NGN bow-tie practice questions
A bow-tie item asks you to connect the most likely condition with two actions and two parameters to monitor. Read the number of selections required, use only the supplied cues, and make all five selections describe one coherent clinical picture. These text versions expose the reasoning without imitating live NCLEX content.
Educational boundary
Each scenario is deliberately simplified for exam preparation. It is not a standing protocol or substitute for patient-specific assessment, current orders, emergency response, medication labeling, and facility policy.
Question 1: Opioid toxicity
Cues: After opioid administration, the client is difficult to arouse, respirations are markedly depressed, and oxygenation is worsening.
Select one condition: opioid toxicity; hypoglycemia; airborne infection.
Select two actions: support airway and ventilation; administer naloxone as ordered; give flumazenil; end observation after the first response.
Select two parameters: respiratory effort and oxygenation; level of consciousness and recurrent sedation; dietary vitamin K intake; stool frequency.
Show answer and rationale
Condition: opioid toxicity. Actions: support airway/ventilation and administer naloxone as ordered. Monitor: respiratory effort/oxygenation and consciousness/recurrent sedation. The naloxone label keeps resuscitative support and surveillance central because the response can be incomplete and opioid effects can recur after naloxone wanes.
Question 2: Conscious client with low glucose
Cues: A conscious client who can swallow has shakiness and sweating; point-of-care glucose is below the instructed threshold.
Select one condition: hypoglycemia; heparin overdosage; C. difficile infection.
Select two actions: give 15 grams of fast-acting carbohydrate according to the plan; recheck glucose after 15 minutes; give long-acting insulin immediately; prohibit all oral intake.
Select two parameters: repeat glucose result; symptom response and recurrence; INR; airborne-room pressure.
Show answer and rationale
Condition: hypoglycemia. Actions: provide the instructed fast-acting carbohydrate and recheck after 15 minutes. Monitor: repeat glucose and symptom response/recurrence. The MedlinePlus self-care guidance describes the 15-gram treatment and 15-minute recheck for a person who can follow that plan; inability to swallow or severe impairment requires a different emergency response.
Question 3: Suspected C. difficile
Cues: A hospitalized client develops new frequent diarrhea after antibiotic exposure, and C. difficile testing is ordered.
Select one condition: suspected C. difficile infection; cardiac arrest; opioid toxicity.
Select two actions: initiate Contact Precautions according to policy; use dedicated equipment when possible; place the client in an airborne-infection isolation room solely for this finding; delay precautions until every test is final.
Select two parameters: stool pattern and hydration-related clinical status; response to the ordered evaluation and treatment; INR; insulin peak time.
Show answer and rationale
Condition: suspected C. difficile infection. Actions: initiate Contact Precautions according to policy and use dedicated equipment. Monitor: stool pattern/hydration-related status and the response to ordered evaluation/treatment. CDC guidance supports prompt isolation/contact precautions and dedicated equipment; it does not classify C. difficile as an airborne indication.
Question 4: Bleeding during heparin therapy
Cues: A client receiving unfractionated heparin develops significant active bleeding and an excessive anticoagulation response.
Select one condition: heparin-associated over-anticoagulation; hypoglycemia; benzodiazepine reversal.
Select two actions: stop heparin and notify the appropriate clinician according to the emergency process; prepare protamine sulfate if ordered; administer naloxone; encourage unsupervised ambulation.
Select two parameters: bleeding and hemodynamic response; ordered coagulation testing; stool isolation category; glucose after oral carbohydrate.
Show answer and rationale
Condition: heparin-associated over-anticoagulation. Actions: stop the heparin/escalate according to the clinical process and prepare ordered protamine. Monitor: bleeding/hemodynamic response and ordered coagulation tests. The heparin and protamine labels support coagulation monitoring and protamine neutralization, with careful administration because protamine itself can cause severe reactions.
Question 5: Cardiac arrest
Cues: An adult suddenly becomes unresponsive, is not breathing normally, and has no definite pulse.
