NCLEX · NGN · BOW-TIE

NCLEX Bow-Tie Question Examples

Last reviewed: by Jayson Minagawa, BSN, RN

Bow-tie items are one of the new Next Generation NCLEX (NGN) item types and the one most NCLEX prep books underprepare you for. They test the Clinical Judgment Measurement Model (CJMM) — recognize cues, analyze, prioritize, take action, evaluate. This page has 8 worked bow-tie examples with full rationales spanning med-surg, peds, OB, psych, and critical care scenarios.

I've tutored two new grads through NGN. Both flunked their first practice bow-tie because no prep book had given them more than one or two examples. Bow-tie format isn't intuitive — you pick TWO actions, ONE condition, and TWO parameters to monitor, all from the same case study. Once you've worked through 8 of these, the pattern clicks. That's what this page is for.

— Jayson Minagawa, BSN, RN

8 worked NCLEX bow-tie examples

Med-Surg

Scenario

65 yo M with COPD exacerbation, day 2 of admission. Suddenly presents with worsening dyspnea, RR 32, SpO2 86% on 4L NC, accessory muscle use, anxious.

2 actions to take
• Increase O2 to non-rebreather and reassess
• Notify provider for immediate evaluation
1 most likely condition
• Acute respiratory failure
2 parameters to monitor
• SpO2 every 5 minutes
• Mental status (CO2 narcosis risk)

Rationale: ABCs: airway/breathing first. Non-rebreather provides higher FiO2. Notify provider for likely escalation (BiPAP/intubation). Watch for CO2 retention with worsening mental status.

Pediatrics

Scenario

4 yo with bacterial meningitis. Vitals: HR 152, BP 78/42, temp 39.8C, weak peripheral pulses, capillary refill 4 seconds, lethargic.

2 actions to take
• Rapid IV fluid bolus 20 mL/kg NS
• Notify rapid response/PICU
1 most likely condition
• Septic shock
2 parameters to monitor
• BP every 5 minutes
• Urine output hourly

Rationale: Pediatric septic shock: weak pulses, prolonged cap refill, hypotension. Rapid 20 mL/kg crystalloid bolus per pediatric sepsis bundle. PICU level care indicated.

Obstetrics

Scenario

G3P2 at 38 weeks, 4 cm dilated, intermittent contractions. After spontaneous rupture of membranes, FHR drops to 80 bpm and stays for 90 seconds.

2 actions to take
• Reposition mother to left lateral
• Discontinue oxytocin and apply oxygen at 10L
1 most likely condition
• Cord prolapse / variable deceleration
2 parameters to monitor
• FHR continuously
• Maternal vital signs every 5 min

Rationale: Prolonged variable deceleration after ROM is a cord prolapse concern. Reposition (left lateral or knee-chest), discontinue oxytocin, apply oxygen, prepare for emergent C-section if persistent.

Psychiatric

Scenario

Patient on day 3 of inpatient psych unit voluntary admission. Suddenly states 'I want to leave AMA' and stands at exit door. Charge nurse aware. Patient denies SI/HI.

2 actions to take
• Implement de-escalation techniques
• Notify provider re: voluntary admission status
1 most likely condition
• Voluntary patient requesting AMA discharge
2 parameters to monitor
• Patient behavior and statements
• Compliance with safety protocols

Rationale: Voluntary patients can request discharge. Provider must evaluate within timeframe (state-dependent, often 72 hours) to determine if involuntary hold is needed (SI, HI, or grave disability).

Critical Care

Scenario

ICU patient on norepinephrine 0.1 mcg/kg/min for septic shock. MAP 58. Lactate 4.2. Urine output 15 mL/hr last 2 hours.

2 actions to take
• Increase norepinephrine titration per order
• Bolus 30 mL/kg NS (not yet given)
1 most likely condition
• Persistent septic shock requiring vasopressor escalation
2 parameters to monitor
• MAP every 15 min
• Urine output hourly

Rationale: Septic shock target: MAP ≥65, urine output ≥0.5 mL/kg/hr. Current MAP 58 and oliguria indicate inadequate perfusion. SSC bundle: 30 mL/kg crystalloid, vasopressors to MAP ≥65.

Cardiac

Scenario

62 yo with new-onset chest pain, ST elevation V1-V4. EKG read by hospitalist as anterior STEMI. Pain 9/10. BP 142/88, HR 96.

2 actions to take
• Aspirin 325 mg chewed and administered
• Activate cath lab per STEMI protocol
1 most likely condition
• Anterior STEMI requiring emergent PCI
2 parameters to monitor
• Cardiac rhythm continuously
• Pain reassessment q15 min

Rationale: STEMI bundle: aspirin 325 mg chewed, cath lab activation within 90-min door-to-balloon time. Continuous cardiac monitoring; ventricular dysrhythmias common with anterior STEMI.

Renal

Scenario

Patient with ESRD missed dialysis. Labs: K+ 6.8, EKG showing peaked T waves V2-V5 but no QRS widening. HR 68, BP 138/82. No symptoms.

2 actions to take
• IV calcium gluconate 1 g over 10 min
• Insulin 10 units IV with 50 mL D50
1 most likely condition
• Severe hyperkalemia with EKG changes
2 parameters to monitor
• Continuous cardiac monitor
• Blood glucose every 30 min

Rationale: Calcium gluconate stabilizes cardiac membrane (does not lower K+). Insulin/D50 shifts K+ intracellularly. Both are temporizing; emergent dialysis is definitive.

Geriatric

Scenario

78 yo postop hip ORIF day 1. Confused this morning, was alert/oriented yesterday. T 38.2C, WBC 14.5, urine cloudy. SpO2 95% RA, BP and HR stable.

2 actions to take
• Obtain UA and urine culture
• Reassess mental status and orient frequently
1 most likely condition
• Postoperative delirium with possible UTI
2 parameters to monitor
• Mental status every shift
• Vital signs every 4 hours

Rationale: Acute delirium in postop geriatric patient — assess for infection (UTI common), hypoxemia, electrolytes, pain, medication side effects. Treat underlying cause; non-pharmacologic delirium prevention first.

How bow-tie items are scored on NGN

NGN bow-tie items use the Clinical Judgment Measurement Model (CJMM). You select 2 actions, 1 condition, and 2 monitors — points are awarded per correct selection across the 5 cells. Partial credit is given (you don't have to get every cell right). The bow-tie tests cue recognition, prioritization, and evaluation in a single integrated case.

Common bow-tie traps