Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items (2022)

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items (2022) provides everything you need to pass your certification test.

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Linda Anne Silvestri, PhD, RN, FAAN
Nursing Instructor
University of Nevada, Las Vegas
Las Vegas, Nevada;
President
Nursing Reviews, Inc. and Professional Nursing Seminars, Inc.
Henderson, Nevada;
Next Generation NCLEX® (NGN) Consultant and Subject Matter Expert
Elsevier Inc.
Angela Elizabeth Silvestri, PhD, APRN, FNP-BC, CNE
Associate Professor and BSN Program Director
University of Nevada, Las Vegas
Las Vegas, Nevada;
President
Nurse Prep, LLC
Henderson, Nevada;
Next Generation NCLEX® (NGN) Subject Matter Expert
Elsevier Inc.
Donna D. Ignatavicius, MS, RN, CNE, CNEcl, ANEF, FAADN
Speaker and Curriculum Consultant for Academic Nursing Programs
Founder
Boot Camp for Nurse Educators;
President
DI Associates, Inc.
Littleton, Colorado;
Next Generation NCLEX® (NGN) Consultant and Subject Matter Expert
Elsevier Inc.
Strategies for Student Success on the
NEXT GENERATION
NCLEX® (NGN)TEST ITEMS

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Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
STRATEGIES FOR STUDENT SUCCESS ON THE NEXT GENERATION
NCLEX® (NGN) TEST ITEMS ISBN: 978-0-323-87229-4
Copyright © 2023 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
International Standard Book Number: 978-0-323-87229-4
Content Strategist: Heather D. Bays-Petrovic
Content Development Manager: Ellen M. Wurm-Cutter
Content Development Specialist: Laura Klein; Meredith Madeira
Publishing Services Manager: Julie Eddy
Senior Project Manager: Jodi Willard
Design Direction: Amy Buxton
Printed in India
Last digit is the print number: 9 8 7 6 5 4 3 2 1

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In loving memory of my parents and Angela’s grandparents,
Arnold Lawrence and Frances Mary, who opened my door of opportunity
to this amazing profession of nursing. My memories of their love, support,
and words of encouragement will remain in my heart forever!
And, to my husband, Larry, for being my rock of support
through all of my life’s journeys.
Linda Anne Silvestri
To my husband, Brent, who has supported my work since the day we met.
I will always remember how he anticipated what I would need
to be successful in this journey.
To nursing students, you have chosen a wonderful profession that will
give back to you what you are putting in now. You can do this!
Angela Elizabeth Silvestri
To my family, who has supported my work as an author and consultant
for many decades.
To nursing students, who have chosen the caring profession that can
change the lives of so many, and to nurse educators, whose passion and
role modeling continues to shape the future of the nursing profession.
Donna D. Ignatavicius

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vi
Linda Anne Silvestri,
PhD, RN, FAAN
Linda is a well-known nurse
educator, entrepreneur, and
philanthropist whose profes-
sional aspirations focus on
assisting nursing students to
become successful. She has
been teaching nursing stu-
dents at all levels of nursing education for many years.
Dr. Silvestri is currently a nursing instructor at the Uni-
versity of Nevada, Las Vegas (UNLV). She earned her
PhD in Nursing from UNLV and conducted research on
self-ecacy and the predictors of NCLEX® success. Her
research ndings are published in the Journal of Nursing
Education and Practice. Dr. Silvestri has received several
awards and honors. In 2019 she was inducted as a Fellow
in the American Academy of Nursing. In 2012 she received
the UNLV School of Nursing Alumna of the Year Award.
In 2010 she received the School of Nursing Certicate of
Recognition for the Outstanding PhD Student. Dr. Silves-
tri is a member of several national nursing organizations,
some of which include the Honor Society of Nursing, Sigma
eta Tau International, the National League for Nursing,
the American Nurses Association, and the American Acad-
emy of Nursing. Dr. Silvestri is a successful Elsevier author
of numerous best-selling NCLEX® preparation resources
on national and international levels. She also serves as an
Elsevier Consultant and Subject Matter Expert for the Next
Generation NCLEX® (NGN) and has presented numerous
webinars on NCLEX® preparation and success. Dr. Silvestri
is the President and Owner of Nursing Reviews, Inc. and
Professional Nursing Seminars, Inc. Both companies are
dedicated to helping nursing graduates achieve their goals
of becoming licensed nurses.
Angela E. Silvestri,
PhD, APRN, FNP-BC, CNE
Angela Silvestri is a well-known
nurse educator, researcher, and
author. She has been teaching and
working in university administra-
tive roles for the last 10 years at all
levels of nursing education. She
has experience teaching across the
program and in both classroom
and clinical settings and working
with graduate students on their
culminating projects and research dissertations. She is cur-
rently serving in a leadership role as the Program Director for
the undergraduate BSN program at the University of Nevada,
Las Vegas (UNLV). Angela earned a bachelor’s in Nursing
and in Sociology from Salve Regina University in Newport,
RI, and her master’s—with a focus in nursing education—and
PhD from the University of Nevada, Las Vegas. She also has a
post-master’s graduate certicate in Advanced Practice and is
a board-certied Family Nurse Practitioner. She is a Scholar
in Sigma eta Tau’s New Academic Leadership Academy.
Angela is passionate about college student success. She works
as a Family Nurse Practitioner with faculty, sta, and stu-
dents on managing primary and episodic health care needs
at UNLV’s Student Wellness Center and Faculty and Sta
Treatment Center. Dr. Silvestri is a successful Elsevier author
of numerous best-selling NCLEX® preparation resources on
national and international levels. She also serves as an Else-
vier Subject Matter Expert for the Next Generation NCLEX®
(NGN). is passion also comes through in her work at the
School of Nursing teaching leadership and licensure exam
preparation, as well as in publishing research and best-selling
licensure exam review resources on national and international
levels.
Donna D. Ignatavicius,
MS, RN, CNE, CNEcl,
ANEF, FAADN
Nationally recognized as an
expert in nursing education
and medical-surgical nurs-
ing, Donna, better known as
“Iggy,” has a wealth of expe-
rience in education, clinical
nursing, and administra-
tion. rough her company, DI Associates, Inc., Iggy speaks
at national and state conferences and provides consultation
on such topics as curriculum transformation and NGN prep-
aration. In addition, she is the author of a number of articles,
chapters, and books, including the tenth edition of her lead-
ing textbook, Medical-Surgical Nursing: Concepts for Interpro-
fessional Collaborative Care. In 2007 Iggy was inducted as a
fellow into the very prestigious Academy of Nursing Educa-
tion for her national contributions to nursing education. In
2021 she was also inducted as a fellow into the Academy of
Associate Degree Nursing for her national inuence and con-
tributions to programs preparing students for nursing prac-
tice. Iggy obtained her Certied Nurse Educator® credential
in 2016 and her Certied Academic Clinical Educator® cre-
dential in 2020.
About the Authors

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vii
We want to acknowledge the many people from Elsevier who
were such a signicant part of our journey as we prepared
this resource for nursing students. First and foremost, we
extend our deepest appreciation to Heather Bays-Petrovic,
Content Strategist, for accepting our proposal and promot-
ing our vision for this project and for supporting us every
step of the way from start to nish. ank you, Heather! Jodi
Willard, Senior Project Manager, has been instrumental in
moving this publication forward. Jodi’s work and attention
to detail has been signicant in the design and nal prod-
uct. ank you, Jodi! We also extend our sincere gratitude
to Laura Klein, Senior Content Development Specialist; Amy
Buxton, Senior Book Designer; and Julie Eddy, Publishing
Services Manager. We thank all of you for your willingness
and exibility to design this resource ensuring that our ideas
and vision were executed and for your consistent attention
to the many details in our manuscript. Finally, we want to
thank Bruce Seibert, Senior Digital Media Producer, and
Bala Cherukumilli, Digital Media Producer, for all of your
patience and assistance in implementing our requests for the
electronic platform that accompanies this resource. A very
grateful and appreciative “ank You” from us to all of you—
we could not have achieved our aspirations for this resource
without you!
Acknowledgments