Select one condition: cardiac arrest; stable chronic pain; isolated dietary interaction.
Select two actions: activate the emergency-response system; begin high-quality CPR and obtain an AED/defibrillator; complete routine discharge teaching; wait for a full chart review.
Select two parameters: rhythm/pulse checks at the protocol-defined times; response to CPR and defibrillation; long-term food preferences; bowel pattern before resuscitation.
Show answer and rationale
Condition: cardiac arrest. Actions: activate emergency response and begin CPR/obtain an AED. Monitor: protocol-timed rhythm/pulse assessment and response to resuscitation. Current adult basic-life-support guidance prioritizes recognition, activation, CPR, and AED use without delaying for nonessential tasks.
Common questions
How many selections does an NGN bow-tie item require?
Follow the directions shown in the item. A common bow-tie configuration asks for one condition, two actions, and two parameters, but you should never assume the count without reading the screen.
How do I keep the five bow-tie selections consistent?
State the condition first, then confirm that both actions address that condition and both parameters evaluate its risk or response. Reject a selection that belongs to a different clinical picture.
Are these copied from the NCLEX?
No. They are original educational examples and are not copied from, recalled from, or represented as live NCLEX content.
Sources and further reading
- NCSBN — 2026 RN Test Plan — National Council of State Boards of Nursing; evidence locator: 2026 RN Test Plan; effective April 1, 2026–March 31, 2029; source updated ; accessed
- NCSBN — Next Generation NCLEX — National Council of State Boards of Nursing; evidence locator: NGN Project and Clinical Judgment Measurement Model sections; source updated ; accessed
- NCSBN — NCLEX Frequently Asked Questions — National Council of State Boards of Nursing; evidence locator: How the NCLEX Works — item selection and initial difficulty; What the Exam Looks Like — partial-credit methods and unanswered-item prompt; live page checked 2026-08-28 and no page-level revision date is published; accessed
- Naloxone Hydrochloride Injection Prescribing Information — DailyMed, U.S. National Library of Medicine; evidence locator: Opioid Overdose — airway and resuscitative support, surveillance, incomplete response, and repeat administration; source updated ; accessed
- MedlinePlus — Low blood sugar: self-care — U.S. National Library of Medicine; evidence locator: When Your Blood Sugar Gets Low — 15 grams, 15-minute recheck, repeat treatment, and conditional follow-up snack; source updated ; accessed
- CDC — C. diff Infection Prevention in Acute Care Facilities — Centers for Disease Control and Prevention; evidence locator: Isolate and initiate contact precautions; dedicated equipment; environmental cleaning; transfer communication; duration after diarrhea resolves; source updated ; accessed
- CDC — Type and Duration of Precautions for Selected Infections — Centers for Disease Control and Prevention; evidence locator: Disease-specific entries for tuberculosis, measles, varicella, zoster, influenza, pertussis, meningococcal disease, mumps, rubella, group A streptococcus, MDROs, C. difficile, scabies, lice, RSV, and wounds; source updated ; accessed
- Heparin Sodium Injection Prescribing Information — DailyMed, U.S. National Library of Medicine; evidence locator: Dosage and Administration — coagulation-test monitoring; Warnings and Precautions — hemorrhage and thrombocytopenia; Overdosage — protamine neutralization; source updated ; accessed
- Protamine Sulfate Injection Prescribing Information — DailyMed, U.S. National Library of Medicine; evidence locator: Indications and Usage — heparin overdosage; Warnings — severe hypotensive and anaphylactoid reactions; Dosage and Administration — slow IV administration and dose dependence on elapsed time; source updated ; accessed
- Part 7: Adult Basic Life Support — 2025 AHA Guidelines — American Heart Association via PubMed; evidence locator: Abstract — recognition of cardiac arrest, emergency-response activation, CPR, AED use, respiratory arrest, and foreign-body airway obstruction; PMID 41122888; source updated ; accessed
Practice this for real. PulseRN includes bow-tie items inside adaptive practice and unfolding case studies.