Practice NCLEX Next Generation clinical judgment — select actions, condition, and parameters for each scenario.
A 72-year-old male is brought by ambulance after sudden onset of right-sided weakness and facial droop with slurred speech. Vital signs: BP 188/102 mmHg, HR 88 bpm, O₂ saturation 94% on room air. Last known well was 90 minutes ago. CT head is pending. He has no known drug allergies and his past medical history includes hypertension and atrial fibrillation.
A 68-year-old female with a known history of heart failure presents with a 3-day history of worsening shortness of breath. Assessment reveals bilateral crackles to the mid-lungs, 3+ pitting edema in bilateral lower extremities, and a weight gain of 4 kg over 3 days. Vital signs: BP 158/96 mmHg, HR 102 bpm, O₂ saturation 89% on room air. She is sitting upright and appears anxious.
A 24-year-old male with type 1 diabetes presents with nausea, vomiting, abdominal pain, and confusion for 12 hours. He reports running out of insulin 2 days ago. Vital signs: T 37.8°C, HR 124 bpm, RR 28 and deep, BP 94/60 mmHg, O₂ saturation 97%. Laboratory results: blood glucose 520 mg/dL, arterial pH 7.18, serum bicarbonate 10 mEq/L, serum potassium 5.8 mEq/L, urine and serum ketones positive.
A 58-year-old female is on post-operative day 2 following a bowel resection. The nurse notes she is increasingly confused. Vital signs: HR 118 bpm, RR 24 breaths/min, T 39.2°C, BP 88/54 mmHg, O₂ saturation 92% on 2 L/min nasal cannula. WBC 18,000 cells/µL. Inspection of the surgical wound reveals purulent drainage at the incision site.
A 45-year-old female on post-operative day 3 after a total hip arthroplasty suddenly reports severe shortness of breath and right-sided pleuritic chest pain. She is diaphoretic and anxious. Vital signs: HR 128 bpm, RR 28 breaths/min, BP 96/62 mmHg, O₂ saturation 87% on room air, T 37.1°C. She has not been ambulating and declined sequential compression devices earlier that morning.
A 32-year-old male with a documented penicillin allergy was mistakenly administered amoxicillin 500 mg PO 15 minutes ago. He now presents with diffuse urticaria, lip swelling, stridor, and reports throat tightness. Vital signs: HR 136 bpm, RR 30 breaths/min, BP 78/44 mmHg, O₂ saturation 90% on room air. He is in visible respiratory distress.
A 67-year-old male with type 2 diabetes and hypertension was admitted 48 hours ago for a urinary tract infection and started on IV gentamicin. Today the nurse notes that urine output over the last 8 hours is 80 mL. Serum creatinine has risen from 1.1 mg/dL on admission to 3.4 mg/dL today. Potassium is 5.9 mEq/L. The patient reports nausea and decreased appetite. BP 162/94 mmHg.
A 55-year-old male with poorly controlled hypertension presents to the emergency department with a severe occipital headache, blurred vision, and confusion. He ran out of his antihypertensive medications 5 days ago. Vital signs: BP 218/136 mmHg, HR 96 bpm, RR 18 breaths/min, O₂ saturation 97% on room air, T 37.0°C. Fundoscopic exam reveals papilledema. Neurologic assessment shows new-onset expressive aphasia.
A 49-year-old male was admitted 36 hours ago with severe community-acquired pneumonia. Despite supplemental oxygen at 15 L/min via non-rebreather mask, his O₂ saturation remains 84%. Chest X-ray shows bilateral diffuse infiltrates. ABG results: PaO₂ 52 mmHg, FiO₂ 1.0, PaO₂/FiO₂ ratio 52, pH 7.28, PaCO₂ 52 mmHg. He is increasingly somnolent and using accessory muscles.
A 28-year-old male is in the neuro ICU following a traumatic brain injury sustained in a motor vehicle collision 18 hours ago. His ICP monitor reads 28 mmHg (normal < 20 mmHg). The nurse notes a widening pulse pressure: BP has changed from 122/80 to 168/54 mmHg over the last 30 minutes. Heart rate has slowed from 88 to 52 bpm. He is unresponsive to verbal stimuli and his pupils are unequal — left pupil 6 mm and non-reactive.