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viii
Welcome to the Strategies for Student Success on the Next Gen-
eration NCLEX® (NGN) Test Items!
is book is focused on providing you with information
about the Next Generation NCLEX® (NGN) and practice
questions to prepare you to successfully answer the new test
item types expected on the NGN.a is book highlights gen-
eral NGN Tips and unique test-taking strategies. Chapter 1
introduces the clinical judgment (CJ) cognitive skills upon
which the new test items will be based. Chapter 2 presents
examples of the new NGN test item types. Chapters 3 through
8 describe the CJ cognitive skills and present unique test-
taking strategies on how to answer practice items that measure
each skill. Chapter 9 demonstrates how Stand-alone items and
Unfolding Case Studies will be presented on the NGN, and
Chapter provides an NGN Practice Test to apply what was
learned throughout the book. e answers, rationales, test-
taking strategies, content area, and CJ cognitive skill(s) for
each practice question throughout the book are presented at
the end of the book. In addition, the priority concept is identi-
ed. e specic focus of each chapter is summarized below.
Organization of the Book
n Chapter 1, Introduction to the Cognitive Skills of Clinical
Judgment, describes how clinical judgment builds on
the nursing process and introduces you to the six essen-
tial cognitive skills of the NCSBN Clinical Judgment
Measurement Model (NCJMM). These cognitive skills are
the basis for the new NGN test item types.
n Chapter 2, Introduction to the NGN and the New NGN Item
Types, explains the purpose and design of the NGN and
presents the new test item types. An example of each item
type is presented, and the correct responses are provided
with brief rationales.
n Chapter 3, Strategies for Answering NGN Questions:
Recognize Cues, describes the CJ cognitive skill, Recognize
Cues, which requires you to identify relevant clinical find-
ings and decide which findings are of immediate con-
cern and most important based on the clinical scenario.
This chapter also identifies test items and enhanced test-
taking strategies that you can use when answering items
that measure this skill. Examples of these test items allow
you the opportunity to practice applying these strategies
within the chapter and in the practice test at the end of the
chapter.
a Please note: The NGN content provided in this book and on the Evolve site
reects the information available at the time of production of this resource.
The NCSBN research about NGN is ongoing, and changes in the items to
measure each cognitive skill may be forthcoming. The NCSBN website at
www.ncsbn.org provides you with the latest updates.
n Chapter 4, Strategies for Answering NGN Questions:
Analyze Cues, describes the CJ cognitive skill, Analyze
Cues, which requires you to connect or link relevant cues
to the clinical scenario, interpret these cues, and establish
their significance. This chapter also identifies test items
and enhanced test-taking strategies that you can use when
answering items that measure this skill. Examples of these
test items allow you the opportunity to practice applying
these strategies within the chapter and in the practice test
at the end of the chapter.
n Chapter 5, Strategies for Answering NGN Questions:
Prioritize Hypotheses, describes the CJ cognitive skill,
Prioritize Hypotheses, which requires you to establish
and rank client needs or hypotheses in order of priority.
This chapter also identifies test items and enhanced test-
taking strategies that you can use when answering items
that measure this skill. Examples of these test items allow
you the opportunity to practice applying these strategies
within the chapter and in the practice test at the end of the
chapter.
n Chapter 6, Strategies for Answering NGN Questions:
Generate Solutions, describes the CJ cognitive skill,
Generate Solutions, which requires you to use knowledge
of evidence-based solutions about treatments and inter-
ventions that would address identified client needs and
modify them to meet priorities of care. This chapter also
identifies test items and enhanced test-taking strategies
that you can use when answering items that measure this
skill. Examples of these test items allow you the opportu-
nity to practice applying these strategies within the chapter
and in the practice test at the end of the chapter.
n Chapter 7, Strategies for Answering NGN Questions: Take
Action, describes the CJ cognitive skill, Take Action, which
requires that you perform appropriate and necessary inter-
ventions based on the client’s situation and generated solu-
tions. This chapter also identifies test items and enhanced
test-taking strategies that you can use when answering
items that measure this skill. Examples of these test items
allow you the opportunity to practice applying these strat-
egies within the chapter and in the practice test at the end
of the chapter.
n Chapter 8, Strategies for Answering NGN Questions:
Evaluate Outcomes, describes the CJ cognitive skill,
Evaluate Outcomes, which requires that you examine out-
comes and measure client progress towards meeting those
outcomes in the plan of care. This chapter also identifies
test items and enhanced test-taking strategies that you
can use when answering items that measure this skill.
Examples of these test items allow you the opportunity to
practice applying these strategies within the chapter and in
the practice test at the end of the chapter.
Preface

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Preface ix
n Chapter 9, Strategies for Answering NGN Stand-alone
Items and Unfolding Case Studies, describes the differences
between Stand-alone items and Unfolding Case Studies.
Samples of Stand-alone items (including the bow-tie and
trend) are illustrated, as well as Unfolding Case Studies.
This chapter also identifies test items and enhanced test-
taking strategies that you can use when answering ques-
tions accompanying each type of case study. Examples
of these test items allow you the opportunity to practice
applying these strategies within the chapter. This chapter
also points out external factors to consider in NGN cases,
such as the environmental and individual factors.
n Chapter , NGN Practice Test: Putting It All Together, pro-
vides you with the opportunity to practice all of the new
types of test items expected on the NGN, starting with
Unfolding Cases Studies and ending with Stand-alone
Bow-tie and Trend items.
Special Features of the Book
n NGN tips within each chapter. These unique tips provide
the student with key points to remember, such as the NGN
item type or cognitive skill (CS) features.
n In-chapter sample questions are presented within Chapters
3 through 9 to provide examples of the new NGN test
item types that best measure the clinical judgment cogni-
tive skill presented in the chapter. Each question within
the chapter specifies the priority concept and content area
being tested. The answer, rationale, enhanced test-taking
strategy, and references are also presented to help students
learn the thinking process needed to select the correct test
item response.
n End-of-chapter practice questions are presented at the end
of Chapters 3 through 8 to provide the opportunity for stu-
dents to apply what they learned in each chapter and expe-
rience answering selected test items that measure each of
the NCSBN’s clinical judgment cognitive skills. Chapter 9
presents Stand-alone items, both Bow-tie and Trend items,
and Unfolding Case Studies.
n A comprehensive practice test is presented in Chapter 10 to
allow students to apply what they learned in Chapters 1
through 9. Students have the opportunity to answer mul-
tiple Unfolding Case Studies and Stand-alone items rep-
resenting all clinical specialty areas. The priority concept,
content area, answer, rationale, enhanced test-taking strat-
egy, and reference for each test item are provided at the
end of the book.
n Enhanced test-taking strategies for the NGN. This unique
feature walks students through the thinking process
needed to navigate complex NGN cases. Each strategy
explains how to apply the cognitive skill when considering
the information presented in the clinical scenario. Each
question is accompanied by test-taking strategies that are
presented both narratively and in a table format to guide
the student through a logical thinking process and to suit
multiple learning styles. This thinking process with test-
taking strategies will also help on current NCLEX-style
(Stand-alone) items and nursing course exams.
n Thinking Space. The Thinking Spaces located in the margins
of the book is a place for personal note-taking. The student
can use these spaces to write down new and important
information they want to remember. To become most famil-
iar with the cognitive skills and to build clinical judgment
skills, using the Thinking Space to make important linkages
between clinical scenario information and the cognitive skill
will reinforce the aspects of the NCJMM model as the stu-
dent is studying and preparing for the NGN.
Special Features Found on Evolve
e Evolve site accompanying this resource provides the stu-
dent with all of the case studies and practice test questions in
the book plus an additional 30 unfolding case studies, each
with 6 NGN items. e book includes 60 single cases (each
with 1 NGN item), 10 Stand-alone items (5 Bow-tie and 5
Trend), and 5 Unfolding Case Studies (items with 6 NGN
items). is equals a total of 100 NGN items. en there are
an additional 30 unfolding cases, each with 6 NGN items, and
4 additional Stand-alone items (2 Bow-tie and 2 Trend) total-
ing 184 NGN items. Altogether, there are a total of 284 NGN
items on Evolve.
e Evolve site lists various category selections. You can
select by type of question—either single case, Stand-alone
items (either bow-tie or trend), or Unfolding Case Study. You
can also select by the specic cognitive skill, content area, or
priority concept. e table below illustrates the various cat-
egories for selection.
Type Cognitive Skill Content Area
Priority
Concept
Single
Stand-
alone
Unfolding
Recognize Cues
Analyze Cues
Prioritize
Hypotheses
Generate
Solutions
Take Action
Evaluate
Outcomes
Foundations
of Nursing
Maternal-
Newborn
Nursing
Medical-
Surgical
Nursing
Mental Health
Nursing
Pediatric
Nursing
Pharmacology
Clotting
Cognition
Elimination
Fluid and
Electrolyte
Balance
Gas
Exchange
Glucose
Regulation
Immunity
Mobility
Mood and
Aect
Perfusion
Stress and
Coping
Tissue
Integrity
How to Use This Book
For Students
As implied in the title, this book was written to help you be
successful when taking the new test item types that will be

