NGN question types, with an example of each
The NCLEX measures clinical judgment with case studies and with question formats beyond multiple choice, known as Next Generation NCLEX (NGN) items. Here is what each format asks you to do, how it's scored and how to answer it, with an example of each.
Where they appear on the exam
The 2026 NCLEX-RN and NCLEX-PN test plans set the two exams out the same way.
- Length
- 85 to 150 questions in up to 5 hours, breaks included. Past the minimum, the exam stops once it's 95% sure which side of the passing standard you're on.
- Case studies
- Three on every exam, six questions each. At the shortest length that's 18 of the 85 questions, beside 52 from the eight content areas and 15 unscored questions being tried out for later exams. You can't tell which those are.
- Stand-alone items
- Single clinical judgment questions with a chart of their own, such as bow-tie and trend items: approximately 10%, depending on how long your exam runs.
A case study follows six steps
A case study is one patient and six questions. The chart grows as the case unfolds, and each question tests one step of NCSBN's Clinical Judgment Measurement Model, in this order.
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1
Recognize cues
Pick out what matters in the chart: the history, the vital signs, what the patient says.
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2
Analyze cues
Connect those cues to what is happening with the patient.
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3
Prioritize hypotheses
Decide which explanation is most likely and most urgent.
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4
Generate solutions
Work out the outcomes to aim for and the interventions that would reach them.
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5
Take action
Carry out the interventions that address the highest priority.
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6
Evaluate outcomes
Compare what happened with what you expected.
Our case studies run the same way: you take all six questions in order, and an answer is final once you move on. The question bank holds 8 NCLEX-RN and 8 NCLEX-PN case studies.
How NGN questions are scored
A question with one correct answer is right or wrong. A question with more than one earns partial credit, by one of three rules. Our question bank scores its questions by the same rules.
Zero/one
The question tells you how many answers to choose.
A point for each correct answer you choose. A wrong one earns nothing and costs nothing.
Plus/minus
You may select as many options as you think apply.
A point for each correct option you select and a point off for each incorrect one. The total never goes below zero.
Rationale
Two answers belong together, such as a finding and the reason for it.
The pair earns its point only when both halves are right.
Select N
A list of options and a number, such as “Select 3.” You choose exactly that many.
How it's scored. Zero/one: a point for each correct answer you choose. A wrong choice earns nothing and costs nothing.
A patient is 15 minutes into a transfusion of packed red blood cells. Which 3 findings should the nurse report right away? Select 3.
- Temperature 101.2°F (38.4°C), up from 98.8°F (37.1°C) before the transfusion
- New pain in the lower back
- Blood pressure 122/76 mm Hg, the same as before the transfusion
- Hives on the chest and arms
- Heart rate 78/min, the same as before the transfusion
How to answer it
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1
Find the number in the question. Here it's 3: choose exactly 3.
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2
Weigh each option against what the question asks: here, which findings are new since the transfusion began.
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3
A wrong choice costs nothing, so always choose as many as the question asks.
Show the answers and rationale
Correct answers
- Temperature 101.2°F (38.4°C), up from 98.8°F (37.1°C) before the transfusion
- New pain in the lower back
- Hives on the chest and arms
Rationale
A new fever, low back pain and hives that start during a transfusion are signs of a transfusion reaction: the transfusion is stopped and they're reported right away. A blood pressure and heart rate that haven't changed aren't a concern.
Matrix
A grid with a row for each finding, action or statement and a column for each choice. A multiple-choice matrix takes one column in every row. A multiple-response matrix lets a row take several.
How it's scored. A multiple-choice matrix is scored zero/one: a point for each row you get right. A multiple-response matrix is scored plus/minus.
A patient had abdominal surgery 2 days ago. For each finding, specify whether it is expected or needs follow-up.
| Finding | Expected | Needs follow-up |
|---|---|---|
| Incision pain rated 4 out of 10 when moving | ||
| Temperature 102.2°F (39°C) | ||
| A small amount of clear yellow (serous) drainage on the dressing | ||
| Swelling and tenderness in one calf |
How to answer it
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1
Treat each row as its own question: here, is this finding expected 2 days after surgery?
