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🧩 NCLEX guideUpdated October 20267 min read4 practice questions

Next Generation NCLEX item types, and how each is scored

The Next Generation NCLEX launched on April 1, 2023, and the 2026 test plan keeps its structure. If you trained on older question banks, the formats are the part of the exam that will look new. Here is every item type NCSBN uses, what it is really asking, and how it is scored.

Case studies: three per exam, six items each

Every candidate gets three case studies, 18 items in all. Each case opens a client record (nurses' notes, vital signs, labs, orders) that may update as the case moves, and its six items follow NCSBN's Clinical Judgment Measurement Model in order:

  1. Recognize cues: which findings matter? Often highlight or SATA.
  2. Analyze cues: what do they mean together? Often drop-down cloze or matrix.
  3. Prioritize hypotheses: the most likely or most dangerous explanation.
  4. Generate solutions: what could be done? SATA, matrix or drop-down.
  5. Take action: what to do first. Drop-down, drag-and-drop or multiple choice.
  6. Evaluate outcomes: did it work? Usually a matrix of findings (improved, no change, worse).

Knowing which step you are on tells you what kind of answer is wanted: findings for steps 1 and 6, conditions for 2 and 3, actions for 4 and 5. The Six Steps Hiding Inside Every Case Study and A Full Case Study, Step by Step walk a full case.

Stand-alone clinical judgment items

Past the 85-item minimum, about 10% of the additional items are stand-alone clinical judgment items. Two formats:

  • Bowtie: a short scenario, then a diagram with the condition in the middle, two actions to take on the left and two parameters to monitor on the right, dragged from lists. Five placements, scored zero/one each. The Bowtie: Condition in the Middle, Actions Left, Parameters Right.
  • Trend: a client record with results over several time points (vital signs across a shift, labs across days), then a question about what the trend means or what to do. The item type is the record; the response can be multiple choice, SATA or drop-down. Highlight Items and Reading a Trend Over Time.

Every item format and its scoring rule

Item typeWhat you doScoring
Multiple choiceOne answer of four or moreRight or wrong (1 point)
Multiple response: select all that applyTick every correct option; the list may run past the old fivePlus/minus: +1 per correct, −1 per incorrect, never below 0
Multiple response: select NThe stem says how many to pickZero/one: +1 per correct pick, nothing off for a wrong one
Matrix / grid, multiple choiceOne choice per row (e.g. indicated / contraindicated)Zero/one per row, summed
Matrix / grid, multiple responseTick any that apply per row or columnPlus/minus per column, summed
Drop-down clozeComplete a sentence or table from drop-down menusZero/one per drop-down
Drop-down rationalePaired drop-downs: "the client is at risk for ___ because of ___"Rationale scoring: both parts must be right to score
Highlight (text or table)Click the words or cells that matterPlus/minus
Drag and drop (cloze or ordering)Drag tokens into blanks or into orderZero/one per target
BowtieCondition, two actions, two parametersZero/one per placement (5)

NCSBN's three partial-credit rules, in its words: plus/minus ("points are deducted when they select the incorrect options"), zero/one ("they do not earn points when selecting incorrect options"), and rationale scoring ("both components of the pair must be correct"). A multi-point item's score is the sum of its parts.

How to handle each

  • SATA and highlight (plus/minus): every option is its own true/false. Pick only what you can defend; an unjustified extra costs a point. The SATA guide goes deeper.
  • Select N, matrix multiple choice, cloze, drag-and-drop (zero/one): no penalty for a wrong pick, so never leave a target blank. Rank, then fill every slot with your best choice.
  • Rationale pairs: decide the effect first (the risk or the problem), then the cause that produces that specific effect. A half-right pair scores nothing.
  • Bowtie: name the condition first; the actions and parameters must fit that condition. Two right actions for the wrong condition score zero on the middle and usually on the sides.
  • Trend: read the direction, not one number. A falling blood pressure with a rising heart rate across three readings is the finding; the latest value alone is the distractor.

Every format is answerable without going back: once you press Next, the item is final. Case-study tabs (notes, vitals, labs) stay open within the case, so read the record before the first item and re-read the updated parts as it moves.

Where to see real examples

NCSBN publishes an NGN sample pack (three RN case studies, two PN case studies and examples of each item type) and a candidate tutorial that shows the Pearson exam software. Do the tutorial once before test day so the interface is not what you are learning in the exam room. Savvy Nurse's practice exams carry 855 Next Gen items and 80 case studies in the same formats, scored by NCSBN's rules, and its 25-, 50- and 85-item sets include whole case studies in clinical-judgment order.

✅ Test yourself: 4 questions

Four select-all-that-apply items, the most common Next Gen format inside case studies. Pick only what you can defend. Every client is fictional; exam practice only, not medical advice.

Question 1 of 4 · Select all that apply

A nurse is obtaining a home medication history from a 79-year-old client admitted with heart failure, who has brought a bag of her pill bottles. Which actions by the nurse help produce an accurate list for medication reconciliation? Select all that apply.

  1. Asking about inhalers, eye drops, patches and injections given weekly or monthly
  2. Asking about vitamins, herbal products and over-the-counter medicines
  3. Asking how she actually takes each drug and when she took the last dose
  4. Leaving off a drug she stopped on her own, since she no longer takes it
  5. Copying the medication list from her discharge summary of 4 months ago
  6. Recording the directions on each bottle's label as the way she takes it
Show the answer and rationale

Answer: A, B, C

An accurate home list comes from the client's own account checked against the bottles and other sources, with specific questions about products people do not think of as medicines (inhalers, eye drops, patches, long-interval injections, vitamins, herbal and over-the-counter products) and about how and when each drug is actually taken. A list from 4 months ago is out of date, a label shows what was prescribed rather than what she really takes, and a drug she stopped on her own still goes on the list with that note, so the provider can decide whether it should be restarted.