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Prefacex
part of the Next Generation NCLEX® (NGN). e rst two
book chapters present a review of clinical judgment and the
NGN item types. All new item types are based on the six cog-
nitive (thinking) skills needed for safe, appropriate clinical
judgment. Be sure that you are very familiar with this infor-
mation before beginning to practice answering the test ques-
tions later in the book.
Chapters 3 through 8 describe each clinical judgment cog-
nitive skill and provide general NGN Tips on how to answer
test items that measure each skill. Sample NGN test items are
then presented with the Rationale and Test-Taking Strategy
for the correct and incorrect responses, followed by six end-
of-chapter practice questions for you to answer. e practice
questions in each chapter represent all content specialties. e
rationale and test-taking strategy that you can use for each
question to determine the correct answers are described in
detail, with tables to help organize the information in each
question. In addition, each test item is labeled by priority
nursing concept and content specialty. References are also
provided to help you review the content associated with each
test item if needed.
When working through Chapters 3 through 8, start with
Chapters 3 and 4 early in your program so that you can learn
how to determine the most important client ndings in a
clinical scenario and what they mean (Recognize Cues and
Analyze Cues). When you feel you have mastered these cogni-
tive skills, work through Chapter 5, which will help you learn
to prioritize client needs and the care required to meet them.
Chapters 6 and 7 are focused on helping you learn to plan and
implement nursing actions to meet the client’s needs. Finally,
Chapter 8 will assist you in determining whether the client’s
condition has improved aer care has been implemented.
Aer working through Chapters 3 through 8 and when you
feel ready to put all the cognitive skills together, Chapter 9 pro-
vides examples for NGN Unfolding Case Studies and Stand-
alone items. Chapter 10 presents a comprehensive practice test
that simulates what you can expect on the NGN. e rationale
and test-taking strategy for each practice test item in these
chapters are described in detail. Many additional practice NGN
test items are available on the Evolve site with rationale, test-
taking strategy, content specialty, priority nursing concept, and
reference for each Unfolding Case Study or Stand-alone item.
For Faculty
is book is designed for you to use as it is organized, begin-
ning with helping students learn what CJ is and gain an
understanding of each of the essential CJ cognitive skills as
described in Chapter 1. Students in their rst nursing course
should learn how to use these skills to make safe, appropri-
ate clinical judgments to ensure client safety. If students are
already making clinical judgments using these skills, Chap-
ter 1 could be used for review. en students should become
familiar with the NGN test design and new item types as pre-
sented in Chapter 2. Finally, by the end of the rst semester
(or other term), students should learn how to Recognize Cues
and Analyze Cues (Chapters 3 and 4). ese cognitive skills
focus on assessing the client, discerning how to determine
which client ndings are the most important, and deciding
what those ndings mean. End-of-chapter practice ques-
tions can be used during class, online, simulation pre- or
post-brieng, or clinical post-conference. e test items can
be assigned to students as individuals or in groups to answer.
Regardless of where or how practice test items are used, such
as in the classroom, online, lab sessions, or clinical setting,
be sure to review the answers, rationales, and strategies for
arriving at the correct response(s) to identify and improve
students’ thinking process as needed.
As students progress to the next course, they should begin
to learn how to prioritize care to determine what nursing
actions they would plan and implement. Part of this thinking
process includes an assessment to decide if the actions were
eective and the client’s condition has improved. erefore
students in this semester would focus on Chapters 5 through
8. Again, you can assign the practice items to students as indi-
viduals or in groups and review the items to help students
improve their thinking as needed.
Chapters 9 and puts together all the cognitive skill steps
and new NGN test item types—both Stand-alone items and
Unfolding Case Studies. ese chapters can be used when-
ever students are applying the individual CJ cognitive skills
to successfully answer the new test items in preparation for
the NGN. Assign these practice Unfolding Case Studies and
Stand-alone items as individual student practice to determine
any skill areas where improvement is needed. Students need-
ing improvement can then review any of the six earlier chap-
ters (Chapters 3 through 8) to hone their thinking skills.
Faculty Tool Kit
e Faculty Tool Kit was created to guide faculty in using this
book with their students at any stage in the program to pre-
pare them for the NGN.
e Tool Kit:
■ Furnishes a guide for how to use this book, Strategies for
Student Success on the Next Generation NCLEX® (NGN)
Test Items, to prepare students for the NGN
■ Provides chapter-to-chapter strategic points to empha-
size to students and ways to prepare students for an-
swering NGN items
■ Provides suggestions for using the Evolve site accompa-
nying this book
■ Presents step-by-step guides for writing Stand-alone
items and Unfolding Case Studies
■ Presents step-by-step guides for writing NGN items
■ Species NCSBN resources that focus on NGN for stu-
dents and faculty
■ Provides Elsevier resources and references for prepar-
ing students for the NGN
Additional Resources for Students
n Ignatavicius, D.D. (2021). Developing Clinical Judgment for
Professional Nursing and the Next-Generation NCLEX-RN®
Examination. St. Louis: Elsevier.

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Preface xi
is workbook helps students preparing to become
RNs learn how to develop NCSBN’s six clinical judg-
ment cognitive skills through practice in answering
new NGN test item types embedded in unfolding and
single-episode cases throughout the entire curriculum.
Clinical scenarios are presented from more basic care
to complex, multisystem care of clients in multiple spe-
cialty areas.
n Ignatavicius, D.D. (2022). Developing Clinical Judgment
for Practical-Vocational Nursing and the Next-Generation
NCLEX-PN® Examination. St. Louis: Elsevier.
is workbook helps students preparing to become LPNs
or LVNs learn how to develop NCSBN’s six clinical judg-
ment cognitive skills through practice in answering new
NGN test item types embedded in unfolding and single-
episode cases. Clinical scenarios in multiple specialty
areas are included, with a primary emphasis on the care
of older adults in a variety of health care settings, and
can be used throughout the entire curriculum.
n Silvestri, L., & Silvestri, A. (2023). Saunders Comprehensive
Review for the NCLEX-RN® Examination (9th ed.). St.
Louis: Elsevier.
is is an excellent resource to use both while you are
in nursing school and in preparation for the NCLEX®
examination. is book contains 20 units with 70 chap-
ters, and each chapter is designed to identify specic
components of nursing content. e book and accom-
panying soware contain more than 5200 practice ques-
tions and include alternate item format questions. e
soware also contains a 75-question preassessment test
that generates an individualized study calendar. A pos-
tassessment test is included, as well as case studies and
accompanying NGN item type practice questions.
n Silvestri, L., & Silvestri, A. (2021). Saunders Q&A Review
for the NCLEX-RN® Examination (8th ed.). St. Louis:
Elsevier.
is book and accompanying Evolve site provide you
with more than 6000 practice questions based on the
NCLEX-RN® test plan. Each practice question includes
a priority nursing tip that provides you with a piece of
important information to remember that will help you
answer questions on nursing exams and on the NCLEX®
examination. e chapters in this book are uniquely
designed and are based on the NCLEX-RN® examina-
tion test plan framework, including Client Needs and
Integrated Processes. Alternate item format questions
and accompanying NGN item type practice questions
are included. With practice questions focused on the
Client Needs, Integrated Processes, and Clinical Judg-
ment/Cognitive Skills, you can assess your level of
competence.
n Silvestri, L., & Silvestri, A. (2020). HESI/Saunders Online
Review Course for the NCLEX-RN® Examination. (3rd ed.)
St. Louis: Elsevier.
e online NCLEX-RN® review course provides a sys-
tematic and individualized approach and addresses all
areas of the test plan identied by the National Council
of State Boards of Nursing, Inc. is self-paced online
review contains 10 interactive, multimedia-rich mod-
ules featuring animations and videos, practice ques-
tions, end-of-lesson case studies, and much more! A
diagnostic pretest generates a study calendar to guide
your review. NCLEX®-style questions—including every
type of alternate item format question—are provided,
concluding with a comprehensive examination that
will sharpen your test-taking skills. In addition, case
studies and accompanying NGN practice questions
are included. Unique videos that simulate a live review
course focus on dicult subjects such as dysrhythmias
and make them easier to understand.
n Silvestri, L., & Silvestri, A. (2021). Saunders 2022-2023
Clinical Judgment and Test-Taking Strategies (7th ed.) St.
Louis: Elsevier.
is book is designed for both RN and PN nursing stu-
dents and provides a foundation for understanding and
unpacking the complexities of NCLEX® exam ques-
tions, including alternate item formats. Saunders 2022-
2023 Clinical Judgment and Test-Taking Strategies takes
a detailed look at all the test-taking strategies you will
need to know in order to pass any nursing examination,
including the NCLEX® examination. Special nursing
content tips are integrated along with other tips, such
as clinical preparation tips and life-planning tips. ere
are 1200 practice questions included so you can apply
the testing strategies. NGN items and practice test ques-
tions are also included on the Evolve site accompanying
this resource.
n Silvestri, L., & Silvestri, A. (2022). Saunders Comprehensive
Review for the NCLEX-PN® Examination (8th ed.). St.
Louis: Elsevier.
is is an excellent resource to use both while you are in
nursing school and in preparation for the NCLEX® exam-
ination. is book contains 19 units and 65 chapters, and
each chapter is designed to identify specic components
of nursing content. e book and accompanying Evolve
site contain more than 4500 practice questions and
include alternate item format questions. e soware also
contains a 75-question preassessment test that generates
an individualized study calendar. A post-assessment test
is also included, as well as case studies and accompanying
NGN item type practice questions.
n Silvestri, L., & Silvestri, A. (2020). Saunders Q&A Review
for the NCLEX-PN® Examination (6th ed.). St. Louis:
Elsevier.
is book and accompanying Evolve site provide you
with more than 5900 practice questions based on the
NCLEX-PN test plan. Each practice question includes
a priority nursing tip that provides you with a piece of
important information to remember that will help you
answer questions on nursing exams and on the NCLEX®
examination. e chapters in this book are uniquely
designed and are based on the NCLEX-PN® examina-
tion test plan framework, including Client Needs and
Integrated Processes. Alternate item format questions

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Prefacexii
and accompanying NGN item type practice questions
are included. With practice questions focused on the
Client Needs, Integrated Processes, and Clinical Judg-
ment/Cognitive Skills, you can assess your level of
competence.
n Silvestri, L., & Silvestri, A. (2020). HESI/Saunders Online
Review Course for the NCLEX-PN® Examination. (3rd ed.)
St. Louis: Elsevier.
is online NCLEX-PN® review course provides a sys-
tematic and individualized approach and addresses all
areas of the test plan identied by the National Council
of State Boards of Nursing, Inc. is self-paced online
review contains 10 interactive, multimedia-rich mod-
ules featuring animations and videos, practice ques-
tions, end-of-lesson case studies, and much more! A
diagnostic pretest generates a study calendar to guide
your review. NCLEX®-style questions—including every
type of alternate item format question—are provided,
concluding with a comprehensive examination that
will sharpen your test-taking skills. In addition, case
studies and accompanying NGN practice questions
are included. Unique videos that simulate a live review
course focus on dicult subjects such as dysrhythmias
and make them easier to understand.

