NGN Overview

What is the Next Generation NCLEX?

The NGN (launched April 2023) adds new question types built around one goal: testing whether you can use clinical judgment, not just recall facts. Most appear in unfolding case studies — one patient whose situation changes across six linked questions, one for each cognitive skill.

The six skills the questions test

Recognize Cues → often a Highlight question
Analyze Cues → often a Matrix/Grid question
Prioritize Hypotheses → Matrix or multiple-response
Generate Solutions → Drop-down or drag-and-drop
Take Actions → Multiple-response or drop-down
Evaluate Outcomes → Matrix/Trend question

How to approach every NGN question (the universal method)

Read the scenario and separate relevant from irrelevant findings.
Compare each finding to normal ranges and the patient's baseline.
Ask "what's the priority — what could harm this patient fastest?"
Choose the answer that fits this patient right now, not the textbook-perfect one.
Watch for partial credit — most NGN items score each correct choice, so don't guess wildly.

A note for this course: In these lessons you'll learn the reasoning behind each item type. On the real exam you'll physically highlight, drag, or select — here, we walk through how to think, which is what actually earns the points.

Highlight Questions

What is a Highlight item?

The nurse must identify the important information within a clinical scenario.
The goal is to recognize cues that signal risk, deterioration, or a priority concern.
Not every piece of information is equally important.

This item type tests Recognize Cues.

Example (you are able to click on this it's interactive)

Question: Highlight the findings that require immediate nursing attention.

Item 1 of 6 • Recognize Cues Click the findings that require immediate nursing attention, then press Submit. A nurse is caring for a patient admitted with pneumonia. The patient reports shortness of breath. The temperature is 38.4°C (101.1°F). The patient states they ate 50% of their lunch. The oxygen saturation is 86% on room air. The patient has a productive cough with yellow sputum. Submit Rationale
Oxygen saturation of 86%, shortness of breath, and fever are the priority cues — they signal impaired oxygenation, respiratory compromise, and active infection (ABCs). Eating 50% of lunch and sputum color are useful but not urgent. [tcb-script](function(){ document.querySelectorAll('#hlText .hl').forEach(function(s){ s.addEventListener('click',function(){s.classList.toggle('sel');}); }); document.getElementById('hlSubmit').addEventListener('click',function(){ document.querySelectorAll('#hlText .hl').forEach(function(s){ var correct=s.getAttribute('data-c')==='1'; var picked=s.classList.contains('sel'); s.style.background='';s.style.outline=''; if(correct){s.style.background='#a8e6a3';} if(picked&&!correct){s.style.background='#f5a9a9';} if(correct&&!picked){s.style.outline='2px dashed #1e7e34';} }); document.getElementById('hlResult').style.display='block'; });})();[/tcb-script]

Answer: Shortness of breath Oxygen saturation 86% Fever 38.4°C

Why these are correct

Oxygen saturation of 86% shows impaired oxygenation — an airway/breathing threat (ABCs).
Shortness of breath signals respiratory compromise.
Fever indicates an active infection driving the illness.

Why the other findings are less urgent

Eating 50% of lunch matters for nutrition but isn't a priority right now.
Yellow sputum gives useful information but doesn't require immediate intervention.

Tip: Read every finding and label it in your head — "normal, abnormal, or dangerous?" Highlight only the dangerous/abnormal ones tied to the priority problem. When in doubt, ABCs first.

Matrix / Grid Questions

What is a Matrix item?

A grid that asks you to make a decision about several findings at once.
Each row is a finding or intervention; each column is a category (e.g., effective / ineffective, expected / unexpected, indicated / contraindicated).
You judge every row against the columns — like a checklist of clinical reasoning.

This item type usually tests Analyze Cues or Evaluate Outcomes.

Example (you are able to click on this it's interactive)

Item 2 of 6 • Analyze Cues A patient with heart failure is admitted with fluid overload. For each finding, click whether it is Expected or Unexpected for worsening heart failure.

Finding	Expected	Unexpected
Crackles in the lungs
Weight gain of 4 lb overnight
Shortness of breath lying flat
Blood pressure 150/92
Warm, dry skin with strong pulses

Submit Rationale
Crackles, rapid weight gain, orthopnea (shortness of breath lying flat), and elevated blood pressure all fit fluid backing up — expected in worsening heart failure. Warm, dry skin with strong pulses shows good perfusion and no overload, so it does not fit the picture — unexpected. [tcb-script](function(){ var btn=document.getElementById('nclexSubmit'); btn.addEventListener('click',function(){ var rows=document.querySelectorAll('#nclexMatrix tbody tr'); rows.forEach(function(row){ var correct=row.getAttribute('data-correct'); row.querySelectorAll('td.opt').forEach(function(td){ td.style.background=''; var input=td.querySelector('input'); if(input.checked && td.getAttribute('data-val')!==correct){td.style.background='#fdecea';} if(td.getAttribute('data-val')===correct){td.style.background='#e6f4ea';} }); }); document.getElementById('nclexResult').style.display='block'; });})();[/tcb-script]

Walk through the reasoning

Crackles, rapid weight gain, and shortness of breath lying flat (orthopnea) all fit the pattern of fluid backing up — expected in worsening heart failure.
Elevated blood pressure commonly accompanies fluid overload — expected.
Warm, dry skin with strong pulses suggests good perfusion and no overload — it doesn't fit the picture, so it's unexpected.