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2
Choose one column in every row. In a multiple-response matrix, a row can take more than one.
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3
Each row you get right earns a point, so don't leave one empty.
Show the answers and rationale
Correct answers
- Incision pain rated 4 out of 10 when moving:
- Expected
- Temperature 102.2°F (39°C):
- Needs follow-up
- A small amount of clear yellow (serous) drainage on the dressing:
- Expected
- Swelling and tenderness in one calf:
- Needs follow-up
Rationale
Some pain on moving and a little serous drainage are expected 2 days after surgery. A fever this high can mean an infection, and a swollen, tender calf can mean a blood clot (deep vein thrombosis): both need follow-up.
Drop-down
A sentence or a table with lists built into it. You choose one option from each list to complete it.
How it's scored. Zero/one: a point for each list you get right. When the lists are linked, such as a problem and the reason for it, the rationale rule applies and a pair earns its point only when both are right.
A patient with type 1 diabetes took insulin at breakfast but skipped lunch. At 2 p.m., the patient is shaky and sweating. Complete the sentence by choosing from the lists of options.
The patient is most likely experiencing List 1 , as shown by List 2 .
List 1
- hyperglycemia
- hypoglycemia
- dehydration
List 2
- a blood pressure of 128/80 mm Hg
- a temperature of 98.4°F (36.9°C)
- a blood glucose of 54 mg/dL
How to answer it
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1
Read the whole sentence first, so you know what each list has to complete.
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2
Choose one option from each list.
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3
When lists are linked, as a condition and the finding that shows it are here, check that your choices go together: the pair earns its point only when both are right.
Show the answers and rationale
The sentence, completed
- The patient is most likely experiencing hypoglycemia, as shown by a blood glucose of 54 mg/dL.
Rationale
Shakiness and sweating after insulin and a missed meal, with a blood glucose of 54 mg/dL (below 70), point to hypoglycemia. The blood pressure and the temperature are normal and don't explain it.
Drag and drop
Blanks in a sentence or a table, and one list of choices to fill them from. Each choice goes in one blank at most, and there are more choices than blanks.
How it's scored. Zero/one: a point for each blank you fill correctly. Linked blanks are scored by the rationale rule, as linked drop-downs are.
The same patient is awake and able to swallow, and the blood glucose is 54 mg/dL. Complete the sentence by placing an action in each blank.
The nurse should first Blank 1 , then Blank 2 .
Choices
- give the next scheduled dose of insulin
- recheck the blood glucose in 15 minutes
- give 15 g of a fast-acting carbohydrate, such as 4 oz (120 mL) of juice
- encourage the patient to rest until dinner
How to answer it
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1
Read every choice first. There are more choices than blanks, and each choice goes in one blank at most.
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2
Place a choice in each blank: drag it there, or select it and then select the blank.
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3
Each blank you fill correctly earns a point.
Show the answers and rationale
The sentence, completed
- The nurse should first give 15 g of a fast-acting carbohydrate, such as 4 oz (120 mL) of juice, then recheck the blood glucose in 15 minutes.
Rationale
A patient who is awake and can swallow is treated with 15 g of a fast-acting carbohydrate, and the blood glucose is checked again 15 minutes later. More insulin would lower it further, and rest doesn't treat it.
Highlight
A passage or a table from the patient's chart. You select the phrases that answer the question, such as the findings that need follow-up.
How it's scored. Plus/minus: a point for each correct phrase and a point off for each incorrect one, never below zero.
The nurse reads a patient's note. Highlight the findings that need follow-up right away.
Nurses' note
08:00. Patient reports chest pressure that spreads to the left arm. Skin is cool and clammy. Ate most of breakfast. Heart rate 118/min. Daughter visiting at the bedside.
The underlined phrases are the ones you can highlight.
How to answer it
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1
Read the passage with the question in mind: here, what needs follow-up right away.