📚 Learn it: The Rights of Medication Administration and the Errors That Beat Them

Question 2 of 4 · Select all that apply

A nurse is planning mealtime care for a 16-year-old client with anorexia nervosa on an inpatient eating disorders unit. Which actions should the nurse include? Select all that apply.

  1. Talk through the calorie content of each food so that she understands the plan
  2. Replace any food left at the end of the meal with the prescribed liquid supplement
  3. Allow as much time as she needs to finish, however long the meal takes
  4. Keep the client in view, with no bathroom use, for a set time after the meal
  5. Let the client eat alone in her room so that she feels less pressure
  6. Sit with the client for the whole meal and watch for food being hidden or thrown away
Show the answer and rationale

Answer: B, D, F

Meals on an eating disorders unit are structured and supervised: staff sit with the client throughout to notice food being hidden or discarded, uneaten food is replaced with the prescribed supplement so intake meets the plan, and the client stays in view, without bathroom use, for a set period afterward so she cannot purge or exercise the meal away. Eating alone removes the supervision the plan depends on. Talk of calories feeds the preoccupation treatment is trying to reduce, so mealtime conversation stays neutral. Meals have a set time limit, because an open-ended meal lets restriction drag on.

📚 Learn it: Don't Argue With the Delusion, and Other Rules for Psychosis

Question 3 of 4 · Select all that apply

An agency RN with 5 years of medical-surgical experience reports for her first shift on a medical unit. Which actions by the charge nurse are appropriate? Select all that apply.

  1. Skip the unit orientation, since the agency has already verified her license and skills
  2. Confirm she has been checked off on the unit's infusion pumps before she uses them
  3. Show her where the emergency equipment is and how to call a rapid response
  4. Give her the most complex clients, since agency nurses are hired for their experience
  5. Pair her with an experienced unit RN she can go to with questions
  6. Have her chart under another nurse's login until her own access is set up
Show the answer and rationale

Answer: B, C, E

A contracted nurse brings general skills but not this hospital's equipment, policies or emergency procedures, so the charge nurse orients her to the emergency equipment and rapid response process, confirms she is validated on equipment such as the unit's pumps, and gives her a resource nurse for questions. The agency's checks of license and skills do not replace the hospital's own orientation and competency assessment. Experience earns a fair assignment, not the unit's most complex clients on a first shift in unfamiliar surroundings, and charting under another nurse's login falsifies the record and breaches security.

📚 Learn it: The Five Rights of Delegation

Question 4 of 4 · Select all that apply

A client who had a deep vein thrombosis 2 years ago and no longer takes an anticoagulant is planning a 10-hour flight. Which instructions should the nurse include? Select all that apply.

  1. While seated, raise and lower your heels and toes and tighten your calf muscles often.
  2. Take an aspirin before the flight to keep a clot from forming.
  3. Take a sleep aid so you can rest through the whole flight without getting up.
  4. Choose an aisle seat so it is easier to get up and walk every 2 to 3 hours.
  5. Ask your provider before the trip whether you should wear compression stockings or take medicine.
  6. Limit fluids during the flight so you will not need to use the restroom.
Show the answer and rationale

Answer: A, D, E

Hours of sitting slow venous return from the legs, and a past DVT adds risk, so the client walks every 2 to 3 hours, which an aisle seat makes easier, does heel, toe and calf exercises while seated, and asks the provider before the trip about compression stockings or medicine, which are considered for travelers with extra risk factors. CDC does not recommend aspirin to prevent travel-related clots, a sleep aid keeps the client still for hours, and limiting fluids leads to dehydration, which adds to the clot risk.

📚 Learn it: DVT Prevention and the Pulmonary Embolism You Must Not Miss

Try a 25-item set with a full case study →

Case studies, bowtie, matrix, cloze and highlight items scored by NCSBN's rules, in tutor or timed mode. Free, no sign-up.

📱 On Android? Join the free Google Play test · iPhone and desktop: the web app works as is.

❓ Frequently asked

How many case studies are on the NCLEX?

Three, with six items each (18 items), for every candidate on both the RN and PN exams.

What is a bowtie question on the NCLEX?

A stand-alone clinical judgment item: a scenario, then a diagram where you drag the condition into the middle, two actions to the left and two parameters to monitor to the right. Each of the five placements is scored zero/one.

Are Next Gen NCLEX questions all or nothing?

No. Multi-point items earn partial credit under plus/minus, zero/one or rationale scoring; only paired rationale items are all-or-nothing within the pair.

Did the 2026 test plan change the Next Gen formats?

No. The 2026 plan, effective April 1, 2026, keeps the case studies, item types and scoring methods and adjusts the category weights.

📝 Practice this topic

📚 Learn it in the app's lessons

Sources

  1. NCSBN, NCLEX-RN Test Plan effective April 2026 (categories, 85–150 items, case studies, scoring methods, how the exam ends)
  2. NCLEX.com, Frequently Asked Questions (scoring rules, no going back, Quick Results)
  3. NCSBN, Next Generation NCLEX test design (2021 Midyear Meeting slides): item types, 52 + 18 + 15 structure, +/− and 0/1 scoring
  4. NCSBN, Next Generation NCLEX News, Summer 2021: scoring models by item type
  5. NCLEX.com, Prepare: candidate tutorial, exam preview and NGN sample pack

Accessed October 2026. Yearly figures name their year; NCSBN publishes a new statistics brief each June and a new test plan every three years (next: April 2029). Exam preparation only, never medical advice. NCLEX® is a registered trademark of NCSBN, which does not endorse this site.

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