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Field Notes
Field NotesJul 2026

NCLEX® Case Study Example: A 6-Step Walkthrough

See a full unfolding NGN case study: one patient, 6 questions, one clinical-judgment step each. Walk through all 6 parts with reasoning and takeaways.

July 3, 20269 min readBy Harrison Hesslink
A stack of nursing study guides with bookmarks and a page of notesNURSING NOTESTHE STUDY GUIDEONE TOPIC AT A TIMEKEEP LEARNING

TL;DR: An unfolding NGN case study is one patient followed across exactly 6 questions, with each question testing one step of the Clinical Judgment Measurement Model in order, and you cannot go back. Below is a full walkthrough of one patient so you can see the flow before test day. The NGN launched April 1, 2023, and your real exam includes 3 case studies, or 18 items, in a minimum-length exam (NCSBN 2026 RN Test Plan).

A Next Generation NCLEX® case study looks nothing like what you practiced in your first two years of school. But the skeleton never changes: one patient, six questions, one Clinical Judgment Measurement Model (CJMM) step per question, always in the same order (ATI, 2023).

Nothing here needs new memorization. You think like a nurse, one step at a time, in the order you would at the bedside. First-time US-educated NCLEX-RN® test takers passed at 86.7% in 2025, so people clearly learn this format (NCSBN, 2026). This post follows one patient through all six steps so the structure feels familiar by test day.

Note: The patient and vitals below are an illustrative teaching example written to show the case-study format. They are not an official NCSBN item, and your actual exam questions will differ. Always follow your course materials and clinical protocols for real practice.

What is an unfolding NGN case study?

An unfolding case study is one patient story told across exactly six linked questions. Each question maps to one CJMM step, in a set order. As you answer, new assessment data and orders appear, like a real shift (Osmosis).

The six CJMM steps, in order, are: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, and Evaluate Outcomes (ATI, 2023). Your real NCLEX® includes three case studies, which is 18 items of the 85-item minimum exam (NCSBN 2026 RN Test Plan).

The rule that matters most: you can't go back. Once you submit, the patient moves forward and so do you. That's real nursing. You act on what you have, then reassess. Treat each screen as its own decision and trust the work you did on the last one.

Why do case studies take longer than standalone questions?

Case studies take longer because you're reading a growing chart, not a one-line stem. Six questions around one patient can eat several minutes. That's normal. It doesn't mean you're slow (Osmosis).

Your whole exam runs 85 to 150 questions with a five-hour limit (NCSBN 2026 RN Test Plan). Read the chart tabs once, slowly. Then answer the six parts in order. If one stumps you, make your best clinical call and move on. Credit comes part by part, so a hard question 3 doesn't sink 4, 5, and 6.

How does partial credit work?

Many NGN item types earn partial credit, so a half-right answer still scores. NCSBN uses three scoring rules across the new formats: 0/1, plus/minus, and rationale (NCSBN, 2023; Nurse Plus, 2023).

In plain language, missing one piece of a Select All That Apply no longer means zero. You earn points for correct choices and lose points only for wrong ones, often with a floor of zero so you can't go negative (Nurse Plus, 2023). So answer every part fully, and don't leave a box unchecked if you're confident about it.

A full 6-question case study walkthrough

Meet Ms. R, a 78-year-old woman admitted from home with a urinary tract infection. We'll follow her through all six CJMM steps. For each one: a sample question, the reasoning, and a one-line takeaway. Again, this is a teaching example, not an official item.

The chart so far. Ms. R, 78, was admitted yesterday for a UTI and started on IV antibiotics. This morning her daughter says she is "more confused than usual" and "just not herself." Vitals this morning: temperature 38.6 C (101.5 F), heart rate 104, respiratory rate 22, blood pressure 98/56, oxygen saturation 94% on room air. She is alert but disoriented to time and place.

Handwritten NCLEX® study notes on a desk

Step 1. Recognize Cues

Sample question (Highlight or Multiple Response): "Highlight the assessment findings that require immediate follow-up."

The reasoning: Spot what matters in a busy chart. Your cues are the new confusion, the temperature of 38.6 C, heart rate of 104, respiratory rate of 22, and blood pressure of 98/56. Each is outside the expected range, and together they point toward an infection that may be worsening. You're not diagnosing yet. You're collecting the findings worth following up.

Takeaway: Recognize Cues is "what is abnormal or relevant here?" Pull the findings. Don't interpret yet.

Step 2. Analyze Cues

Sample question (Drag-and-Drop or Matrix): "For each finding below, indicate whether it supports the hypothesis of sepsis, dehydration, or stroke."

The reasoning: Now connect cues to causes. Fever, rising heart rate, faster breathing, and low blood pressure in a patient with a known infection support developing sepsis. New confusion in an older adult fits too, since altered mental status is a common early sign in that group. An isolated stroke fits less well. It usually brings focal deficits, not global confusion plus fever. Dehydration may contribute but doesn't explain everything alone.

Takeaway: Analyze Cues is "what could these findings mean, and which fit best?" Tie evidence to hypotheses.

Step 3. Prioritize Hypotheses

Sample question (Multiple Response or Drop-Down): "Which condition is the priority for Ms. R right now, and why?"

The reasoning: Several explanations are in play, so rank them by urgency and likelihood. Early sepsis comes first. The cues support it, and it's the most life-threatening if missed. Lean on your safety framework: airway, breathing, circulation, and a falling blood pressure with a rising heart rate threatens circulation. Dehydration and medication effects stay on the list, below a worsening infection.