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xiii
CHAPTER 1
Introduction to the Cognitive Skills of Clinical Judgment, 1
What Are the Purpose and Design of the Current
NCLEX®?, 1
Why Is There a Need for NCLEX® Change?, 2
What Is the NCSBN’S Denition and Model of Clinical
Judgment?, 3
What Are the Six NCSBN Clinical Judgment Measurement
Model Cognitive Skills?, 3
How Will the Six Clinical Judgment Skills Be Measured on
the NGN?, 8
How Can You Prepare for the NGN?, 8
CHAPTER 2
Introduction to the NGN and the New NGN Item Types,
Test Item Types Used for Unfolding Case Studies, 10
Test Item Types Used for Stand-alone Items, 20
CHAPTER 3
Strategies for Answering NGN Questions: Recognize Cues,
23
What Are Cues?, 23
How Are Client Findings (Cues) Presented in an NGN
Clinical Scenario?, 23
Which Client Findings Are Relevant?, 24
Which Relevant Client Findings Are of Immediate Concern
to the Nurse?, 25
What Types of Clinical Scenarios May Be Included on the
NGN?, 25
What NGN Item Types Optimally Measure Recognize
Cues?, 25
Practice Questions, 32
CHAPTER 4
Strategies for Answering NGN Questions: Analyze Cues,
36
How Do You Analyze Cues?, 36
How Does Analyzing Cues Help You Guide Client Care?, 36
How Do You Analyze Cues in an NGN Clinical Situation?,
37
What Will You Think About to Analyze Cues in This
Clinical Scenario?, 38
Which Client Findings Are Most Important When
Analyzing Cues?, 39
When Might You Need to Analyze Cues in a Clinical
Situation?, 39
What NGN Item Types Optimally Measure Analyze Cues?,
39
Practice Questions, 48
CHAPTER 5
Strategies for Answering NGN Questions: Prioritize
Hypotheses, 53
What Do Hypotheses Mean?, 53
What Does Prioritizing Mean?, 53
What to Consider When Prioritizing Hypotheses, 53
External Factors and Prioritizing Hypotheses, 54
How Do You Know That You Need to Prioritize?, 56
What Three Strategies Can You Use to Prioritize
Hypotheses?, 57
How Do You Prioritize Hypotheses in an NGN Clinical
Situation?, 58
What Will You Think About to Prioritize Hypotheses in This
Clinical Scenario?, 59
What NGN Item Types Optimally Measure Prioritize
Hypotheses?, 59
Practice Questions, 
CHAPTER 6
Strategies for Answering NGN Questions: Generate
Solutions, 73
What to Consider When Generating Solutions, 73
The Plan of Care and Generating Solutions, 73
How Do You Know That You Need to Generate Solutions?,
73
How Do You Generate Solutions in an NGN Clinical
Situation?, 74
What Will You Think About to Generate Solutions in This
Clinical Scenario?, 75
What NGN Item Types Optimally Measure Generate
Solutions?, 75
Practice Questions, 82
CHAPTER 7
Strategies for Answering NGN Questions: Take Action, 85
How Do You Know What Actions to Take?, 85
How Will Nursing Actions Be Tested?, 85
What NGN Item Types Optimally Measure Take Action?, 
Practice Questions, 92
CHAPTER 8
Strategies for Answering NGN Questions: Evaluate
Outcomes, 96
How Do You Evaluate Outcomes?, 96
How Will Evaluate Outcomes Be Tested?, 97
NGN Question Stems Addressing Evaluate Outcomes, 97
What NGN Item Types Optimally Measure Evaluate
Outcomes?, 98
Practice Questions, 105
Contents

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Contentsxiv
CHAPTER 9
Strategies for Answering NGN Stand-alone Items and
Unfolding Case Studies, 111
What Are Stand-alone Items?, 111
What Are Unfolding Case Studies?, 125
How Are Stand-alone Items and Unfolding Case Studies
Dierent?, 125
CHAPTER 10
NGN Practice Test: Putting It All Together, 134
Unfolding Case Studies, 134
Stand-alone Items, 157
Answers to Practice Questions, 163
References and Bibliography, 289

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1
is chapter will help yu understand the need fr change in the NCLEX® and the six
clinical judgment cgnitive (thinking) skills that serve as the basis fr new test item
types n the NGN. Aer a brief review f the current NCLEX® design, thinking skills
needed t make safe, evidence-based clinical judgment are intrduced. General NGN
Tips are prvided t help yu relate each thinking skill with the new exam.
e new NGN item types will be included n the NCLEX® n sner than 2023 and
are described in Chapter 2 f this bk. Specic Test-Taking Strategies that will help
yu crrectly answer these new items are prvided thrughut ther chapters f this
bk and accmpany all practice questins in the bk and n the Evlve site. Be sure
t review this chapter before reading the rest f this bk r practicing NGN questins!
What Are the Purpose and Design of the Current NCLEX®?
As yu knw, prelicensure nursing educatin prgrams like the ne yu’re currently in
prepare students fr eligibility t take either the NCLEX-RN® r the NCLEX-PN® aer
graduatin. ese natinal licensure examinatins are develped and updated under
the directin f the NCSBN. is rganizatin als versees the administratin f the
NCLEX® in the United States, Canada, and a number f ther cuntries.
e primary purpse f the NCSBN is t protect the public by prviding cmpe-
tency assessments, such as the NCLEX®, that are sund and secure. e NCLEX® is cm-
prehensive and reects current nursing practice. T ensure examinatin currency, the
NCSBN cllects and analyzes nursing practice data every 3 years frm thusands f
graduates t determine what knwledge and activities are required in their jbs as new
nurses. is infrmatin is used t develp the cntent f the NCLEX® and is rganized
in a new licensure test plan every 3 years (https://www.ncsbn.rg/testplans.htm). e
test plan is rganized by fur majr Client Needs Categries, sme f which have sub-
categries. In additin, ve Integrated Prcesses are dened and included thrughut
the NCLEX® Test Plan as shwn in Bx 1.1
e NCLEX® currently measures the new graduate’s minimum cmpetence in safety
t ensure public prtectin thrugh a variety f test items. Mst f the test items (abut
95%) are either Multiple Chice r Multiple Respnse, als knwn as Select All at
Apply (SATA) questins. Fr each f these item types, client infrmatin is presented
in a shrt clinical scenari fllwed by a questin abut the nurse’s rle in client care.
Examples f these test item types are presented in Bx 1.2
As yu’ll ntice in the afrementined test items, each questin fcuses n what the
nurse wuld d r say in respnse t specic client data. Only the client infrmatin
that is the mst imprtant, relevant, r, in sme cases, f immediate cncern t the
nurse is presented in the clinical situatin. e answer is then selected frm a list f
chices prvided. e narrw fcus f these test items des nt represent the scpe f
actual nursing practice and des nt allw measurement f clinical judgment. Rather,
these types f items reect whether the candidate can distinguish between right and
wrng. At this pint in yur educatin, yu likely are very familiar with these item types
n yur curse exams.
Introduction to the Cognitive
Skills of Clinical Judgment
C H A P T E R 1
THINKING SPACE

