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 reviews the admission assessment for this 58-year-old patient with a 3-day history of productive cough and fever.
The nurse is reviewing Mr. Jenkins' wound assessment findings. Which findings indicate wound infection that requires intervention BEYOND topical wound care alone?
[NURSE'S NOTES] Marcus Williams is a 58-year-old male, day 10 post-chemotherapy (R-CHOP) for diffuse large B-cell lymphoma. Admitted 6 hours ago with febrile neutropenia (ANC 320/mm³, T 38.9°C). Started on piperacillin-tazobactam 4.5 g IV q6h per neutropenic fever protocol. Blood cultures drawn x2 p
Keisha Thompson is a 26-year-old G2P2 who underwent emergency C-section 3 days ago for failure to progress after 22 hours of labor. She had prolonged rupture of membranes (18 hours), multiple vaginal examinations (8 during labor), and required internal fetal monitoring. Her delivery was complicated
James Parker is a 38-year-old male with depression and chronic low back pain. He takes sertraline 150 mg daily and tramadol 50 mg four times daily. He is hospitalized for MRSA wound infection and started on linezolid 600 mg IV q12h (a monoamine oxidase inhibitor class antibiotic). Twenty-four hours
George Miller is a 78-year-old male with moderate Alzheimer's disease (MMSE 14, baseline 16) living with his wife. He is admitted for a urinary tract infection causing worsening confusion. His wife reports he has baseline sundowning — increased agitation and confusion in the late afternoon and eveni
James Thomas is a 34-year-old homeless male who presents to the free TB clinic with 3 months of productive cough (yellow sputum, occasionally blood-tinged), drenching night sweats, and 20-lb weight loss. He is HIV-positive (CD4 220, not yet on antiretroviral therapy). He has had no prior TB treatmen
Linda Morrison is a 52-year-old female discharged home after hospital management of right tibia osteomyelitis with a right arm PICC line (size: 4 French, single lumen, tip confirmed in distal SVC by CXR prior to discharge). She is receiving vancomycin 1250 mg IV q12h. She has no prior central line e
Marcus is a 71-year-old male admitted 2 days ago for a UTI. History: type 2 diabetes (A1C 9.1%), CKD stage 3 (baseline creatinine 1.6 mg/dL). Started on IV ceftriaxone. At 0615 the day nurse assesses: T 38.9°C (was 37.6°C at midnight), HR 118 bpm (was 88), BP 96/58 mmHg (was 128/76), RR 24, SpO2 93%
CASE 14 — Mrs. Dorothy Evans, 78-year-old female. PMH: COPD (GOLD Stage 2), Type 2 DM, hypertension, osteoporosis. Lives alone. Medications: tiotropium, fluticasone/salmeterol, metformin, lisinopril, alendronate. 4-day productive cough, fever 39.4C, INCREASING CONFUSION (MMSE baseline 29/30; today 2
Claudette Monroe is an 82-year-old female with T2DM (A1C 9.8%), vascular dementia (moderate), HTN, and PVD. She is mostly bedbound at a LTCF. She is transferred to the ED after 48 hours of increasing lethargy and a new Stage 4 sacral wound: 10 cm × 8 cm × 3.5 cm deep, foul odor, black eschar in cent
Baby Olivia Chen is an 18-hour-old female neonate. GBS status: POSITIVE on maternal culture at 36 weeks. IAP: penicillin G given only 2.5 hours before delivery (adequate prophylaxis requires ≥4 hours). Membranes ruptured 19 hours before delivery. Maternal fever during labor: 38.3°C. At 18 hours of l
[NURSE'S NOTES] Patient: Claudette Monroe, 82-year-old female Setting: Long-Term Care Facility → Emergency Department → Medical ICU Clinical Context: Claudette Monroe is an 82-year-old female with a history of type 2 diabetes (A1C 9.8%), vascular dementia (moderate stage), HTN, and PVD. She is a res
Mrs. Vasquez, 82-year-old female from assisted living, is brought to the ED by staff. She has new onset confusion, new urinary incontinence, T 38.4C, HR 108, BP 108/66 mmHg, RR 22. Labs: WBC 16,200, UA shows greater than 100 WBC/hpf, nitrite positive, many bacteria. Her baseline is alert and oriente
Sofia Martinez, 8-year-old female, is brought to the pediatric ED by her parents with a 12-hour history of severe headache, high fever, and neck stiffness. She has vomited three times. Parents report she has been increasingly difficult to arouse over the past 2 hours. Assessment: T 39.9C, HR 136, BP
Mr. Park, 58-year-old male with T2DM (poorly controlled, A1c 10.4%) and rheumatoid arthritis on methotrexate and prednisone 10mg daily, presents with a 5-day history of progressively worsening left knee pain, swelling, warmth, and inability to bear weight. He reports no trauma. T 38.9C, HR 108, BP 1
Ms. Obi, 42-year-old female with known myasthenia gravis (MG) on pyridostigmine and prednisone, presents to the ED after 48 hours of worsening dysphagia, dysarthria, diplopia, and progressive bilateral ptosis. She reports she started azithromycin for a respiratory infection 3 days ago. Assessment: R
Mr. Watkins, 62-year-old male with ESRD on continuous ambulatory peritoneal dialysis (CAPD) for 3 years, calls the dialysis clinic reporting his dialysate effluent has been 'cloudy' for 2 days with new onset abdominal pain and low-grade fever. He is instructed to come in immediately. Assessment: T 3
Ms. Monroe, 26F G1P0 at 20 weeks with cystitis progressing to pyelonephritis and urosepsis. Pregnancy-safe antibiotics, test-of-cure culture, sepsis recognition.
Mr. Thompson, 69M with pneumonia-source septic shock. Cultures, antibiotics, LR resuscitation, norepinephrine, post-sepsis syndrome.
Complete the Bow-Tie clinical reasoning diagram for a 3-year-old male with sudden onset high fever, neck stiffness, and rapidly spreading petechial rash. Select the condition most consistent with the presentation, TWO priority nursing actions, and TWO parameters to monitor.
An 82-year-old man has been hospitalized for 6 days with pneumonia complicated by sepsis. Despite aggressive treatment including broad-spectrum antibiotics, IV fluids, and vasopressor support in the ICU, his condition has progressively worsened. He has multi-organ dysfunction and is now on mechanical ventilation. A family meeting yesterday resulted in a decision to transition to comfort-focused care. Orders have been written for compassionate extubation and comfort measures this afternoon. The
A client with suspected active pulmonary tuberculosis is admitted and requires appropriate infection control precautions.
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