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Exploring New Question Types on the Next Generation NCLEX®

The NCLEX®, or National Council Licensure Exam, is a standardized test that would-be nurses must pass to become an LPN or RN. There two versions of the test — the NCLEX-RN and the NCLEX-PN — but for ease of discussion, we’ll refer to both as the NCLEX. This test allows states to independently verify that graduates of a nursing program have the knowledge and skills to safely practice nursing.

The NCLEX in its current format was first implemented in 1994, when the NCSBN began using a computerized adaptive test (CAT). With a computerized adaptive test, the questions change in difficulty depending on the correct or incorrect answers to the previous question. The exam items on this version of the test, and those before it, are standard multiple-choice questions.

As the NCSBN realized that healthcare was becoming more complex and nurses needed to make increasingly complex patient care decisions, they began to consider adding new exam items that would assess a nursing candidate’s clinical judgment and decision-making abilities.

What Is the Clinical Judgment Measurement Model?

To assess a prospective nurse’s clinical judgment abilities and decision-making skills within the context of a high-stakes exam, the NCSBN developed the Clinical Judgment Measurement Model (NCJMM). To create this model, “NCSBN researchers drew upon the prevailing literature in nursing, nurse pedagogy, cognitive psychology, psychological assessment, and decision science related to decision making and nursing clinical judgment.”

This model is a layered approach to assessment, with each layer outlining a separate aspect of clinical decision making. For example, the first layer may require the exam-taker to assess a patient. Proceeding to the higher layers, they would then analyze the information, devise a treatment plan, implement that plan, and finally evaluate the outcome.

To move to a clinical judgment model, the NCSBN saw that new question types were necessary.

In 2017, the NCSBN began to include new question types, as a trial run, to develop a more rigorous examination. This new section of the test — the Special Research Section — was only given to a select group of candidates and was not counted toward the final score. These new item types are the basis of the Next Generation NCLEX (NGN).

Testing New Item Types for the Next Gen NCLEX

The NCSBN, in its quest for a better exam, added different item stems to the traditional multiple-choice questions. According to NCSBN, these are:

  • Chart/Exhibit Questions: These items require the exam-taker to gather information from charts or exhibits to choose the correct answer.
  • Audio Questions: Exam-takers choose the best answer after listening to an audio file.
  • Graphic Questions: With this item type, candidates select an answer based on the information presented in the graphic provided.

None of these alternate format questions counted toward the final grade and not all exams included these item types.

The other alternate format test questions are as follows:

  • Multiple Response Questions
  • “Hot Spot” Questions
  • Fill-in-the-Blank Questions
  • Drag-and-Drop/Ordered Response Questions

6 New Item Types on the NGN

After usability studies prior to field testing, and psychometric analysis of the results from the alternate exam items, the NCSBN chose six new question types: the four listed immediately above, plus Cloze (Drop-Down) and Bowtie. The first cohort of LPN and RN candidates to take the Next Generation NCLEX will be in 2023.

The following question types are intended to evaluate a new nurse’s decision-making capability and ability to make clinical judgments in various healthcare settings:

  1. Extended Multiple Response: Similar to the multiple-choice item type on the previous iterations of the NCLEX, the item stem for an extended multiple-response question is a text-based scenario that outlines a realistic situation in healthcare. The extended model has more options and requires, or allows, for more than one correct answer. Exam-takers can earn partial credit on these questions.
  2. Extended Drag-and-Drop: Like the ordered response questions (alternate-format NCLEX questions), the extended drag-and-drop items often require test-takers to prioritize aspects of patient care or presenting symptoms. A major difference between the two is that not all response options are required or appropriate.
  3. Cloze (Drop-Down): With this item type, exam-takers must choose from a list of possible options from drop-down menus that appear in a sentence, chart, or table. There could be up to six responses for each item.
  4. Enhanced Hot Spot (Highlighting): These items allow exam-takers to highlight one or more portions of a text or table concerning a client’s medical record to answer the question.
  5. Matrix/Grid: Used to measure multiple aspects of a clinical scenario, this question type requires exam-takers to choose one or more answers from a row and/or column in the matrix (grid).
  6. Bowtie: For this item type, exam-takers place answers in the five spaces that resemble a bow. For example, a candidate will place the answer for the condition the patient is most likely experiencing in the middle of the bowtie. The two answers on the left may correspond to appropriate actions to take given the condition. The two answers on the right side of the bowtie would then represent the parameters to monitor and gauge the patient’s progress.

How ExamSoft Can Help You Prepare Your Nursing Students for the NGN

Prepping nursing students for the NCLEX is not an easy job, and with so many additional item types on the Next Generation NCLEX, it becomes even more complex. However, it doesn’t have to be.

With ExamSoft’s all-in-one digital assessment platform, you can configure NGN item types and deliver them to your students. After your students complete the exam, you can analyze performance data to identify where they did well and where they had challenges. You will be able to provide timely, actionable feedback to your students and adjust teaching methods to ensure effective content coverage and strong pass rates on the NGN.

For more information about the Next Generation NCLEX and how ExamSoft can help, schedule a demo today.  


NCSBN: NCSBN Historical Timeline: 1986-1994

NCSBN: NCSBN Clinical Judgment Measurement Model

NCSBN: Next Generation NCLEX Project

NCSBN: What the Exam Looks Like

Next Generation NCLEX News: The Next Generation NCLEX Usability Studies

Next Generation NCLEX News: Approved NGN Item Types

Ameritech College of Healthcare: Tackling NCLEX Alternate Format Questions: Practice Questions and Tips

Next Generation NCLEX News: Next Generation NCLEX: Stand-Alone Items

Published: October 26, 2021

Updated: January 5, 2023

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