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items2
Why Is There a Need for NCLEX® Change?
Althugh natinal NCLEX® rst-time pass rates fr bth RN and PN graduates have
been abve 80% fr many years, health care emplyers cntinue t reprt increasing
errrs in client care and lack f apprpriate clinical judgment skills amng new nursing
graduates. A recent literature review cnducted by the NCSBN fund that 50% f all
nurses have been invlved in at least ne client errr. Sixty percent f thse errrs were
the result f pr clinical judgment. Over 80% f nursing emplyers are not satised
with the ability f new nursing graduates t make accurate r apprpriate clinical deci-
sins regarding client care. In respnse t these data, the NCSBN began t questin if
the NCLEX® was measuring “the best thing” t prtect the public.
e 2013–2014 Strategic Practice Analysis f activities perfrmed by practicing RNs
and RN rle experts cnrmed the imprtance f sund clinical judgment skills fr
Integrated Processes Client Needs Categories/Subcategories
Nursing Processa
Teaching and Learning
Communication and Documentation
Caring
Culture and Spirituality
Safe and Eective Care Environment
 Management of Careb
 Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
 Basic Care and Comfort
 Pharmacological and Parenteral
Therapiesc
 Reduction of Risk Potential
 Physiological Adaptation
BOX 1.1 NCLEX-RN® Test Plan Organizing Concepts
aThis Integrated Process on the NCLEX-PN ® Test Plan is the Problem-Solving Process.
bThis Client Needs subcategory on the NCLEX-PN ® Test Plan is Coordinated Care.
cThis Client Needs subcategory on the NCLEX-PN ® Test Plan is Pharmacological Therapies.
Example : Multiple Choice Single Response
The nurse is planning care for a client admitted to the hospital with a diagnosis of acute
pancreatitis and controlled hypertension. What is the nurse’s priority for the client’s care
at this time?
☐ Administer an antiemetic medication.
☐ Manage the client’s acute pain.
☐ Monitor the client’s blood pressure.
☐ Administer supplemental oxygen.
Example : Multiple Response (Select All That Apply)
The nurse is assessing an adolescent who was taken to the ED for threatening to commit
suicide. What is (are) the most appropriate question(s) for the nurse to ask the client at
this time? Select all that apply.
☐ “What made you want to kill yourself?”
☐ “Do you have a plan for killing yourself?”
☐ “Do you plan to kill yourself with anyone else?”
☐ “Is this the ųrst time you’ve threatened to kill yourself?”
☐ “Did you write a suicide note to explain why you are doing this?”
BOX 1.2 Examples of Current Multiple Choice and Multiple Response
NCLEX® Test Items
Note: Indicates correct response(s).
THINKING SPACE

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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 3
many tasks and activities perfrmed by entry-level nurses. is analysis als highlighted
that nurses tday make mre cmplex decisins t prvide safe care fr clients with
higher acuity and advanced age.
e NCSBN literature review als fund that the nurse’s primary practice activity is
the ability t prblem slve and critically think—thinking prcesses needed fr mak-
ing apprpriate clinical judgments. Problem solving is the prcess f develping and
evaluating nursing slutins r appraches t client prblems. Critical thinking can be
described as a prcess requiring the use f lgic and clinical reasning t identify the
strengths and weaknesses f nursing slutins r appraches t client prblems. e
NCBSN built n these prcess descriptins t create a denitin and mdel f clinical
judgment t be used as a basis fr develping new NCLEX® test item types.
What Is the NCSBN’S Definition and Model of Clinical
Judgment?
As a result f the literature review, Strategic Practice Analysis, and input frm a vari-
ety f nurse clinicians and educatrs, the NCSBN develped this denitin f clinical
judgment:
Clinical judgment is dened as the observed outcome of critical thinking and decision
making. It is an iterative process that uses nursing knowledge to observe and assess present-
ing situations, identify a prioritized client concern, and generate the best possible evidence-
based solutions in order to deliver safe client care.
S, what des this denitin mean fr yu as a nursing student and future prfes-
sinal nurse? ink abut each f these key pints in the clinical judgment denitin:
■ Recgnize that clinical judgment is the result r outcome of thinking t make deci-
sins abut client care when ptential r actual health prblems ccur. The same
prcess f thinking t make clinical decisins ccurs repeatedly as yu manage client
prblems (iterative process).
■ Acquire and recall nursing knowledge t make apprpriate clinical judgments.
(Hwever, having knwledge des nt guarantee that an accurate r apprpriate
clinical judgment will be made.)
■ Learn hw t prioritize a client’s need fr care based n the data presented abut a
clinical situatin.
■ Be familiar with the best current evidence regarding a presented client situatin s
yu can cme up with pssible slutins r appraches fr care t keep the client
safe.
Yu will want t acquire these skills and a strng knwledge base during yur nurs-
ing prgram t be ready fr a dynamic, cmplex health care system and the NGN.
Aer the NCSBN develped its denitin f clinical judgment, the rganizatin cre-
ated a mdel f clinical judgment, called the NCSBN Clinical Judgment Measurement
Mdel (NCJMM). As the name implies, this mdel was created t measure the nursing
graduate’s ability t make clinical judgments. Althugh it is nt imprtant fr yu t be
familiar with the entire mdel, it is essential that yu master the thinking skills assci-
ated with clinical judgment. e NCJMM identies six cgnitive (thinking) skills that
are needed fr eective prfessinal nursing practice and serve as the basis fr the new
NGN test item types. ese skills are smetimes referred t as Layer 3 f the NCJMM
and are intrduced in the next sectin f this chapter.
e NCJMM als identies factrs that inuence the ability f nurses t make appr-
priate clinical judgments. Examples f these Envirnmental and Individual factrs,
smetimes referred t as Layer 4 f the NCJMM, are listed in Table 1.1. Individual fac-
trs are thse related t the nursing graduate candidate taking the NGN.
What Are the Six NCSBN Clinical Judgment Measurement
Model Cognitive Skills?
e NGN includes new test item types that measure the six cgnitive skills f clinical
judgment. Each f these thinking skills, smetimes referred t as cgnitive prcesses,
THINKING SPACE

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items4
is intrduced in this chapter. Chapters 3 thrugh 8 in this bk describe these skills in
mre detail and present examples f NGN test items that are designed t measure each
skill. e six cgnitive skills essential fr clinical judgment are listed in Bx 1.3 with key
questins that explain the fcus f each skill.
Recognize Cues
Fr clients in any health care setting, the nurse cllects client data frm a number f
surces. Cues are client ndings r assessment data that prvide infrmatin fr nurses
as a basis fr decisin making t make apprpriate clinical judgments and can be divided
int fur majr types as listed belw. Chapter 3 describes these surces f cues in mre
detail.
■ Envirnmental cues; e.g., presence f family member
■ Client bservatin cues; e.g., signs and symptms
■ Medical recrd cues; e.g., lab values r vital signs
■ Time pressure cues; e.g., rapid clinical decline
In actual clinical practice, the nurse reviews all client ndings t determine which
data are mst imprtant, relevant, and, in sme cases, f immediate cncern. T help
yu Recognize Cues, ask yurself which client data are mst imprtant in the presented
clinical scenari. Carefully review the client’s presenting data, such as vital signs and
medical diagnsis, t determine their relevance. Fr example, a heart rate f 140 bpm
wuld be f immediate cncern fr a middle-aged adult, but is within the typical range
fr a newbrn.
In sme clinical scenaris the client has a histry f ne r mre acute and/r chrnic
health prblems. Fr example, an lder adult with a lng histry f COPD may have a
Pao2 f 65 mm Hg. is arterial xygen level is abnrmal because it is belw the usual
range f 80 t 100 mm Hg. Hwever, fr this client, the lw arterial xygen level is
likely nt imprtant r f immediate cncern because it is expected. Many clients with
advanced COPD have chrnically lw arterial xygen, but they cmpensate by using
breathing techniques cmbined with lw-w supplemental xygen.
Analyze Cues
Aer relevant cues have been identied in a clinical scenari, the nurse rganizes and
links them t the client’s presenting clinical situatin. Ask yurself: “What d the rel-
evant client data mean r indicate at this time?” Fr example, cnsider a middle-aged
Recognize Cues: What matters most?
Analyze Cues: What could it mean?
Prioritize Hypotheses: Where do I start?
Generate Solutions: What can I do?
Take Action: What will I do?
Evaluate Outcomes: Did it help?
BOX 1.3 Clinical Judgment Cognitive Skills With Key Questions
Remember: To Recognize Cues,
carefully review the client’s as-
sessment data like developmental
age and history to help determine
if ndings are relevant or of im-
mediate concern to the nurse.
NGN TIP
TABLE 1.1 Example of Environmental and Individual Factors That
Inuence Clinical Judgment
Examples of Environmental Factors Examples of Individual Factors
Environment
Medical records
Time pressure
Task complexity
Resources
Cultural considerations
Client observation
Consequences and risks
Knowledge
Skills
Specialty
Prior experience
Level of experience
Candidate characteristics

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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 5
client wh had a small bwel resectin 2 days ag and begins having increasing abdm-
inal pain, distentin, vmiting, and absent bwel sunds. ese data, when gruped
tgether, are cnsistent with a pstperative paralytic ileus. T link these assessment
ndings with an ileus, yu need knwledge f pathphysilgy, especially signs and
symptms.
In sme clinical scenaris, the client may have multiple relevant cues that are assci-
ated with several dierent client cnditins. e example in Bx 1.4 illustrates this type
f scenari fr an lder adult hspitalized fr a urinary tract infectin and sepsis. In
this inking Activity, yu wuld need t review each client nding t determine if it is
cnsistent with ne r mre f the specied client cnditins.
In this example, ne nding may be linked with tw r three client cnditins, such
as generalized weakness and acute cnfusin. Hwever, dyspnea n exertin is assci-
ated with nly ne f the listed prblems—anemia. e crrect respnses t the ink-
ing Activity are fund in Bx 1.5
In ther clinical scenaris, the client may nt be experiencing an actual health prb-
lem, but is at risk fr ne r mre ptential cmplicatins. Fr example, the wman wh
recently had a spntaneus vaginal delivery is at risk fr pstpartum hemrrhage within
the rst 24 hurs, particularly if the uterus becmes bggy (a client bservatin cue). In
sme clinical situatins then, part f the thinking prcess t Analyze Cues is t identify
if cues are linked t r assciated with ptential cmplicatins.
Prioritize Hypotheses
Aer rganizing, gruping, and linking relevant client ndings with actual r ptential
client cnditins, the next cgnitive skill requires yu t narrw dwn what the data
mean and priritize the client’s prblems r needs. Althugh yu may have learned
abut pririty decisin-making mdels such as the ABCs r Maslw’s Hierarchy f
Needs, these mdels are en nt very useful in helping yu make clinical judgments in
mre cmplex clinical situatins.
T Prioritize Hypotheses, review and evaluate each f the client’s needs r health prb-
lems in the clinical situatin. en rank them t decide what is most likely the pririty
Client Finding Dehydration Hypernatremia Anemia
Generalized weakness
Acute confusion
Dry mouth
Increased heart rate
Dyspnea on exertion
BOX 1.4 Example of a Thinking Activity That Requires the Ability to
Analyze Cues
Remember: To Analyze Cues, you
are not required to make a medi
cal diagnosis but rather will be
expected to connect or link client
ndings with selected client con-
ditions or health problems, either
actual or potential.
NGN TIP
Client Assessment Finding Dehydration Hypernatremia Anemia
Generalized weakness X X X
Acute confusion X X X
Dry mouth X X
Increased heart rate X X X
Dyspnea on exertion X
BOX 1.5 Example of a Thinking Activity That Requires the Ability to
Analyze Cues

