or deteriorating, teaching comes after stabilization. Stable conditions allow for education.
Confusing what the RN can do independently vs. what requires a provider order
✓ Independent nursing actions (positioning, supplemental oxygen per standing order, comfort, safety) precede dependent actions (calling the provider, administering new medications).
Failing to connect medications, lab values, and symptoms into a clinical pattern
✓ Ask: What are the known effects of this medication? What lab values does this condition affect? Does the symptom fit the pattern of a complication?
Free NGN case study — practice now
This is an original case study created for rnclarity.com. Apply the six-step approach above. After finishing all items, use the post-case debrief questions below to extract maximum learning from the case.
Original Case Study
Heart Failure Exacerbation
68-year-old client with known heart failure — morning assessment
0600: Client admitted via ED. Reports waking up breathless at 3 AM. States "I had to sit up in bed all night — couldn't breathe lying down." Known history of heart failure, HTN, and type 2 diabetes. Lives alone. Adherent to furosemide and lisinopril per self-report. 0800: Client appears anxious and diaphoretic. Using accessory muscles to breathe. Bilateral crackles audible on auscultation. +2 pitting edema bilateral lower extremities. SpO₂ 87% on room air.
Select all relevant cues from the client's presentation.
After every case study — five debrief questions
Reviewing a case without structured debrief is like doing questions without reading rationales. These five questions extract the full learning value from every scenario you complete.
- 1
What changed over time in this scenario?
- 2
Which cue made the situation most urgent?
- 3
Did I prioritize airway, breathing, circulation, safety, or acute change correctly?
- 4
Did my chosen action match the most important problem?
- 5
Did I evaluate using an objective outcome indicator — not just client comfort?
Curious how case studies fit into the full exam? Read the complete 2026 NCLEX-RN® guide — question types, adaptive scoring, clinical judgment and study strategy.