Next Gen NCLEX Case Studies
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How a case study is marked
A case study gives you a client and then asks several questions about that same client, with new chart data appearing as you go. The questions are scored individually, so a wrong answer early does not sink the rest — but it does mean you must re-read the exhibit for each item instead of carrying forward the picture you formed at the start.
Work the chart before the options. Note what is abnormal, what changed, and what is missing; most case-study items turn on one value in one tab.
Worsening Heart Failure
A 72-year-old client with a history of chronic heart failure presents to the emergency department reporting increasing breathlessness over the last three days. The client says they now need three pillows to sleep and wake at night short of breath. They report taking their furosemide ‘most days’ and admit to eating tinned soup and cured meats over the weekend.
Client Chart
Based on the client information provided, which findings indicate worsening fluid overload? Select all that apply.
- AWeight increase of 2.4 kilograms in three days
- BNew bibasilar crackles
- COxygen saturation fallen from 96 to 91 percent
- DSerum sodium of 138 mEq/L
- EReports needing three pillows to sleep instead of one
Show answer and rationale
Correct answers: A. Weight increase of 2.4 kilograms in three days; B. New bibasilar crackles; C. Oxygen saturation fallen from 96 to 91 percent; E. Reports needing three pillows to sleep instead of one
Rapid weight gain, new crackles, falling oxygen saturation and increasing orthopnoea all point to accumulating pulmonary congestion from left-sided heart failure.
Why the other options are wrong
- D. A sodium of 138 is within the normal range and does not indicate worsening overload.
Based on the client information provided, which prescribed intervention should the nurse question?
Show answer and rationale
Correct answer: B. Intravenous normal saline at 125 millilitres per hour
A maintenance infusion of isotonic fluid at 125 millilitres per hour adds roughly 3 litres a day to a client who is already fluid overloaded. This order is clarified with the provider before it is started.
Why the other options are wrong
- A. A loop diuretic is the expected treatment for acute fluid overload.
- C. Daily weights are essential to track the response to diuresis.
- D. Supplemental oxygen is appropriate for a saturation of 91 percent with dyspnoea.
Based on the client information provided, which finding after 12 hours of treatment indicates the plan of care is working?
Show answer and rationale
Correct answer: A. Urine output of 1,400 millilitres with a weight loss of 1.3 kilograms and clearer lung sounds
Diuresis with corresponding weight loss and improving lung sounds shows the excess fluid is being removed and pulmonary congestion is resolving. This is exactly the intended outcome.
Why the other options are wrong
- B. A potassium of 2.9 is a complication of loop diuretic therapy requiring replacement, not evidence of success.
- C. A rising heart rate suggests deterioration or over-diuresis.
- D. Increasing orthopnoea means congestion is worsening.
Day One After Bowel Resection
A 58-year-old client is one day after an open bowel resection. Overnight the client received two doses of intravenous opioid analgesia. The nurse assesses the client at the start of the day shift.
Client Chart
Based on the client information provided, which findings require immediate nursing intervention? Select all that apply.
- AUrine output of 15 millilitres per hour for the last two hours
- BOxygen saturation of 89 percent on room air
- CIncisional pain rated 6 out of 10
- DHeart rate of 118 beats per minute
- ETemperature of 37.4 degrees Celsius
Show answer and rationale
Correct answers: A. Urine output of 15 millilitres per hour for the last two hours; B. Oxygen saturation of 89 percent on room air; D. Heart rate of 118 beats per minute
Urine output well below 30 millilitres per hour signals inadequate perfusion. A saturation of 89 percent is hypoxaemia. Tachycardia at 118 supports developing hypovolaemia or hypoxia. All three need action now.
Why the other options are wrong
- C. Pain rated 6 out of 10 the day after surgery needs treatment but is not the immediate physiological threat.
- E. A temperature of 37.4 degrees Celsius is essentially normal.
Based on the client information provided, which nursing action should be taken first?
Show answer and rationale
Correct answer: A. Apply supplemental oxygen and reposition the client upright
Oxygenation is the most immediate threat. Supplemental oxygen and an upright position improve gas exchange within moments and require no order under most standing protocols.
Why the other options are wrong
- B. Analgesia is needed but does not address the hypoxaemia.
- C. A catheter measures output but does not treat the cause of the low output.
- D. Laboratory studies inform later decisions and do not correct the immediate problem.
Based on the client information provided, which prescription should the nurse anticipate?
Show answer and rationale
Correct answer: A. An intravenous fluid bolus of isotonic crystalloid
Low urine output with tachycardia after surgery most often reflects hypovolaemia from blood and third-space losses. An isotonic fluid bolus restores intravascular volume and renal perfusion.
Why the other options are wrong
- B. A diuretic in a hypovolaemic client makes the volume deficit worse and can precipitate acute kidney injury.
- C. Fluid restriction is for overload, which is the opposite of this picture.
- D. Lowering blood pressure further in a client compensating for hypovolaemia is dangerous.
Young Adult With Hyperglycaemia
A 19-year-old client with type 1 diabetes is brought to the emergency department by a friend. The client has had a vomiting illness for two days, has not eaten, and stopped taking insulin because they ‘were not eating anything anyway’. The client is drowsy but rousable and reports intense thirst.
Client Chart
Based on the client information provided, which findings support a diagnosis of diabetic ketoacidosis? Select all that apply.
- ABlood glucose of 486 mg/dL
- BDeep rapid respirations
- CArterial pH of 7.18
- DBlood pressure of 148/92 mmHg
- EFruity odour on the breath
Show answer and rationale
Correct answers: A. Blood glucose of 486 mg/dL; B. Deep rapid respirations; C. Arterial pH of 7.18; E. Fruity odour on the breath
Marked hyperglycaemia, Kussmaul respirations compensating for acidosis, a low arterial pH and the fruity acetone odour of ketones together define diabetic ketoacidosis.
Why the other options are wrong
- D. Clients in ketoacidosis are volume depleted and typically hypotensive or normotensive with tachycardia, not hypertensive.
Based on the client information provided, which intervention should the nurse expect to initiate first?
Show answer and rationale
Correct answer: A. Intravenous isotonic fluid replacement
Clients in ketoacidosis are profoundly dehydrated from osmotic diuresis. Isotonic fluid restores intravascular volume and renal perfusion, and begins lowering glucose by dilution and improved excretion, before or alongside the insulin infusion.
Why the other options are wrong
- B. Long-acting subcutaneous insulin acts too slowly and unpredictably in a dehydrated client; regular insulin by infusion is used.
- C. Oral agents have no role in acute ketoacidosis.
- D. Bicarbonate is reserved for severe acidosis and can worsen potassium shifts and cerebral oedema.
Based on the client information provided, which laboratory value should the nurse monitor most closely once the insulin infusion begins?
Show answer and rationale
Correct answer: B. Serum potassium
Insulin drives potassium into cells along with glucose. Even a client whose initial potassium is normal or high will fall rapidly once the infusion starts, and untreated hypokalaemia causes lethal dysrhythmias.
Why the other options are wrong
- A. Calcium is not significantly affected by insulin therapy.
- C. Albumin reflects nutritional and hepatic status over weeks.
- D. Magnesium is monitored but is not the primary concern during insulin infusion.
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