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items6
health prblem. Evaluate factrs in the clinical situatin such as urgency, risk, diculty,
and time sensitivity fr the client. Fr example, cnsider this clinical situatin:
A 42-year-old postpartum client who just gave birth to a third child in 4 years reports
severe “aerbirth pains” of 9/10 on a 0 to 10 pain intensity scale. e client also reports
having problems with getting the baby to latch for breast-feeding/chest-feeding. e
nurse assesses that the client has a boggy uterus and is saturating a peri-pad every 20 to
30 minutes.
In this example, the client has three prblems that yu wuld evaluate and rank in
this rder:
1. Excessive pstpartum bleeding due t bggy uterus
2. Severe abdminal pain due t uterine cntractins
3. Diculty with breast-feeding/chest-feeding due t inability f baby t latch
e pririty fr this client at this time is t manage excessive pstpartum bleeding
because the client culd becme hypvlemic and develp shck. In this situatin, man-
aging the client’s bleeding is mre urgent than managing severe pain r breast-feeding/
chest-feeding diculty t prevent the risk f a life-threatening cmplicatin.
Generate Solutions
Aer identifying the client’s pririty prblem in a given clinical scenari, yu want t
think abut all the pssible actins that can be used t reslve r manage the prblem.
T assist in selecting the pssible actins r apprach t care yu might include, rst
determine what utcmes are desired r expected fr the client. Fr example, cnsider
this scenari:
e birth parent of an 11-year-old brings the child to the ED for a right forearm injury
experienced as a result of a scooter accident. e nurse observes that the child is crying and
guarding the right arm, which is swollen, deformed, and bruised. e child is le-handed.
During the head-to-toe assessment, the nurse notes old bruising on the le side of the child’s
chest and scarring on both upper thighs. Both knees have large abrasions with small stones
and dirt embedded in them. e child denies having had any previous accidents or injuries.
An x-ray conrms a right nondisplaced metaphyseal ulnar fracture.
In this example, the client has an acute injury and signs f previus injuries, pssibly
frm abuse. e desired utcmes wuld include that the client:
■ States that pain is n mre than a 2–3/10 n a 0 t 10 pain intensity scale
■ Des nt experience cmprmised neurvascular cmprmise in the right arm
■ Has decreased swelling f the right arm
■ Will experience healing f bilateral knee abrasins withut infectin
■ Is safe at hme (n neglect r abuse) with the birth parent r ther family/significant
ther
e next step in this thinking prcess is t identify multiple ptential actins r nurs-
ing interventins that culd achieve the desired utcmes. Als identify which actins
wuld be avided r are cntraindicated. T develp a list f actins r interventins
fr this pediatric client, yu need knwledge f child develpment, fracture treatment,
child abuse, and pain management.
Sme nursing actins may fcus n cllecting additinal infrmatin abut the cli-
ent. Fr instance, the nurse wuld likely want t interview the birth parent t btain
infrmatin abut the ld bruising and scarring bserved n the child’s chest and
thighs. Other ptential actins that culd help achieve the desired utcmes in this
clinical situatin include:
■ States that pain is n mre than a 2–3/10 n a 0 t 10 pain intensity scale
■ Administer nnpiid pain medicatin; avid piids if pssible.
■ Prvide distractin fr the child, such as an iPad r gaming device.
■ Reassure the child that analgesics will be available as needed aer discharge.
Remember: The urgency of a clini-
cal situation and risk to the client
are important factors that will
help you Prioritize Hypotheses.
NGN TIP
Remember: To Generate Solutions
to meet a client’s priority needs,
determine the client’s desired or
expected outcomes rst.
NGN TIP

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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 7
■ Des nt experience cmprmised neurvascular cmprmise in the right arm
■ Assist in applying a right synthetic frearm cast.
■ Mnitr the child’s right arm neurvascular status aer cast applicatin.
■ Has decreased swelling f the right arm
■ Apply ice pack t arm utside cast and teach child need t use ice fr the next 24
hurs.
■ Teach child t keep arm elevated as much as pssible.
■ Will experience healing f bilateral knee abrasins withut infectin
■ Clean bth knees t remve debris and dirt.
■ Apply triple antibitic cream n pen areas and cver with clean gauze.
■ Apply tpical lidcaine t knees t decrease pain.
■ Is safe at hme (n neglect r abuse) with the birth parent r ther family/significant
ther
■ Cmmunicate cncern abut child’s safety t primary health care prvider.
■ Cnsult with the scial wrker abut the child’s ptential safety risk, family situa-
tin, and pssible change in placement f the child.
■ Reprt ptential child abuse t Child Prtective Services (CPS).
Aer the list f ptential actins has been identied fr each desired utcme, deter-
mine which actins shuld be implemented t meet the pririty needs f the client in
the Take Action prcess.
Take Action
Deciding which actin t implement is the fcus f this clinical judgment thinking
skill. Aer generating a list f pssible interventins, determine the mst apprpriate
interventin r cmbinatin f interventins that will reslve r manage the client’s
pririty health prblems r cncerns. Als determine hw each interventin will be
implemented. Examples f methds t accmplish r implement interventins include
what t cmmunicate, dcument, perfrm, administer, teach, r request frm a primary
health care prvider r ther member f the health care team.
Fr example, in the pediatric clinical scenari described in the previus sectin n
Generate Solutions, yu might request a cnsultatin with the scial wrker t interview
the birth parent abut the child’s injuries and hme situatin. Scial wrkers are experts
in interviewing and addressing family situatins, and can determine if the child’s inju-
ries are ptentially cnsistent with abuse.
When deciding n hw t implement interventins, avid memrized textbk meth-
ds r prcedures. Instead cnsider the elements f the clinical situatin t determine
which apprach t use. Fr example, teaching the birth parent abut the care f the child
aer discharge wuld be apprpriate fr mst situatins. Hwever, in the pediatric clinical
example, yu might not want t teach the birth parent abut hme care aer discharge
frm the ED until it is determined whether the child will g hme with the birth parent. If
abuse is suspected, the child wuld be remved frm the current family situatin.
Evaluate Outcomes
e last clinical judgment thinking skill is t determine if the interventins imple-
mented fr the client reslved r eectively managed the health prblem(s). e best
way t make that determinatin is t cmpare what the desired r expected utcmes
are with current client ndings r bserved utcmes. Ask yurself, “Which assessment
ndings/signs and symptms indicate that the client’s cnditin has imprved?” “Which
ndings indicate that the client’s cnditin has declined?”
Fr example, cnsider this clinical scenari:
A 78-year-old client has been hospitalized for 6 days for exacerbation of chronic heart failure.
On admission the client was placed on supplemental oxygen and IV furosemide for peripheral
Remember: When deciding to
Take Action, avoid memorized
textbook methods and proce
dures; instead, customize your
action to meet the needs of the
client in the clinical scenario.
NGN TIP
THINKING SPACE