Tip: Take one row at a time. Ask "does this finding fit the condition — yes or no?" Don't overthink the whole grid at once; a matrix is just several small yes/no decisions stacked together.

Trend Questions

What is a Trend item?

Information is shown over time — vitals or labs across several hours or days.
Your job is to decide whether the patient is improving, staying the same, or worsening, and what to do about it.
The single most recent number matters less than the direction it's moving.

This item type tests Recognize/Analyze Cues and Evaluate Outcomes.

Example (you are able to click on this it's interactive)

Stand-alone Item • Trend A post-op patient's vital signs are recorded over three checks. Review the trend, then select the best interpretation and action.

Time	BP	HR	O₂ sat
0800	118/74	82	97%
1000	104/66	98	94%
1200	88/54	122	90%

The patient is most likely: Improving — continue routine monitoring Worsening (possible hemorrhage/shock) — assess for bleeding, keep flat, notify provider Stable — no action needed Fluid overloaded — administer a diuretic Submit Rationale
No single reading is critical, but the direction is: BP falling, HR rising, O₂ dropping across all three checks — a classic pattern of early shock (possible post-op hemorrhage). A trend heading the wrong way is a cue to act and escalate before values become critical. [tcb-script](function(){ document.getElementById('trSubmit').addEventListener('click',function(){ document.querySelectorAll('#trQ .tro').forEach(function(l){ var correct=l.getAttribute('data-c')==='1'; var picked=l.querySelector('input').checked; l.style.background='';l.style.borderColor='#d3dce4'; if(correct){l.style.background='#e6f4ea';l.style.borderColor='#1e7e34';} if(picked&&!correct){l.style.background='#fdecea';l.style.borderColor='#c0392b';} }); document.getElementById('trResult').style.display='block'; });})();[/tcb-script]

Question: Based on the trend, what is the patient most likely experiencing, and what should the nurse do?

Answer: The patient is worsening — falling blood pressure, rising heart rate, and dropping oxygen point to developing shock (possible post-op hemorrhage). The nurse should act and escalate: assess for bleeding, keep the patient flat, and notify the provider immediately.

Walk through the reasoning

No single row screams "emergency," but the direction does: BP down, HR up, O₂ down across all three checks.
That pattern is classic early shock — the body compensating for lost volume.
A trend that's heading the wrong way is a cue to intervene before the numbers become critical.

Tip: Read columns top-to-bottom and draw an arrow — up, down, or flat. Then ask "is this direction good or bad for the patient?" Trends reward you for catching deterioration early.

Bow-Tie Questions

What is a Bow-Tie item?

The bow-tie is the "capstone" question — it makes you show the whole clinical judgment arc in one item. It has three parts shaped like a bow-tie:

Left wing – Actions to take (what the nurse should do)
Center – The condition/problem (what the patient is experiencing)
Right wing – Parameters to monitor (what the nurse should watch to evaluate)

You drag the correct options into each spot. To answer it, you reason: condition → actions → what to monitor. Start in the center (identify the problem), then fill the wings.

Example (you are able to click on this it's interactive)

Stand-alone Item • Bow-Tie A patient with diabetes is found drowsy and confused. Blood glucose is 44 mg/dL, skin is cool and diaphoretic, and the patient is shaky. Choose the condition, then the actions and parameters. Actions to take (choose 2) Give 15 g fast-acting oral carbohydrate Recheck blood glucose in 15 minutes Administer scheduled insulin Restrict oral fluids Condition (choose 1) Hypoglycemia Hyperglycemia Diabetic ketoacidosis Parameters to monitor (choose 2) Blood glucose level Level of consciousness Daily weight Urine ketones Submit Rationale
Solve the center first: glucose 44 with confusion, shakiness, and diaphoresis is hypoglycemia. Treat it (fast carbohydrate) and recheck in 15 minutes — giving insulin would be dangerous. Monitor glucose and level of consciousness to see if it worked; daily weight and urine ketones don't fit this acute event. [tcb-script](function(){ document.getElementById('btSubmit').addEventListener('click',function(){ document.querySelectorAll('.bt').forEach(function(l){ var correct=l.getAttribute('data-c')==='1'; var picked=l.querySelector('input').checked; l.style.background='';l.style.borderColor='#d3dce4'; if(correct){l.style.background='#e6f4ea';l.style.borderColor='#1e7e34';} if(picked&&!correct){l.style.background='#fdecea';l.style.borderColor='#c0392b';} }); document.getElementById('btResult').style.display='block'; });})();[/tcb-script]

Question: Complete the bow-tie.

