Each case presents a real patient scenario with 6–7 linked clinical-judgment questions — exactly the NCSBN April 2026 NGN format. Bow-tie, matrix, cloze, trend, and extended-response items across all 6 CJMM layers.
The nurse is assessing an 8-year-old male brought to the emergency department following allergen exposure. He has a history of moderate persistent asthma and received albuterol MDI 2 puffs at home with no relief 30 minutes before arrival. Which clinical FINDINGS from this assessment indicate an acut
The nurse is completing the initial assessment of a 78-year-old nursing home resident with a 3-day history of productive cough and fever. Which clinical FINDINGS indicate acute illness severity requiring immediate escalation of care?
The nurse assesses the 48-year-old patient who was admitted 36 hours ago for pneumonia and has a history of heavy alcohol use.
The nurse is assessing a 69-year-old male with GOLD Stage III COPD presenting with worsening dyspnea over 4 days. Which clinical findings are consistent with acute hypercapnic respiratory failure requiring immediate intervention?
The nurse is reviewing the clinical findings for this 52-year-old post-surgical patient. Which findings indicate HIGH-RISK (massive) pulmonary embolism requiring urgent intervention? Select ALL that apply. A. Systolic blood pressure 88/52 mmHg despite 2L IV fluid resuscitation B. SpO2 88% on room a
The NICU nurse completes the initial assessment of the 28-week neonate on arrival. Select ALL findings that indicate significant respiratory distress requiring immediate intervention.
The nurse is reviewing Mr. Webb's risk factors for deep vein thrombosis using Virchow's Triad as a clinical framework. Select ALL factors from the patient's history and presentation that contribute to his highest-risk DVT classification.
Robert Chen is a 52-year-old male with poorly controlled hypertension and Marfan syndrome features (tall, long limbs, high-arched palate). He presents with sudden-onset tearing chest pain radiating to his mid-back, instantly at maximum intensity 45 minutes ago. Diaphoretic and in severe distress. Vi
Jasmine Torres is a 16-year-old female with severe persistent asthma, multiple prior ICU admissions and one prior intubation. Current medications: fluticasone/salmeterol, montelukast, albuterol PRN. She triggered an attack during PE class. EMS administered three albuterol nebs with no improvement. O
Dorothy Peterson is a 71-year-old female with GOLD Stage IV COPD (FEV1 28% predicted), former 50 pack-year smoker (quit 3 years ago), who lives alone in a first-floor apartment. She has one son who lives 2 hours away. She uses a rollator walker for mobility and requires home oxygen at rest. She pres
CASE 13 — Mr. Samuel Oduya, 58-year-old male. PMH: Uncontrolled hypertension, Marfan syndrome features. Sudden onset 'worst pain of my life' — tearing, ripping quality, radiating to back between shoulder blades. BP: RIGHT arm 198/114, LEFT arm 142/88 (pulse deficit >20 mmHg). HR 108, SpO2 94% (RA),
Vanessa Torres is a 38-year-old female who presents via EMS after collapsing at work. She flew home from a 14-hour international flight 48 hours ago. She is on combined oral contraceptive pills and smokes 0.5 PPD. Arrival: BP 82/54 mmHg, HR 132, RR 28, SpO₂ 84% on room air → 91% on 15 L/min NRB, GCS
[NURSE'S NOTES] Patient: Vanessa Torres, 38-year-old female Setting: Emergency Department → Medical ICU Clinical Context: Vanessa is a 38-year-old female who presents via EMS after collapsing at work. She flew home from a 14-hour international flight 48 hours ago. She reports 3 days of progressive d
[NURSE'S NOTES] Patient: Omar Khalil, 38-year-old male Setting: Emergency Department → Medical ICU Clinical Context: Omar Khalil is a 38-year-old male who presents with a 3-week history of progressive dyspnea, nonproductive dry cough, low-grade fever, and profound fatigue. He lost 22 lb over the pas
Tyler Rodriguez, 9-year-old male with known asthma on daily inhaled corticosteroids, is brought to the ED with 2-day worsening wheeze and shortness of breath. Assessment: T 37.2C, HR 118, RR 32, SpO2 91% on room air, using accessory muscles, tripod positioning, expiratory wheezing bilateral, PEFR 45
Baby Malik is a 3-day-old male, born at 38 weeks gestation to a 26-year-old G2P2 mother with blood type O-negative. Malik is blood type A-positive. He is exclusively breastfed. The mother reports he is 'very yellow' and feeding poorly (latching but falling asleep after 2 minutes). Assessment: jaundi
Mr. Okonkwo, 41-year-old male with HIV (CD4 count 180 cells/mm3, not on ART), presents with a 6-week history of productive cough, night sweats, 15-pound weight loss, and low-grade fever. He immigrated from Nigeria 8 months ago and has been living in a homeless shelter. Assessment: T 38.2C, HR 104, R
Mr. Osei, 58M with chronic HTN, develops tearing chest pain with BP asymmetry and intimal flap on CTA. Requires IV beta-blocker, BP control, and immediate cardiothoracic surgery.
Mr. Simmons, 68M with GOLD III COPD, presents with purulent sputum, SpO2 84%, respiratory acidosis. Requires Venturi mask O2 titration, albuterol/ipratropium, corticosteroids, antibiotics.
Mr. Asante, 47M with pneumonia-ARDS P/F 72. ARDSnet LTV, PROSEVA proning, ET tube safety, PICS education.
Mr. Dawson, 68M GOLD IV COPD with RV failure. Controlled O2, careful diuresis, LTOT, O2 order clarification.