A 29-year-old G2P2 female delivered vaginally 30 minutes ago after a prolonged labor augmented with oxytocin. The nurse notes the uterine fundus is boggy, displaced to the right, and above the umbilicus. Estimated blood loss so far is 600 mL and continues. Vital signs: BP 88/56 mmHg, HR 122 bpm, RR 22 breaths/min, O₂ saturation 96% on room air. The bladder is visibly distended.
A 71-year-old female with type 2 diabetes managed with insulin glargine and glipizide is found unresponsive by the nurse during morning rounds. Her roommate reports she refused her breakfast tray. Point-of-care blood glucose reads 32 mg/dL. She does not respond to sternal rub. IV access is in place. Vital signs: HR 108 bpm, BP 138/84 mmHg, RR 14 breaths/min, O₂ saturation 97% on room air.
A 61-year-old male presents to the emergency department with crushing substernal chest pain radiating to his left jaw and arm, onset 45 minutes ago. He is diaphoretic and nauseated. Vital signs: BP 102/68 mmHg, HR 54 bpm, RR 20 breaths/min, O₂ saturation 93% on room air. 12-lead ECG shows 3 mm ST elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. He has no known drug allergies.
A 19-year-old female with a history of moderate persistent asthma presents to urgent care after using her rescue inhaler six times in the past 4 hours without relief. She can only speak in 2–3 word sentences. Accessory muscle use is prominent, with audible expiratory wheeze. Vital signs: HR 118 bpm, RR 32 breaths/min, BP 128/76 mmHg, O₂ saturation 88% on room air, peak expiratory flow 35% of her personal best.
A 70-year-old male with GOLD Stage III COPD presents with a 3-day history of increased dyspnea, productive cough with green sputum, and decreased exercise tolerance. He is a 50-pack-year smoker. Vital signs: HR 104 bpm, RR 26 breaths/min, BP 144/88 mmHg, O₂ saturation 82% on room air. ABG: pH 7.32, PaCO₂ 58 mmHg, PaO₂ 46 mmHg. Chest auscultation reveals prolonged expiration and diffuse expiratory wheeze.
A 23-year-old male is in the trauma bay following a high-speed motor vehicle collision with suspected blunt chest trauma. He was intubated in the field. The ventilator alarms are indicating high peak airway pressures. His neck veins are distended and the trachea is deviated to the right. Vital signs: HR 138 bpm, BP 74/40 mmHg, O₂ saturation 78%, with absent breath sounds over the left lung field.
A 57-year-old male with a history of peptic ulcer disease and daily NSAID use presents with two episodes of hematemesis (bright red blood) and melena for 12 hours. He feels lightheaded when standing. Vital signs supine: BP 104/68 mmHg, HR 112 bpm; sitting: BP 88/56 mmHg, HR 128 bpm. O₂ saturation 96% on room air. Hemoglobin 7.2 g/dL. He has no IV access.
A 52-year-old male with known cirrhosis secondary to chronic alcohol use is brought in by his wife for increasing confusion and inappropriate behavior over 3 days. She reports he has not been taking his lactulose. Physical examination reveals asterixis, jaundice, and a distended abdomen with a fluid wave. Vital signs: T 37.6°C, HR 98 bpm, BP 108/64 mmHg, O₂ saturation 95%. Serum ammonia is 142 µmol/L.
A 34-year-old male is found unresponsive by a bystander in a public restroom. He is brought by EMS with pinpoint pupils bilaterally, shallow respirations, and cyanotic lips. A used syringe is found nearby. Vital signs: RR 4 breaths/min, HR 56 bpm, BP 88/50 mmHg, O₂ saturation unable to obtain accurately, GCS 4 (E1V1M2). He has no known medical history on file.