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items8
edema and impending pulmonary edema. e primary health care provider adjusted the cli-
ent’s cardiac medications and restricted salt intake (no added table salt). e nurse preparing for
the client’s discharge performs a head-to-toe assessment to determine the eectiveness of heart
failure management. e nurse documents the following client ndings:
■ Lungs clear with no adventitious breath sounds
■ No shortness of breath when walking short distances
■ Lost 5 lb (2.3 kg) during hospital stay
■ Bilateral ankle and foot edema decreased from 3+ to 1+
■ States planning to continue using table salt at home
In this example, all f the client assessment data at the time f discharge demnstrate
that the interventins used t manage heart failure were eective because the client is
imprving. Hwever, the client plans t cntinue using table salt at hme, which culd
cntribute t anther exacerbatin f heart failure. e nurse may need t reinfrce
teaching abut the relatinship f sdium t uid retentin r cnsult with the regis-
tered dietitian nutritinist t prvide the teaching.
How Will the Six Clinical Judgment Skills Be Measured on the
NGN?
e new NGN exam is cmpsed f current test item types and new test item types. e
ttal number f test items shuld range between 85 and 150 ttal questins. e six NCJMM
cgnitive skills intrduced in this chapter are measured n the NGN thrugh use f a variety
f new test item types that are embedded int tw types f case studies—the Unflding Case
Study and the Stand-alne item. Bth types f cases present a clinical scenari and include
part f a medical recrd similar t the recrd shwn in the gure.
Additinal medical recrd tabs may be included as the scenari requires.
e Unfolding Case Study presents the client ver time thrugh several phases f care
in the clinical scenari. It is en referred t as the NGN Case Study. e time between
phases can be minutes, hurs, r even days. e client may initially be evaluated in an
ED, acute care hspital, clinic, schl, r urgent care center. As the scenari changes,
r “unflds,” new NGN test items require that the candidate use the infrmatin in the
current phase f the client’s care t answer each questin. Nursing candidates can expect
t have three NGN Case Studies with six questins each. Each f the six questins rep-
resents ne f the clinical judgment cgnitive skills discussed earlier.
e Stand-alone item smetimes referred t as the Stand-alne clinical judgment
item, presents a client at ne pint in time and includes ne f the new NGN test item
types. Each item measures ne r mre f the six clinical judgment cgnitive skills.
Nursing candidates are expected t have varying numbers f Stand-alne items n the
NGN, depending n the candidate’s ability in taking the exam. Hwever, it is expected
that mst candidates will have abut seven Stand-alne items.
How Can You Prepare for the NGN?
In additin t using this bk, ther resurces such as the Developing Clinical Judgment
wrkbks written by ne f this bk’s authrs (D.D.I.) prvide thinking exercises t
Remember: To Evaluate Out-
comes, compare desired or
expected client outcomes with
current observed outcomes.
NGN TIP
Health History Nurses’ Notes Vital Signs Laboratory Results

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CHAPTER 1 Introduction to the Cognitive Skills of Clinical Judgment 9
help yu master the six cgnitive skills t make apprpriate clinical judgments. If yu
need help with basic NCLEX® test-taking strategies and want beginning practice with
NGN test items, tw f this bk’s authrs (L.A.S. and A.E.S.) created a bk entitled
Clinical Judgment and Test-Taking Strategies. All f these bks are included in the NGN
Resurce list at the end f this bk.
Anther way t prepare fr the NGN is t practice multiple test items in the Unfld-
ing Case Study and Stand-alne item frmats. NGN practice questins are lcated at the
end f Chapters 3 thrugh 8 f this bk. Chapter 9 illustrates Stand-alne and Unfld-
ing Case Studies with apprpriate NGN test items. Chapter is a cmprehensive NGN
Practice Test that includes questins in all specialty areas. Crrect answers, ratinales,
test-taking strategies, specialty cntent area, selected cncepts, and references are avail-
able fr all NGN practice questins in the bk.
In additin t the questins in this bk, 50 Stand-alne items and Unflding Case
Studies with accmpanying questins are available fr yur practice n the Elsevier
Evlve site. Categries fr selectin f questins n Evlve include Cntent Area, Prir-
ity Cncept, and Clinical Judgment Cgnitive Skill.
Nw that yu have been intrduced t the six cgnitive skills needed t make appr-
priate clinical judgment, yu are ready t learn abut the new NGN test item types. e
next chapter describes and illustrates examples f the new NGN test item types.
THINKING SPACE

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As described in Chapter 1, the NGN will be composed of current test item types and
new test item types. e six NCJMM cognitive (thinking) skills introduced in Chapter
1 will be measured on the NGN through use of a variety of new test item types that are
embedded into two types of cases—the Unfolding Case Study and the Stand-alone item.
Both types of cases present a common, realistic clinical situation that new graduates will
likely encounter.
is chapter describes the 15 new item types that will likely be part of the NGN. An
example of each item type is presented and the correct responses are provided with brief
rationales. Multiple examples of all item types, each with detailed Rationales, Content Area,
Priority Concept, Cognitive Skill, and References, are presented throughout this book.
Unlike the current NCLEX® items, most new NGN items will be scored using partial credit
rather than being completely correct or incorrect. is means that for most NGN items you
will receive credit for any correct responses but will not receive credit for incorrect responses.
Test Item Types Used for Unfolding Case Studies
As described in Chapter 1, the Unfolding Case Study, also known as the NGN Case Study,
presents a client and the initial data describing the clinical situation. ese data will typi-
cally be part of a client medical record. e client either will be experiencing an urgent or
emergent health problem or will be at risk for experiencing an urgent or emergent health
problem. You’ll need the information in the initial clinical scenario to answer the rst
NGN test item, which will measure the clinical judgment cognitive skill of Recognize Cues.
e second NGN test item will likely measure your ability to Analyze Cues. As the clinical
scenario continues, the client’s condition will change over time through several phases of
care in the clinical scenario. Four additional NGN test items will measure the other clinical
judgment cognitive skills based on what client data are provided.
Twelve of the new item types on the NGN will be integrated into multiple unfolding
case studies. e remaining two types will be used for the Stand-alone items discussed
later in this chapter. Table 2.1 organizes these item types by major category and the cog-
nitive skills that they best measure. Chapter 1 describes each of the six cognitive skills
essential for making appropriate clinical judgment when caring for clients across the
lifespan in a variety of health care settings.
Chapter 9 provides examples of complete unfolding cases with six accompanying test
items and examples of the two types of Stand-alone items. e new item types that will
be used as part of unfolding cases are described in the following sections.
Multiple Choice Test Items
Multiple choice test items have been a large part of the NCLEX® for many years. ese
items currently present a short clinical scenario and four choices with one correct
response and three distractors (the wrong options) (see Box 1.2 in Chapter 1 for an
example). For the NGN, there are two variations of the multiple choice item type: Mul-
tiple Choice Single Response and Matrix Multiple Choice.
Introduction to the NGN and
the New NGN Item Types
C H A P T E R 2
Remember: Data presented in
the new NGN test item formats
will usually be presented as part
of a medical record as shown in
the gure in Chapter 1. Many of
the test items presented in this
book are displayed in the medical
record format.
NGN TIP
Remember: Expect each unfold-
ing case on the NGN to present
client data that change over time
(minutes, hours, days) and six
NGN test items, each measuring
one of the six clinical judgment
cognitive skills.
NGN TIP

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C H A P T E R 2 Introduction to the NGN and the New NGN Item Types 11
Multiple Choice Single Response Item
On the NGN, the format for the Multiple Choice Single Response test item will be similar to
the current NCLEX® format. However, the clinical scenario will be longer with more infor-
mation about the client situation, usually within a portion of the medical record. In addition,
the number of responses will not be restricted to four options, and as many as 10 options
may be included. Sample Question 2.1 shows an example of this type of item to measure the
clinical judgment cognitive skill of Take Action for an adult client with a mental health issue.
TABLE 2.1 NGN Item Types for Unfolding Case Studies
NGN Item Types and Variations Cognitive Skills That Can Be Optimally Measured
Multiple Choice
Multiple Choice Single Response
Matrix Multiple Choice
Recognize Cues
Analyze Cues
Prioritize Hypotheses (except Matrix Multiple Choice)
Generate Solutions
Take Action
Evaluate Outcomes
Multiple Response
Multiple Response Select All That Apply
Multiple Response Select N
Multiple Response Grouping
Matrix Multiple Response
Recognize Cues
Analyze Cues
Prioritize Hypotheses (except Matrix Multiple Choice)
Generate Solutions
Take Action
Evaluate Outcomes
Drop-Down
Drop-Down Cloze
Drop-Down Rationale
Drop-Down in Table (may be replaced by a
Drag-and-Drop in Table)
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Generate Solutions
Take Action
Evaluate Outcomes
Drag-and-Drop
Drag-and-Drop Cloze
Drag-and-Drop Rationale
Recognize Cues
Analyze Cues
Prioritize Hypotheses
Generate Solutions
Take Action
Evaluate Outcomes
Highlight
Highlight in Text
Highlight in Table
Recognize Cues
Evaluate Outcomes
Based on the client information provided, what is the nurse’s rst
action?
☐ Ask the client’s friends to check the client for additional
weapons.
☐ Reassure the client that the client is safe and secure in the ED.
☐ Call Security for assistance.
Allow the client to vent own feelings.
☐ Administer an antianxiety medication.
☐ Distract the client and guide the client to practice coping
skills.
Multiple Choice Single ResponseSample Question .
Health History Nurses’ Notes Vital Signs Laboratory Results
: A 28-year-old client is brought to the ED by friends,
who state that the client became violent this evening in
a local bar after a partner “break up.” The client accused
the partner of “cheating” and pulled out a knife. The cli-
ent’s friends were able to stop the client and take the knife
before any harm occurred. They state that they have never
seen the client act like this and are worried that something
might be seriously wrong. Currently the client seems agi-
tated and restless, and begins pacing in the ED demand-
ing to “see my partner right now.”