Center – Condition: Hypoglycemia

Left wing – Actions to take (choose 2): Give 15 g of fast-acting oral carbohydrate Recheck blood glucose in 15 minutes Administer the patient's scheduled insulin (would worsen it)

Right wing – Parameters to monitor (choose 2): Blood glucose level Level of consciousness Daily weight (not relevant to this acute problem)

Walk through the reasoning

Center first: glucose 44 with confusion, shakiness, and diaphoresis is textbook hypoglycemia — name the problem before anything else.
Actions: treat the low glucose (fast carbohydrate) and re-check in 15 minutes. Giving insulin would be dangerous — recognizing a wrong option is part of the skill.
Monitor: watch the things that tell you if the treatment worked — glucose and level of consciousness. Daily weight has nothing to do with this acute event.

Tip: Solve the center first — everything else flows from the correct condition. Then match actions and monitoring parameters to that condition. If you pick the wrong center, the whole bow-tie falls apart, so anchor there.

Practice Case Studies

How to use these: A full case study links all six skills around one patient. Walk through the whole cycle so you see how each item type connects.

Example (you are able to click on this it's interactive)

Unfolding case: Sepsis

Unfolding Case Study • Sepsis A 68-year-old is admitted with a urinary tract infection and presents with mild confusion that is new for this patient.

Temp	HR	BP	RR	O₂
38.9°C	108	106/64	22	95%

Step 1 • Recognize Cues (Highlight) Which findings are concerning? Reveal answer Fever 38.9°C, HR 108, RR 22, and new confusion. → Early signs of infection turning systemic. Step 2 • Analyze Cues (Matrix) Do these findings fit sepsis? Reveal answer Fever, tachycardia, tachypnea, and new confusion all cluster into early sepsis — the pattern, not any single number. Step 3 • Prioritize Hypotheses Most likely and most urgent? Reveal answer Sepsis (over simple UTI) — it threatens perfusion and can deteriorate fast. Step 4 • Generate Solutions (Drop-down) What is the expected outcome and plan? Reveal answer Expected outcome: BP and mental status stable, no progression to septic shock. Interventions: obtain cultures, give ordered IV fluids and antibiotics, monitor closely. Step 5 • Take Actions (Multiple-response) What are the priority actions? Reveal answer Start IV fluids per order, administer antibiotics promptly, notify the provider, and recheck vitals frequently. Not: wait and reassess in 4 hours. Step 6 • Evaluate Outcomes (Trend/Matrix) Two hours later: BP 118/70, HR 88, confusion clearing. What does this mean? Reveal answer Improving — outcomes being met. Continue monitoring. If instead BP had fallen and HR risen, that would be worsening → escalate. [tcb-script](function(){ document.querySelectorAll('#caseSteps .rv').forEach(function(b){ b.addEventListener('click',function(){ var a=b.parentNode.querySelector('.ans'); if(a.style.display==='none'){a.style.display='block';b.textContent='Hide answer';} else{a.style.display='none';b.textContent='Reveal answer';} }); });})();[/tcb-script]

Setup: A 68-year-old is admitted with a urinary tract infection. Temp 38.9°C, HR 108, BP 106/64, RR 22, O₂ 95%, mild confusion (new for this patient).

1. Recognize Cues (Highlight): Which findings are concerning? Fever 38.9°C, HR 108, RR 22, new confusion. → Early signs of infection turning systemic.

2. Analyze Cues (Matrix): Do these findings fit sepsis? Fever, tachycardia, tachypnea, and new confusion all cluster into early sepsis — the pattern, not any single number.

3. Prioritize Hypotheses: Most likely and most urgent? → Sepsis (over simple UTI) because it threatens perfusion and can deteriorate fast.

4. Generate Solutions (Drop-down): Expected outcome: "BP and mental status stable, no progression to septic shock." Interventions: obtain cultures, give ordered IV fluids and antibiotics, monitor closely.

5. Take Actions (Multiple-response): Priority actions: start IV fluids per order, administer antibiotics promptly, notify the provider, recheck vitals frequently. (Not: wait and reassess in 4 hours.)

6. Evaluate Outcomes (Trend/Matrix): Two hours later — BP 118/70, HR 88, confusion clearing. → Improving; outcomes being met. Continue monitoring. If instead BP had fallen and HR risen, that's worsening → escalate.

Tip: Move through the six boxes in order and name the item type at each step. The lesson you should take away: the six skills are one connected loop — cues lead to analysis, analysis to priorities, priorities to a plan, the plan to action, and action back to evaluation, which either closes the loop or restarts it.

Feel Ready? Go to the NCLEX Simulator

References

ATI Nursing Education. (2023). What are the NCSBN's 6 functions of clinical judgment?https://www.atitesting.com/educator/blog/knowledge/2023/10/01/6-functions-next-gen-nclex

National Council of State Boards of Nursing. (n.d.). Clinical Judgment Measurement Model.https://www.nclex.com/clinical-judgment-measurement-model.page

National Council of State Boards of Nursing. (2023). Next Generation NCLEX (NGN) test plan and sample item types.https://www.ncsbn.org/

Nurse Plus. (n.d.). NCLEX-NGN stand-alone test items (bow-tie and trend).https://nurse.plus/become-a-nurse/ngn-stand-alone-items/

NGN Case Study Practice

You must be logged in to access this course

Welcome & Getting Started

Launch RN Simulator

Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review