A 64-year-old male with end-stage renal disease on hemodialysis missed his last two dialysis sessions. He presents with generalized muscle weakness and palpitations. Vital signs: HR 44 bpm (irregular), BP 156/92 mmHg, RR 18 breaths/min, O₂ saturation 97%. 12-lead ECG shows absent P waves, widened QRS complexes (0.18 seconds), and peaked T waves. Serum potassium is 7.2 mEq/L.
A 78-year-old female residing in an assisted living facility presents with a 4-day history of productive cough with rust-colored sputum, fever, and increasing confusion. Her caregiver notes she has not eaten in 2 days. Vital signs: T 39.4°C, HR 106 bpm, RR 24 breaths/min, BP 102/64 mmHg, O₂ saturation 88% on room air. Chest auscultation reveals dullness to percussion and bronchial breath sounds over the right lower lobe.
A 38-year-old female with known Graves' disease presents to the ED after stopping her propylthiouracil 2 weeks ago. She is agitated, tremulous, and complains of palpitations. Her skin is flushed and diaphoretic. Vital signs: T 40.2°C, HR 158 bpm (irregular), RR 28 breaths/min, BP 168/88 mmHg. She experienced a seizure en route and has vomited twice. TSH is undetectable; free T4 is critically elevated.
A 44-year-old female with a known history of primary adrenal insufficiency (Addison's disease) is brought to the ED by her husband after a week of progressive nausea, vomiting, diarrhea, and weakness. She ran out of her hydrocortisone 4 days ago. Vital signs: T 38.2°C, HR 128 bpm, BP 72/44 mmHg, RR 22 breaths/min, O₂ saturation 97%. Sodium 124 mEq/L, potassium 6.1 mEq/L, glucose 52 mg/dL.
A 21-year-old male college student is brought to the ED with a 12-hour history of severe headache, high fever, photophobia, and neck stiffness. His roommate reports he is becoming increasingly confused. Vital signs: T 39.8°C, HR 118 bpm, BP 102/66 mmHg, RR 20 breaths/min, O₂ saturation 97%. Examination reveals a non-blanching petechial rash on his trunk and lower extremities. Kernig's and Brudzinski's signs are positive.
A 48-year-old male with chronic alcohol use disorder was admitted 3 days ago for pneumonia. He reports his last drink was the morning of admission. The nurse notes he is now profusely diaphoretic, agitated, and grabbing at things that are not there. Vital signs: T 38.8°C, HR 138 bpm, BP 172/104 mmHg, RR 24 breaths/min, O₂ saturation 96%. CIWA-Ar score is 28. He has one peripheral IV.
A 42-year-old male with a history of heavy alcohol use presents with severe epigastric pain radiating to his back, onset 6 hours ago. He rates the pain 9/10 and reports nausea and two vomiting episodes. Vital signs: T 38.4°C, HR 112 bpm, BP 96/60 mmHg, RR 20 breaths/min, O₂ saturation 95% on room air. Serum lipase is 1,840 U/L (normal < 60 U/L). Hematocrit is 52% (hemoconcentration). He has no IV access.
A 54-year-old female is receiving her second unit of packed red blood cells for post-operative anemia following a hysterectomy. Approximately 50 mL into the transfusion, she complains of severe lower back pain, chills, and a feeling of "doom." The nurse notes her skin is flushed and she has a new fever. Vital signs (pre-transfusion): T 37.1°C, HR 82, BP 126/78. Current: T 39.0°C, HR 112 bpm, BP 88/54 mmHg, O₂ saturation 94%.
A 26-year-old primigravida at 34 weeks gestation presents with a persistent headache, visual disturbances ("floaters"), and epigastric pain for 6 hours. She reports a 4 kg weight gain in the past week. Vital signs: BP 166/112 mmHg (confirmed on repeat), HR 96 bpm, RR 18 breaths/min, O₂ saturation 98%. Laboratory results: platelet count 88,000/µL, AST 98 U/L, ALT 104 U/L, creatinine 1.4 mg/dL, urine protein 4+ on dipstick.