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items12
Remember: As with any client
who is upset, paranoid, angry,
or potentially violent, you would
rst allow the client to vent feel-
ings, which may help diuse the
situation. Allowing a client to
vent and keeping the client and
sta safe are the initial focus of
nursing care when encounter-
ing any client with an actual or
potential mental health problem
or crisis.
NGN TIP
The nurse provides health teaching for a 70-year-old client
who had a TKA 3 days ago and is preparing to go home with
a daughter.
For each client statement, click or specify (with an X) whether the
statement indicates understanding or no understanding of the
teaching provided.
Client Statement Understanding No Understanding
“I’ll call my surgeon
if my incision gets
red or has drainage.”
☐
“I can stop taking
my blood thinner
when I get home.”
☐
“I’ll have physical
therapy for about a
week.”
☐
“I’m allowed to bear
weight on my right leg.”
☐
“I can probably drive
in a few months.”
☐
Matrix Multiple ChoiceSample Question .
Rationale: e rst nursing action is to allow the client to vent feelings. is action may
help to de-escalate and decrease the client’s agitation and restlessness. e nurse would
not want to ask friends to check for weapons because they could possibly be harmed.
Although calling Security may be needed later, the client may feel threatened by the pres-
ence of that authority gure and become more agitated or violent at this time. Reassuring
the client that the client is safe does not address the concern. Although the client is agi-
tated, distraction and practicing coping skills may be a better option at a later time aer the
current concern is addressed. Medication is usually the last resort unless needed to calm
the client so that communication can occur. Although the client is restless and pacing in
the ED, there is no evidence that the client would not vent feelings to the nurse.
Matrix Multiple Choice Item
e Matrix Multiple Choice test item is more complex than the Multiple Choice Single
Response item. A Matrix Multiple Choice item provides a clinical scenario and selected data
about the client. e test item is structured in a tabular format (matrix) with at least four
rows and three columns. For this item, you would select only one response for each row.
Sample Question 2.2 shows an example of this type of item to measure the clinical judgment
cognitive skill of Evaluate Outcomes for an adult client who has had a surgical procedure.
Rationale: As indicated in the test item, the client’s statements that are not correct and show
that the client does not understand the health teaching include: “I can stop taking my blood
thinner when I get home,” and “I’ll have physical therapy for about a week.” Clients who have
total joint arthroplasty (especially knee and hip) are at a high risk for venous thromboem-
bolism—DVT or PE. To help prevent these problems, the client is prescribed an oral antico-
agulant, which is typically continued for 10 days to several weeks aer surgery and should be
taken aer the client is home. e client would call the surgeon if the incision becomes red
and/or has drainage because these symptoms indicate possible infection.
Aer surgery, most clients have 3 to 6 weeks of physical therapy depending on the
type of prothesis and the client’s overall health and tolerance. e surgical joint is oen
sti, painful, and swollen, which limits the client’s range of motion; however, weight
bearing to tolerance helps promote ambulation and increase muscle strength. Physi-
cal therapy plus exercises that clients practice every day help to improve joint function
and independence. e client will be allowed to drive when muscle strength and joint
mobility improve. Driving is dicult until the surgical knee is able to ex more than 90
degrees. is goal may not be achieved for 6 to 8 weeks or more aer surgery.

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C H A P T E R 2 Introduction to the NGN and the New NGN Item Types 13
Multiple Response Test Items
Multiple Response test items have been a large part of the NCLEX® for many years.
ese items currently present a short clinical scenario with ve or six options. e cor-
rect response(s) could be one, some, or all options (see Box 1.2 in Chapter 1 for an
example). For the NGN, there are four variations of the Multiple Response test item:
■ Multiple Response Select All That Apply Item
■ Multiple Response Select N Item
■ Multiple Response Grouping Item
■ Matrix Multiple Response Item
Multiple Response Select All That Apply Item
On the NGN, the format for the Multiple Response Select All at Apply test item will
be similar to the current NCLEX® format. However, the clinical scenario will be longer
with more information about the client situation, usually within a portion of the medi-
cal record. e item will have at least ve choices and no more than 10 choices. e cor-
rect response could be one, some, or all options. Sample Question 2.3 shows an example
of this type of item to measure the clinical judgment cognitive skill of Analyze Cues for
an older client who is residing in an assisted-living facility and who experiences acute
confusion.
Rationale: e client’s assessment ndings indicate that the client likely has a UTI (as evi-
denced by multiple bacteria in the urine). Fever, acute confusion, and a low BP suggest that
the client is dehydrated and may have urosepsis. Acute confusion is also known as delirium,
a common assessment nding in older clients who have a UTI. Because the client has type 2
diabetes, the client also is likely experiencing a diabetic complication called hyperglycemic
hyperosmolar syndrome. e client’s elevated blood glucose and dehydration are consistent
with a hyperosmolar state. A low blood pressure is also consistent with dehydration.
Multiple Response Select N Item
e Multiple Response Select N test item is similar to the Multiple Response Select All
at Apply item except that the number of required correct responses is specied in the
question. is item will also have at least ve options but no more than 10 options from
which to choose. Sample Question 2.4 shows an example of this type of item to measure
the clinical judgment cognitive skill of Recognize Cues for an adult client who has new
onset of symptoms.
An 81-year-old client was admitted to an acute care unit from an
assisted-living facility with a low-grade fever and acute confusion.
The client’s daughter tells the admitting nurse that the client’s
mother had a stroke 2 years ago that resulted in left hemiparesis
and urinary incontinence, and the client has been in the assisted-
living facility for the past 5 months. The client has a long history
of DM type 2, which has been well controlled. Until this morning,
the client’s daughter had not been allowed to visit the facility due
to the COVID-19 pandemic. During the visit today, the daughter
noted that her mother was lethargic, confused, and unable to am-
bulate with a walker. POC testing in the ED indicated the presence
of multiple bacteria in the client’s urine and FSBG of 331 mg/dL
(18.4 mmol/L). The client’s BP is currently 96/48 mm Hg.
The nurse reviews the client assessment ndings and determines
that the client most likely has which of the following conditions?
Select all that apply.
Urosepsis
Delirium
Dehydration
☐ COVID-19
☐ DKA
☐ Transient ischemic attack
Hyperglycemic hyperosmolar syndrome
Multiple Response Select All That ApplySample Question .
THINKING SPACE

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items14
The nurse assesses a 53-year-old client whose partner brought
the client to the ED with report of acute onset dyspnea and back
pain that started about an hour ago. The client’s medical history
includes DM type 2, obesity, hypertension, hypercholesteremia,
and asthma. The client’s admission vital signs include:
 • Temperature = 98.8°F (37.1°C)
 • HR = 78 BPM and irregular
 • RR = 26 bpm and slightly labored
 • BP = 148/90 mm Hg
 • SpO2 = 95% (on RA)
The nurse reviews the client’s assessment data. Select 4 client nd-
ings that are relevant and of immediate concern to the nurse
Dyspnea
Back pain
☐ Temperature
☐ History of obesity
☐ History of diabetes
Tachypnea
☐ History of asthma
Elevated BP
Multiple Response Select NSample Question .
Remember: When reviewing cli-
ent ndings, rst determine what
is most relevant for that particu-
lar client in the clinical scenario.
Organize these ndings to deter-
mine which data are consistent
with specic client conditions or
health problems.
NGN TIP
The nurse admits an 11-month-old infant who has possible bac-
terial meningitis to the acute pediatric care unit.
For each body system listed below, click or specify (with an X) the po-
tential nursing interventions that are appropriate for the client’s care.
Each body system may support more than one potential intervention.
Body System Potential Nursing Interventions
Respiratory ☐ Incentive spirometer every 2 hours
Oxygen therapy via nasal cannula
☐ Chest x-ray now and at bedtime
Continuous pulse oximetry monitoring
Droplet Precautions
Neurologic Seizure Precautions
☐ Neurologic checks every day
Cardiovascular ☐ Type and crossmatch for 2 units of
packed red blood cells (PRBCs)
Vital signs every hour
Contact physician if temperature above
102.4°F (39.1°C)
Begin IV cefotaxime infusion
Blood cultures
Multiple Response GroupingSample Question .
Rationale: e client’s new symptoms include dyspnea and back pain, which could
indicate a possible MI and therefore are relevant in this clinical scenario. Women with
an MI oen present with symptoms that dier from those in men, including having back
or jaw pain. e client’s RR and BP are both elevated, but the temperature is normal. HR
is within normal limits but is irregular. e medical history may help explain or predict
the current client condition, but is not relevant at this time for planning nursing care.
Other examples of questions or statements that could be part of a Multiple Response
Select N test item with their associated cognitive skills include:
■ Select the three priority health problems that the client is experiencing. Analyze Cues
■ What are the five assessment findings that indicate the client is improving? Evaluate
Outcomes
■ Select the four physician orders that the nurse would anticipate for this client. Take Action
Multiple Response Grouping Item
e Multiple Response Grouping test item is similar to the Multiple Response Select
All at Apply item except that the options are presented in categories or by group in
a table with a minimum of two columns and ve rows. Each category will have two to
four options per row and require that at least one response option be selected. Sample
Question 2.5 shows an example of this type of item to measure the clinical judgment
cognitive skill of Generate Solutions for a pediatric client who has bacterial meningitis.

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Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items (2022)

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