NGN Practice Questions: Clinical Judgment Prep [2026]

All findings are EXPECTED for community-acquired pneumonia.

• Fever (101.8°F) — expected; pneumonia triggers an inflammatory/infectious response
• Tachycardia (98 bpm) — expected as a compensatory response to fever and hypoxemia
• SpO2 91% — expected; impaired gas exchange from alveolar consolidation reduces oxygenation
• BP 128/76 — expected; normotensive in early pneumonia
• WBC 14,200 — expected; elevated WBC indicates bacterial infection/immune response
• Yellow-green sputum — expected; purulent sputum is characteristic of bacterial pneumonia
• Crackles in RLL — expected; crackles indicate fluid/exudate in the alveoli at the infection site
• A&O x4 — expected; altered mental status would be unexpected and concerning for sepsis

If the question included "SpO2 91% on 4L nasal cannula," that would be UNEXPECTED — indicating inadequate response to supplemental oxygen and potential clinical deterioration.

CJMM Step: Recognize Cues

Highlight these findings:

1. "feeling dizzy when sitting up in bed" — Orthostatic dizziness in a post-surgical patient could indicate hypovolemia from blood loss, anemia, or medication effects. This requires assessment of orthostatic vital signs before ambulation.
2. "Hemoglobin from this morning is 8.2 g/dL, which is down from 10.1 g/dL pre-operatively" — A hemoglobin drop from 10.1 to 8.2 g/dL (nearly 2 points) indicates significant blood loss. This is below the typical transfusion threshold for symptomatic patients and correlates with the dizziness. The provider should be notified.

Findings that do NOT require immediate follow-up:

• Pain 4/10 on PCA morphine — acceptable post-op pain level
• Temperature 99.0°F — low-grade, expected post-op
• IS 8 times per hour — meets the goal
• Foley output 450 mL / 8 hours (56 mL/hr) — adequate
• SCDs in place — correct DVT prophylaxis
• Refused breakfast but drank juice — monitor but not urgent

CJMM Step: Analyze Cues

Correct answers:

1. Diabetic ketoacidosis (DKA) — The presentation (very high glucose, rapid deep respirations, fruity breath, altered consciousness) is classic DKA. HHS typically presents with even higher glucose (>600) but without ketosis or Kussmaul respirations. Hypoglycemia presents with low blood glucose and adrenergic symptoms.
2. Kussmaul respirations and fruity breath — Kussmaul respirations (rapid, deep breathing) are the body's attempt to blow off CO2 to compensate for metabolic acidosis. Fruity breath indicates ketone production. These are hallmarks of DKA, not HHS or hypoglycemia.
3. Initiate IV regular insulin infusion — DKA requires continuous IV regular insulin to lower blood glucose steadily. Oral glucose would worsen hyperglycemia. Subcutaneous NPH is too slow and unpredictable for an acute emergency.
4. Serum potassium — Insulin drives potassium into cells, which can cause life-threatening hypokalemia during DKA treatment. Potassium must be monitored frequently (every 1–2 hours) and replaced as needed. Sodium is also monitored but potassium is the higher priority due to cardiac arrhythmia risk.

CJMM Step: Generate Solutions

Contributing factors (select 2):

• ☑ Nursing home residence — institutional living increases exposure to respiratory pathogens and drug-resistant organisms
• ☑ History of diabetes — diabetes impairs immune function (reduced neutrophil activity, impaired wound healing, increased susceptibility to infection)

COPD and age-related immune decline are also contributing factors, but nursing home exposure and diabetes are more directly linked to the development of sepsis.

Central condition: Sepsis secondary to pneumonia (confirmed by: fever, tachycardia, tachypnea, hypotension, elevated WBC, elevated lactate >2 mmol/L)

Priority interventions (select 2):

• ☑ Administer IV broad-spectrum antibiotics within 1 hour — the Surviving Sepsis Campaign guidelines emphasize antibiotics within 1 hour of sepsis recognition
• ☑ Initiate IV fluid resuscitation with crystalloid bolus — hypotension (BP 92/58) requires volume resuscitation (30 mL/kg within 3 hours per sepsis bundle)

Monitoring parameters (select 2):

• ☑ Monitor lactate levels every 2–4 hours — lactate clearance indicates response to treatment; target is <2 mmol/L or 10%+ decrease
• ☑ Monitor MAP target ≥65 mmHg — MAP is the hemodynamic goal in sepsis management; MAP <65 indicates need for vasopressors

CJMM Step: Take Actions + Evaluate Outcomes

Complication: Hypovolemic shock (likely post-operative hemorrhage)

Evidence from the trend:

• HR: steadily increasing (78 → 86 → 98 → 112) — compensatory tachycardia
• BP: steadily decreasing (128/82 → 118/74 → 108/68 → 94/60) — progressive hypotension
• RR: increasing (16 → 20 → 24) — respiratory compensation for decreased perfusion
• SpO2: decreasing (98% → 93%) — declining tissue oxygenation
• Urine output: decreasing (60 → 45 → 30 → 15 mL/hr) — renal hypoperfusion from inadequate circulating volume

No single reading at any time point would trigger alarm (a HR of 98 and BP of 108/68 are individually acceptable). The trend — all parameters moving in the same direction simultaneously — reveals the developing emergency.

Priority action: Notify the provider/rapid response team immediately. Assess the surgical site for signs of bleeding. Prepare for IV fluid resuscitation and possible return to the operating room.

CJMM Step: Evaluate Outcomes

Correct selections: A, B, C, E, F, H (6 correct out of 8 options)

• ☑ A — Supplemental oxygen is needed immediately (SpO2 89% is hypoxemic). Target SpO2 >94%.
• ☑ B — Upright positioning (high Fowler's or tripod) maximizes lung expansion and reduces work of breathing.
• ☑ C — Albuterol is the first-line rescue bronchodilator for acute asthma. It relaxes bronchial smooth muscle within minutes.
• ☒ D — Morphine is CONTRAINDICATED in acute asthma. It causes respiratory depression and histamine release, which can worsen bronchospasm.
• ☑ E — PEFR monitoring before and after treatment objectively measures bronchodilator response and guides further treatment decisions.
• ☑ F — Pursed-lip breathing prevents airway collapse during exhalation and helps trapped air escape. This is appropriate for both asthma and COPD.
• ☒ G — NG tube insertion is not indicated for asthma. It's used for GI decompression.
• ☑ H — If bronchodilators and oxygen don't improve the patient's status, intubation and mechanical ventilation may be necessary. Preparing for this possibility is appropriate proactive nursing.

Scoring: If you selected A, B, C, E, F, H: 6 points. If you also incorrectly selected D: 6 − 1 = 5 points. Partial credit is awarded.

CJMM Step: Take Actions