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2
Highlight only the phrases that answer it. Selecting a phrase highlights it, and selecting it again clears it.
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3
Each wrong highlight takes a point away, so don't highlight everything that seems related.
Show the answers and rationale
Correct answers
- chest pressure that spreads to the left arm
- Skin is cool and clammy
- Heart rate 118/min
Rationale
Chest pressure spreading to the left arm, cool and clammy skin and a fast heart rate can be signs of a heart attack (myocardial infarction), which needs follow-up right away. A good appetite and a family visit don't.
Multiple response grouping
Several groups, such as body systems or parts of a teaching plan, each with its own options. You select every option that applies in each group.
How it's scored. Plus/minus: a point for each correct option you select and a point off for each incorrect one, never below zero.
A patient has had vomiting and diarrhea for 2 days. For each body system, select the findings that suggest dehydration.
Cardiovascular
- Heart rate 112/min
- Capillary refill under 2 seconds
- Blood pressure 92/58 mm Hg, lower than usual
Renal
- Dark amber urine
- Urine specific gravity 1.010
- Urine output 20 mL/h
Skin and mucous membranes
- Moist mucous membranes
- Dry mouth and lips
- Skin stays tented after a pinch
How to answer it
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1
Take each group on its own: here, each body system.
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2
In every group, select each option that applies. A group can have one or several.
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3
A wrong selection takes a point away within its group, so select only what fits.
Show the answers and rationale
Correct answers
- Cardiovascular:
- Heart rate 112/min; Blood pressure 92/58 mm Hg, lower than usual
- Renal:
- Dark amber urine; Urine output 20 mL/h
- Skin and mucous membranes:
- Dry mouth and lips; Skin stays tented after a pinch
Rationale
Vomiting and diarrhea lose fluid: the heart rate rises and the blood pressure falls, the kidneys make less, darker urine, and the mouth dries and the skin stays tented. A normal capillary refill, a normal urine specific gravity and moist mucous membranes don't suggest dehydration.
Bow-tie
A whole patient problem on one screen. The condition the patient is most likely experiencing goes in the middle, two actions to take on one side and two parameters to monitor on the other.
How it's scored. Zero/one: five points, one for each correct choice.
A patient with heart failure has gained 3 lb (1.4 kg) in 2 days and has crackles in both lungs and swelling in both ankles. Complete the diagram: the condition the patient is most likely experiencing, 2 actions to take and 2 parameters to monitor.
Actions to take
Choose 2
- Give the prescribed furosemide
- Encourage 3 L of fluid a day
- Place the patient flat in bed
- Raise the head of the bed
- Apply warm compresses to the ankles
Condition most likely experiencing
Choose 1
- Dehydration
- Fluid volume excess
- Pneumonia
- Hypoglycemia
Parameters to monitor
Choose 2
- Blood glucose
- Daily weight
- Pupil size
- Lung sounds
- Hemoglobin A1C
How to answer it
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1
Start in the middle: decide what the patient is most likely experiencing, since the actions and parameters depend on it.
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2
Then choose 2 actions that address that condition, and 2 parameters that would show whether it's getting better.
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3
Each correct choice earns a point, 5 in all, and a wrong one costs nothing.
Show the answers and rationale
Correct answers
- Condition:
- Fluid volume excess
- Actions to take:
- Give the prescribed furosemide; Raise the head of the bed
- Parameters to monitor:
- Daily weight; Lung sounds
Rationale
Rapid weight gain, crackles and ankle swelling in heart failure point to fluid volume excess. Furosemide removes fluid and raising the head of the bed eases breathing; more fluid or lying flat would make it worse. Daily weight and lung sounds show whether the extra fluid is going. Blood glucose, pupil size and A1C don't.
Trend items
A trend item is a stand-alone question, in any of these formats, whose chart shows the patient's data at several times: vital signs across a shift, or laboratory results over three days.
The work is comparing them: what has improved, what hasn't changed and what is getting worse.
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