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.
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 teaching walkthrough of one patient so you can see the flow before test day. The NGN launched April 1, 2023, and your real exam includes roughly 3 scored case studies (NCSBN, 2023).
If you have ever opened a Next Generation NCLEX® case study and felt your stomach drop, you are not alone. The format looks different from anything you practiced in your first two years. The good news is that it is predictable. Every case study uses the same skeleton: one patient, six questions, and one Clinical Judgment Measurement Model (CJMM) step per question, presented in a fixed order (ATI, 2023).
Here is the part that should calm you down. You are not being asked to memorize a new test. You are being asked to think like a nurse, one step at a time, in the same order you would at the bedside. First-time US-educated test takers passed at 87.1% as of November 1, 2025, so this format is very learnable (Nurse.org, 2025). This post walks you through a single realistic patient across all six steps so the structure stops feeling scary and starts feeling familiar.
Note: The patient, vitals, and labs below are an illustrative teaching example written to demonstrate 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 that develops across exactly six linked questions. Each question maps to one step of the CJMM, and they appear in a set order. As you answer, new assessment data and orders unfold, just 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 roughly three scored case studies, which is about 18 of your scored questions (NCSBN 2026 RN Test Plan).
One rule matters more than any other. You cannot go back. Once you submit a question, the patient moves forward and so do you. That mirrors real nursing. You act on the information you have, then you reassess. So treat each screen as its own decision and trust the work you did on the screen before it.
Why do case studies take longer than standalone questions?
Case studies take longer because you are reading a growing chart, not a one-line stem. A single case study packs six questions around one patient, so you may spend several minutes inside it before moving on. That is normal and expected, not a sign you are slow (Osmosis).
Your whole exam runs 85 to 150 questions with a five-hour limit (NCSBN 2026 RN Test Plan). Budget your time so a case study never panics you. Read the chart tabs once, slowly. Then answer each of the six parts in order. If one part stumps you, make your best clinical decision and keep moving. You earn credit part by part, so a hard question 3 does not sink questions 4, 5, and 6.
How does partial credit work?
Many NGN item types earn partial credit, so a half-right answer still earns you something. NCSBN uses three scoring rules across the new formats: 0/1 scoring, plus/minus scoring, and rationale scoring (NCSBN, 2023; Nurse Plus, 2023).
In plain language, you no longer get zero for missing one piece of a Select All That Apply. You get points for the correct choices you make and lose points only for wrong ones, often with a floor of zero so you cannot go negative (Nurse Plus, 2023). This is great news. It rewards careful, partial reasoning instead of punishing one slip. So answer every part fully and never leave a box you are confident about unchecked.
A full 6-question case study walkthrough
Here is your patient. Meet Ms. R, a 78-year-old woman admitted from home for a urinary tract infection. We will follow her across all six CJMM steps. Read the scenario, look at each sample question, then read the reasoning and the one-line takeaway. Remember, 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.
Step 1. Recognize Cues
Sample question (Highlight or Multiple Response): "Highlight the assessment findings that require immediate follow-up."
The reasoning: This step asks you to spot what matters from a busy chart. Your relevant cues are the new confusion, the temperature of 38.6 C, the heart rate of 104, the respiratory rate of 22, and the blood pressure of 98/56. Each one is outside the expected range, and together they point toward an infection that may be worsening. You are not diagnosing yet. You are gathering the findings worth following up.
Takeaway: Recognize Cues is "what is abnormal or relevant here?" Pull the findings, do not interpret them 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 you connect cues to possible causes. The fever, rising heart rate, increased respiratory rate, and low blood pressure in a patient with a known infection support a developing sepsis or systemic infection picture. New confusion in an older adult also fits infection, since altered mental status is a common early sign in older patients. The data is less consistent with an isolated stroke, which usually brings focal deficits, not just global confusion plus fever. Dehydration may be a contributing factor but does not explain the full picture alone.
