With the Next Generation NCLEX possibly launching in 2023, students who are beginning nursing school in 2021 are understandably asking a lot of questions about the NCLEX and the potential new format they’ll be facing after graduation.
First, let’s talk about what the NCLEX is and how it works.
The NCLEX is the licensing exam that RN and LVN/LPN candidates take to secure licensure. Currently the NCLEX RN exam consists of 75-145 questions that must be answered in a maximum of five hours. This includes 15 “pretest items” that do not count toward your score, but must be completed in order to take the rest of the exam. These are experimental questions that are being evaluated as potential future NCLEX exam questions. At the end of your exam, you may receive questions that are voluntary research questions. These questions do not count toward your score and you can choose to answer none, some or all of them.
Both the NCLEX-RN and NCLEX-PN utilize computer adaptive testing or CAT. What this means is the test is essentially created for YOU as you answer each question. The computer analyzes how you answer a question and determines your level of competency. If you selected the correct answer(s), the computer knows you are competent and gives you a more difficult question. On the other hand, if you selected an incorrect answer, the computer selects an easier question for you. This process continues until the algorithm decides you have met or not met the testing requirements and at that point your test ends and you have either passed or failed.
What types of questions are on the NCLEX?
There are several types of questions on the NCLEX, with some new additions coming in the Next Generation test. Current NCLEX question types are:
- Multiple Choice – Standard “NCLEX-style” question with four options
- Multiple Response – Choose any of the options that are correct; also known as “select all that apply” or SATA. Students tend to find these types of questions intimidating as they are very open ended. The correct response could be all the options, only one of the options or anything in between.
- Image or “Hot Spot” Questions – These questions will feature an image (illustration, table or chart) and ask you to click on the “hot spot” that answers the question.
- Fill-in-the-Blank – These questions could include dosage calculations, I/O calculation or some other kind of medical math such as a tube feeding dilution concentration. Your answer will be typed into the answer box and you’ll need to pay careful attention to rounding rules.
- Drag and Drop – In these questions, you’ll place the steps to an intervention in the proper order.
- Graphic Questions – In these questions, the answer options will be images rather than words.
- Chart-Based Questions – These questions will show you information you’d find in a patient’s chart. You may need to click around on various tabs to find the information you need to answer the question.
- Video and Audio – These questions may ask you to interpret things like lung sounds or assessment techniques.
Next Generation NCLEX
The Next Generation test includes some exciting new formats to help bridge the gap between book knowledge and clinical decision making. The goal is to more accurately determine readiness to enter into practice. Format types include:
- Enhanced Multiple Response – If you didn’t enjoy SATA before, you’ll probably enjoy them even less but they are an EXCELLENT way to mimic real-world situations. When my patient deteriorates, I don’t just have four or five options to choose from! These questions could possibly present a patient scenario and then provide a long list of options for the appropriate actions to take. At this time, NCBSN states these questions will allow for partial credit scoring…that’s great news!
- Extended Drag and Drop – These questions will include more information than the standard drag and drop, assessing a deeper ability to make sound clinical judgments.
- CLOZE – These are short-answer questions with drop-down menus that contain a few options. I’ve seen samples with two – four options and can be within tables, charts and sentences.
- Enhanced Hot Spots – These questions could be case studies, illustrations or chart data and ask you to click on specific information to show you know which information is important to your clinical decision making.
- Case Studies – Unfolding patient scenarios place you into a patient situation and assess your ability to recognize key data and make the appropriate care planning decisions. These questions honestly look fun to me and the example I saw showed a patient chart with a written scenario.
- In these questions, you’ll need to be able to recognize which of the assessment findings and lab/diagnostic results are relevant and require action. You’ll need to be able to focus on the most important data to make a clinical decision and be able to identify potential risks to the patient. You’ll also need to show you can prioritize what needs to be addressed for the patient in this particular scenario. Additionally, you’ll need to be able to predict what types of treatments and interventions will be part of the patient’s plan of care, and show you are able to take action on that plan of care. You’ll also need to show you can objectively evaluate the patient’s outcomes and can recognize if the patient is not meeting the goals of care.
- They’re LOADED with critical thinking and clinical judgments and really seem to mimic the type of multi-layered decision making you will utilize every single day as a nurse. I love these!
- Dynamic Exhibit and Constructed Response – These questions will present information in a “dynamic exhibit” and ask a question that is answered in short format.
