NCLEX Bow-Tie Questions: Ultimate Guide with Practice Examples

The Next Generation NCLEX (NGN) introduced several advanced question formats, but none are as clinically realistic—or as confusing to new test-takers—as bow-tie questions. These items evaluate your ability to connect patient cues with nursing actions and prevent complications. In other words, bow-tie questions measure the real-world thinking nurses use every day.

Understanding how NCLEX bow-tie items work will give you an immediate advantage on the exam.

What Are bow-tie Questions?

Bow-tie questions are named after their distinctive shape:

• Left section → Two actions the nurse should take
• Center section → The most likely condition or clinical issue
• Right section → Two potential complications to prevent

These questions assess multiple layers of clinical judgment at once. They mirror real bedside decisions, making them a central part of NGN scoring.

How Bow-Tie Questions Work

Each bow-tie question provides:

• A client scenario
• Assessment findings
• Lab values or diagnostic results
• A list of options to place in the left, center, and right panels

Your job is to choose:

1. The correct clinical problem (center)

2. Two immediate nursing actions (left)

3. Two complications you must prevent (right)

Because bow-tie questions use partial scoring, you earn points for each correct placement—even if you miss one.

Example Bow-Tie Question

Scenario:
A client with type 1 diabetes reports nausea and abdominal pain. Respirations are deep and rapid. Lab

results:

• Blood glucose: 480 mg/dL
• pH: 7.18
• Serum ketones: elevated

Possible options include:

• Start IV regular insulin
• Administer 1L normal saline
• Monitor for hypokalemia
• Assess risk for dysrhythmias
• Diabetic ketoacidosis
• Hyperosmolar hyperglycemic state

Correct Bow-Tie Solution:

• Center (Condition): Diabetic ketoacidosis
• Left (Actions):
  • Start IV regular insulin
  • Administer 1L normal saline
• Right (Complications to Prevent):
  • Hypokalemia
  • Dysrhythmias

This example highlights how bow-tie questions connect assessment cues with immediate priorities and possible risks.

How to Master NCLEX Bow-Tie Questions

1. Follow the CJMM Framework

Use the Clinical Judgment Measurement Model: recognize cues → analyze → prioritize → act → evaluate.

2. Memorize High-Risk Complications

Most bow-tie items involve conditions with predictable dangers (DKA → potassium imbalance, heart failure → pulmonary edema).

3. Think Like a Nurse, Not a Student

Ask yourself: “What must I do right now to keep this patient safe?”

4. Practice Daily NGN Bow-Tie Items

Repetition builds confidence and reduces test anxiety.

Final Thoughts

NGN bow-tie questions may look challenging, but once you understand their structure, they become one of the most predictable NCLEX item types. Mastering bow-tie reasoning not only boosts your exam score—it also builds the clinical judgment skills every nurse needs in real practice.