Takeaway: Analyze Cues is "what could these findings mean, and which fit best?" Link 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: You have several possible explanations, so you rank them by urgency and likelihood. Early sepsis is your top hypothesis because it is both well supported by the cues and the most life-threatening if missed. Use your safety framework here. Airway, breathing, and circulation come first, and a falling blood pressure with a rising heart rate threatens circulation. Dehydration and medication effects stay on your list, but they sit below a possible 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: You plan before you act. For suspected early sepsis, reasonable nursing goals include maintaining adequate perfusion and oxygenation and identifying the source of infection. Appropriate, standard nursing actions to consider are notifying the provider about the changes, anticipating orders such as blood cultures and fluids, monitoring vitals closely, and reassessing mental status. Note that Generate Solutions is an official CJMM step name. You are matching goals to interventions, not inventing new 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 do something. Strong first nursing actions here are to notify the provider promptly about the change in status, stay with or closely monitor the patient, recheck vital signs, and prepare to carry out new orders such as obtaining cultures and administering ordered IV fluids. Put safety first: keep the bed low and call light in reach for a confused older adult at fall risk. Take Action rewards the safe, in-scope nursing response, not a heroic or invented 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: After your actions and new orders, the chart updates. Say one hour later her blood pressure is 112/68, heart rate is 92, temperature is 38.0 C, oxygen saturation is 96%, and she is more oriented. You compare new data to your goals. Improved perfusion markers and clearer mental status suggest your interventions are working. If instead her pressure had kept dropping, that would signal decline and a need to escalate. Evaluation always loops back to the goals you set in 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 is the whole case study at a glance. Use this table as your mental map when you open any case study on test day. Each step has a job, and each job tends to show up in a few familiar item formats (ATI, 2023).
| CJMM step | What it asks you | Common item formats |
|---|---|---|
| 1. Recognize Cues | Which findings are relevant or abnormal? | Highlight, Multiple Response |
| 2. Analyze Cues | What might these findings mean? | Matrix, Drag-and-Drop |
| 3. Prioritize Hypotheses | What is most urgent and most likely? | Multiple Response, Drop-Down |
| 4. Generate Solutions | What is the plan and the goals? | Matrix, Multiple Response |
| 5. Take Action | What do I do, and in what order? | Drop-Down Cloze, Multiple Response |
| 6. Evaluate Outcomes | Did it work, and what is next? | Matrix, Trend comparison |
How should I practice case studies before test day?
Practice them as full units, not single questions. The skill the NGN tests is carrying one patient through all six steps without losing the thread. So when you study, run a whole case start to finish, then check each part against the CJMM order. That builds the muscle memory the exam rewards (Osmosis).
A simple drill helps. After any practice case, name the CJMM step each question was testing. If you can label all six in order, you understand the structure. If you cannot, that gap is exactly what to review. Pair this with your safety frameworks, airway-breathing-circulation and Maslow, so your prioritizing and acting stay grounded in standard nursing logic.
Study With Lily turns your course material into adaptive NCLEX® practice, including full case studies, so you can rehearse the unfolding format with patients drawn from what you are already learning. Practice NGN case studies 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 roughly three scored case studies, which adds up to about 18 case-study questions (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 decision on each screen, then trust it and keep going. That habit mirrors real bedside nursing.
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). So a tough question inside a case will not erase the points you earn on the other five. Answer every part as fully as you can.
How long should a case study take? Plan for a few minutes per case, since you are 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 without rushing back and forth.
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). Every student testing now sees this format, so practicing it is no longer optional.
Is the case study format hard to pass? It is learnable. First-time US-educated test takers passed at 87.1% as of November 1, 2025, even with the newer format in play (Nurse.org, 2025). The all-comers rate, which includes repeat and internationally educated takers, was 69.1% that year. Steady practice in the six-step structure is what closes the gap.
Related Articles
- The NCLEX Clinical Judgment Model: 6 Steps
- How to Answer Select All That Apply (SATA)
- How to Answer Bow-Tie Questions
- How Many Questions Is the NCLEX in 2026?
- NCLEX 2026 Changes
Sources
- ATI, 2023. The 6 Functions of the Next Gen NCLEX. https://www.atitesting.com/educator/blog/knowledge/2023/10/01/6-functions-next-gen-nclex
- Osmosis. Tips and Question Types for the Next Generation NCLEX (NGN) Exam. https://www.osmosis.org/blog/tips-and-question-types-for-the-next-generation-nclex-ngn-exam
- NCSBN. 2026 NCLEX-RN Test Plan. https://www.ncsbn.org/publications/2026-nclex-rn-test-plan
- NCSBN, 2023. Are traditional NCLEX Multiple Response (SATA) items scored with partial credit? https://ncsbn.zendesk.com/hc/en-us/articles/7807555764631-Are-traditional-NCLEX-Multiple-Response-Select-all-that-Apply-SATA-items-scored-with-partial-credits
- Nurse Plus, 2023. NGN Scoring. https://nurse.plus/become-a-nurse/ngn-score/
- Nurse.org, 2025. Overall NCLEX Pass Rates Fall in 2025, But First-Time U.S. Graduates Hold Strong. https://nurse.org/news/nclex-pass-rates-decline-remote-testing-update/
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