Takeaway: Prioritize Hypotheses is "what is most urgent and most likely?" Rank by risk to life first.

Step 4. Generate Solutions

Sample question (Matrix or Multiple Response): "Select the appropriate goals and interventions for the priority hypothesis."

The reasoning: Plan before you act. For suspected early sepsis, reasonable goals include keeping perfusion and oxygenation adequate and finding the source of infection. Standard nursing actions to consider: notify the provider of the changes, anticipate orders like blood cultures and fluids, monitor vitals closely, and reassess mental status. You're matching goals to interventions, not inventing treatments.

Takeaway: Generate Solutions is "what is the plan, and what would help?" Match safe, standard goals to interventions.

Step 5. Take Action

Sample question (Drop-Down Cloze or Multiple Response): "Select the actions the nurse should take first."

The reasoning: Now you act. Strong first moves: notify the provider promptly about the change in status, stay with or closely monitor her, recheck vitals, and get ready to carry out new orders like cultures and IV fluids. Keep safety in view too. A confused older adult is a fall risk, so the bed stays low and the call light within reach. Take Action rewards the safe, in-scope response, not a heroic one.

Takeaway: Take Action is "what do I do, and in what order?" Choose safe, in-scope nursing actions first.

Step 6. Evaluate Outcomes

Sample question (Matrix): "For each finding, indicate whether the patient's status has improved, declined, or is unchanged."

The reasoning: The chart updates after your actions and new orders. An hour later her blood pressure is 112/68, heart rate 92, temperature 38.0 C, oxygen saturation 96%, and she's more oriented. Compare that to your goals. Better perfusion and clearer mental status suggest the interventions are working. If her pressure had kept dropping, that would mean decline and a need to escalate. Evaluation always goes back to the goals from step 4.

Takeaway: Evaluate Outcomes is "did it work, and what now?" Compare results to your goals and reassess.

What does each CJMM step ask, and how does it look?

Here's the whole case at a glance, a mental map for any case study on test day. Each step has a job, and each job tends to show up in a few familiar formats (ATI, 2023).

CJMM stepWhat it asks youCommon item formats
1. Recognize CuesWhich findings are relevant or abnormal?Highlight, Multiple Response
2. Analyze CuesWhat might these findings mean?Matrix, Drag-and-Drop
3. Prioritize HypothesesWhat is most urgent and most likely?Multiple Response, Drop-Down
4. Generate SolutionsWhat is the plan and the goals?Matrix, Multiple Response
5. Take ActionWhat do I do, and in what order?Drop-Down Cloze, Multiple Response
6. Evaluate OutcomesDid it work, and what is next?Matrix, Trend comparison
The 6-step NGN case study patient journeySix labeled nodes connected left to right showing the Clinical Judgment Measurement Model order: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take Action, Evaluate Outcomes.1RecognizeCues2AnalyzeCues3PrioritizeHypotheses4GenerateSolutions5TakeAction6EvaluateOutcomesOutcomes loop back into your next round of cues

How should I practice case studies before test day?

Practice them as full units, not single questions. The NGN tests whether you can carry one patient through all six steps without losing the thread. Run a whole case start to finish, then check each part against the CJMM order (Osmosis).

Try this drill. After any practice case, name the CJMM step each question tested. Can you label all six in order? If not, that's your review list. Pair it with airway-breathing-circulation and Maslow so your prioritizing stays grounded in standard nursing logic.

Study With Lily turns your course material into adaptive NCLEX® practice, and Full Access adds Unfolding Case Studies, so you can rehearse the unfolding format with patients drawn from what you're already learning. Start practicing free

Frequently Asked Questions

How many questions are in one NGN case study? Each unfolding case study has exactly six questions, one for each step of the Clinical Judgment Measurement Model, all about the same patient (ATI, 2023). Your full NCLEX® includes three case studies, which adds up to 18 case-study questions in a minimum-length exam (NCSBN 2026 RN Test Plan).

Can I go back and change my answer in a case study? No. The NGN does not let you return to a previous question, inside a case study or anywhere else. Once you submit, the patient story unfolds and you move forward (Osmosis). Make your best clinical call on each screen, trust it, and keep going.

Do case studies count more than regular questions? Each case-study question is scored, and many of the new item types earn partial credit using NCSBN's three scoring rules (NCSBN, 2023). A tough question inside a case won't erase the points you earn on the other five.

How long should a case study take? Plan on a few minutes per case. You're reading a growing chart and answering six linked questions. Your whole exam allows up to five hours for 85 to 150 questions (NCSBN 2026 RN Test Plan). Read the chart once, carefully, then answer each part in order.

When did NGN case studies start appearing on the NCLEX®? The Next Generation NCLEX® launched on April 1, 2023, which is when unfolding case studies and the new item types became part of the live exam (NCSBN, 2023). Everyone testing now sees this format.

Is the case study format hard to pass? People learn it. First-time US-educated NCLEX-RN® test takers passed at 86.7% in 2025, even with the newer format in play (NCSBN, 2026). The all-comers rate, which includes repeat and internationally educated takers, was 69.1% that year. Steady practice with the six-step structure helps close that gap.

Sources

About the Author

Harrison is the founder of Study With Lily. He built the platform after watching his wife and her nursing school classmates wrestle with expensive, outdated prep tools. He writes about NCLEX® strategy, test-plan changes, and evidence-based study methods, drawing on NCSBN primary sources.

Last updated: June 21, 2026 · 9 min read