- Matrix/Grid – These questions provide a list of options and ask you to categorize them as essential, non essential or contraindicated for the patient.
Now, I know students are apprehensive about a new exam format, but from what I understand, the Next Generation questions will not make up the entire exam. There will still be some of the standard NCLEX questions you have come to know and love, though it is not known how many will be utilized.
What we do know at this point is that the new format questions are based on the Clinical Judgment Measurement Model (CJMM) developed by NCBSN, which includes six components:
- Recognize Cues: This segment of the CJMM correlates with the first part of the Nursing Process (assessment), but it takes it further. Rather than just knowing what and how to assess, the Next Gen questions are asking if you know how to recognize patient conditions that warrant further investigation or intervention. In other words, do you know when to get worried about your patient?
The sample video on the NCBSN website shows a nurse caring for a patient who complains of itching at her neck. Rather than blow it off, the nurse recognizes this could be important and assesses the patient’s neck which is red with some hives.
- Analyze Cues: This segment and the one that follows fall into the analysis/diagnosis step of the Nursing Process. Once you’ve recognized that something is off about your patient, do you know what this means for your patient? In the sample video, the worried look on the nurse’s face indicates she’s aware this could be serious.
- Priorities Hypotheses: In this component you develop a hypothesis about what you think is going on with the patient. In the video example, the nurse looks up at the antibiotic that’s infusing and you can almost see the lightbulb go off! The hypothesis is that this is an allergic reaction to the antibiotic.
- Generate Solutions: This component correlates with the planning component of the nursing process. To me, this happens almost simultaneously with taking action, but your plan in this case could be to stop the antibiotic, call the MD, and prioritize the assessment you want to conduct, etc…
- Take Action: This component of the CJMM correlates with the implementation phase of the Nursing Process. In the video, the nurse stops the antibiotic infusion.
- Evaluate Outcomes: This final component of the model correlates with the evaluate component of the nursing process. Did the action we performed result in the desired outcome? In the video, we see the nurse assessing the patient and listening to her lungs, presumably for wheezes (which are often present in anaphylaxis).
So if your school has been heavily relying on the Nursing Process and you feel like you’re going to flounder with this more dynamic style of test, don’t worry…it correlates nicely! You will need to focus your attention on putting the pieces together, thinking through patient problems and prioritizing the nurse-driven interventions to address those problems. Do as many case studies as you can and always read rationales for any NCLEX practice questions you answer (even the ones you think are “easy”).
I also heard that nursing diagnoses are not on the Next Generation NCLEX…so that’s great news as I find nursing diagnoses to be unnecessarily complex. From what I’ve seen of some sample questions, it looks like they are more problem/solution based, rather than relying on convoluted language that no one actually ever uses.
Hopefully the NCLEX preparation materials students rely on will begin incorporating these formats soon. Your school should also be looking at how they will prepare students for this Next Generation exam as well, so anticipate curriculum changes to be coming your way! Personally, I think these changes are fantastic and more closely showcase how nurses think and make decisions in real time. I just know you are going to do great!
For an example of case study questions: https://www.ncsbn.org/14172.htm
Other sample questions: https://www.ncsbn.org/NGN-Sample-Questions.pdf
NCLEX RN Test Plan from NCBSN: https://www.ncsbn.org/2019_RN_TestPlan-English.pdf
NCSBN. (n.d.-a). NCSBN clinical judgment measurement model. NCSBN. https://www.ncsbn.org/14798.htm
NCSBN. (n.d.-b). NGN FAQs for candidates. NCSBN. https://www.ncsbn.org/11436.htm
NCSBN. (n.d.-c). NGN FAQs for educators. NCSBN. https://www.ncsbn.org/11447.htm
NCSBN Examinations. (2019a). The Next Generation NCLEX asking the right questions. https://www.ncsbn.org/14171.htm
NCSBN Examinations. (2019b). The right decisions come from the right questions. https://www.ncsbn.org/14172.htm
NCSBN Examinations Department. (2019). Next Generation NCLEX (NGN) educator webinar. https://www.ncsbn.org/14177.htm
Silvestri, PhD, RN, FAAN, L., & Silvestri, PhD, APRN, FNP-BC, CNE, A. E. (2020). Saunders Comprehensive Review for the NCLEX-RN® Examination, 8th Edition. Saunders.