Mrs. Hendricks, 65F post-THA with proximal DVT progressing to PE. Anticoagulation escalation, IVC filter non-essential.
Mr. Walker, 66M GOLD II COPD. Tiotropium, rescue vs controller, inhaler technique correction, COPD action plan.
Mr. Harold Pierce, a 68-year-old male with a 40 pack-year smoking history and a known diagnosis of COPD (GOLD Stage III — severe), presents to the ED via ambulance after his wife called 911. She reports he has had worsening shortness of breath, increased sputum production (yellow-green, thicker than usual), and a productive cough for the past 3 days. He has been using his albuterol rescue inhaler every 2 hours without relief. He smokes 1 PPD and has not been vaccinated for influenza this season. Medications at home: tiotropium (Spiriva) inhaler daily, fluticasone/salmeterol (Advair) inhaler twice daily, albuterol (ProAir) PRN. Allergies: sulfa drugs (rash). Vital signs: BP 148/86 mmHg, HR 108 bpm, RR 28/min, Temp 38.4°C, SpO₂ 82% on room air. Auscultation: diffuse expiratory wheezing, prolonged expiratory phase, distant breath sounds bilaterally, use of accessory muscles. ABG on room air: pH 7.34, PaCO₂ 58 mmHg, PaO₂ 48 mmHg, HCO₃ 30 mEq/L. CXR: hyperinflation, flattened diaphragms, no infiltrate.
Ms. Destiny Johnson, a 24-year-old female, presents to the urgent care clinic with wheezing, chest tightness, and shortness of breath that started approximately 2 hours ago. She was at a friend's apartment where there was a cat — she has a known cat allergy. She has a history of persistent moderate asthma and uses fluticasone (Flovent) 110 mcg inhaler twice daily (maintenance) and albuterol (ProAir HFA) PRN. She has not used her fluticasone for the past week ('I ran out'). She used her albuterol 3 times in the last 2 hours with minimal relief. She has no fever. Vital signs: BP 122/78 mmHg, HR 110 bpm, RR 24/min, Temp 37.0°C, SpO₂ 93% on room air. Peak expiratory flow rate (PEFR): 55% of personal best. Auscultation: diffuse bilateral expiratory wheezing, prolonged expiratory phase. She is speaking in short phrases and appears anxious.
Baby girl Monroe, a 36-hour-old female neonate born at 38 weeks gestation via uncomplicated vaginal delivery to a 28-year-old G1P1 mother (blood type O positive). Baby's blood type: A positive. APGAR scores: 8 at 1 minute, 9 at 5 minutes. Birth weight: 3,320 g (7 lb 5 oz). She has been breastfeeding, though the mother reports the baby is 'sleepy and hard to wake up for feeds' — she has fed only 3 times in 24 hours. At 36 hours of age, the nurse observes yellow discoloration of the sclera and skin (jaundice to the chest level). Vital signs: HR 148 bpm, RR 44/min, Temp 37.0°C axillary, SpO₂ 98%. Total serum bilirubin (TSB) level: 13.2 mg/dL at 36 hours of age. The Bhutani nomogram plots this in the HIGH-RISK zone for her gestational age and age in hours. Transcutaneous bilirubin check before the blood draw was 12.8 mg/dL.
It is 7:30 AM on a busy 28-bed medical-surgical unit. The charge nurse (RN, 5 years experience) is managing the unit for the day shift. The staffing for the day is: 4 RNs (each caring for 6 patients), 1 licensed practical nurse (LPN/LVN), and 2 unlicensed assistive personnel (UAPs/CNAs). The unit has the following patient situations arising simultaneously at the beginning of the shift: (1) Room 101 — Mr. Adams, 72-year-old post-op day 1 after bowel resection, calling light on, reports his pain is 8/10 and he feels nauseated. (2) Room 108 — Ms. Bell, 58-year-old with pneumonia, SpO₂ has dropped from 95% to 88% on 2L NC per the oncoming nurse's report. (3) Room 115 — Mrs. Chen, 84-year-old with dementia, standing at the side of her bed trying to climb over the rail — fall risk. (4) Room 122 — Mr. Davis, 45-year-old stable with controlled hypertension, requesting his morning bath.
Complete the Bow-Tie clinical reasoning diagram for a 7-year-old female with status asthmaticus. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 52-year-old female with myasthenia gravis in crisis. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 52-year-old male admitted with pneumonia who develops acute agitation, visual hallucinations, autonomic hyperactivity, and fever on hospital day 3 with a history of chronic heavy alcohol use. Select the condition most consistent with the presentation, the most appropriate priority nursing action, and THREE parameters to monitor.
Complete the Bow-Tie clinical reasoning diagram for a 62-year-old male with COPD and spontaneous secondary pneumothorax. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
A 67-year-old woman is admitted to the medical unit with pneumonia. She is alert, oriented to person, place, time, and situation, and speaks English fluently. Her vital signs are: BP 132/78, HR 94, RR 22, T 38.6°C, SpO2 93% on 2L nasal cannula. The provider has ordered a peripherally inserted central catheter (PICC line) for administration of a two-week course of IV antibiotics after discharge to a skilled nursing facility. The IR (interventional radiology) department has sent up the informed c
A 68-year-old man with known severe COPD (FEV1 38% predicted on last pulmonary function testing) presents to the emergency department at 1930 via EMS. His wife reports he has had 'a cold' for the past 4 days with increasing cough, change in sputum from white to yellow-green, and steadily worsening shortness of breath. Today he became unable to complete sentences, appeared confused, and she called 911. Past medical history: severe COPD, former smoker (quit 5 years ago after 50 pack-year history)
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