A 22-year-old male with sickle cell disease (HbSS) presents to the ED with severe bilateral leg and back pain, rated 10/10, that began 24 hours ago. He recently ran a 5K race in hot weather. Vital signs: T 38.2°C, HR 108 bpm, BP 128/78 mmHg, RR 20 breaths/min, O₂ saturation 92% on room air. Hemoglobin is 6.8 g/dL (baseline 7.5 g/dL). He reports his pain is not controlled by his home ibuprofen.
A 67-year-old female with a history of two prior abdominal surgeries presents with a 48-hour history of crampy abdominal pain, nausea, bilious vomiting, and no flatus or bowel movement. Her abdomen is distended with high-pitched, tinkling bowel sounds. Vital signs: T 37.9°C, HR 104 bpm, BP 108/70 mmHg, RR 18 breaths/min, O₂ saturation 97%. Abdominal X-ray shows multiple air-fluid levels. Sodium 130 mEq/L, potassium 3.0 mEq/L.
A 35-year-old male sustained burns from a house fire. EMS reports he was trapped for approximately 5 minutes. He has burns to his face, anterior chest, abdomen, and both arms — estimated 40% total body surface area (TBSA) with partial- and full-thickness involvement. His eyebrows are singed, voice is hoarse, and carbon deposits are visible around his mouth. Vital signs: HR 128 bpm, BP 116/74 mmHg, RR 28 breaths/min, O₂ saturation 90% on 15 L/min NRB mask.
A 2-year-old male is brought to the pediatric emergency department by his parents after witnessing a generalized tonic-clonic seizure lasting approximately 2 minutes that self-terminated. He has no prior seizure history. The parents report he has had a fever and runny nose for 2 days. Currently he appears drowsy but arousable (post-ictal). Vital signs: T 39.6°C (rectal), HR 148 bpm, RR 30 breaths/min, O₂ saturation 97% on room air, weight 13 kg.
A 55-year-old female with breast cancer is receiving her third cycle of doxorubicin and cyclophosphamide chemotherapy. On day 12 of her cycle she develops chills and a fever at home and presents to the oncology clinic. She reports mild shortness of breath but no obvious source of infection. Vital signs: T 38.8°C, HR 108 bpm, BP 110/70 mmHg, RR 22 breaths/min, O₂ saturation 96%. ANC (absolute neutrophil count) is 280 cells/µL.
A 31-year-old male with a T4-level complete spinal cord injury is in the rehabilitation unit. The nurse responds to his call light and finds him diaphoretic above the level of injury, with flushing and a pounding headache (8/10). His BP has acutely risen to 198/114 mmHg from his baseline of 102/64 mmHg. His foley catheter drainage bag is noted to be empty despite the last recorded output 3 hours ago.
A 45-year-old male with known epilepsy is brought by ambulance after his wife observed him seizing continuously for 8 minutes. He is still seizing on arrival — generalized tonic-clonic activity. She reports he has not taken his phenytoin in 5 days. Vital signs: HR 148 bpm, BP 162/98 mmHg, T 38.6°C, RR 10 (agonal during seizure), O₂ saturation 82% on room air. He has no IV access.
A 6-hour-old term male neonate born to a mother with gestational diabetes (GDM) is noted to be jittery and lethargic during his first newborn assessment. He had a weak suck during the initial breastfeeding attempt. A point-of-care heel-stick glucose reads 28 mg/dL. He has mild central cyanosis. Vital signs: HR 168 bpm, RR 64 breaths/min, T 36.7°C (axillary). His weight is 4.2 kg (large for gestational age).
A 71-year-old male with a 2-day history of productive cough, fever, and right-sided pleuritic chest pain was admitted 18 hours ago with community-acquired pneumonia. He was started on ceftriaxone and azithromycin IV. The nurse notes he is now more confused than on admission. Vital signs: T 39.8°C (up from 38.2°C on admission), HR 118 bpm, RR 28 breaths/min, BP 92/58 mmHg (down from 128/78 mmHg on admission), O₂ saturation 88% on 4 L/min nasal cannula. Urine output over the past 4 hours is 60 mL.