Next Generation NCLEX Question Types and How They Are Scored

Since April 2023 the NCLEX-RN and NCLEX-PN have used a wider set of question formats, and several of them earn partial credit. This guide walks through every format a 2026 candidate can meet, what you actually do on each screen, how each one is scored, and which formats from older prep material you can stop worrying about.

What the Next Generation NCLEX changed

The Next Generation NCLEX, usually shortened to NGN, launched on April 1, 2023. It did not replace the exam. It added new ways of asking questions so that the NCLEX could measure clinical judgment directly: noticing what matters in a client's record, working out what it means, and deciding what to do about it. NCSBN built the new formats around its Clinical Judgment Measurement Model, and the same formats appear on both the RN and the PN exam.

NCSBN names five item types that measure clinical judgment: extended multiple response, extended drag and drop, cloze (drop-down), enhanced hot spot (highlighting) and matrix/grid. Most of the screens in this guide are one of those five under a more everyday name, and the sections below say which.

The frame around them is unchanged in spirit. Both exams are computerized adaptive tests of 85 to 150 questions with a five-hour limit that includes breaks, and the computer picks each question from your answers so far. Under the 2026 test plans, every exam carries three clinical judgment case studies of six questions each, plus stand-alone clinical judgment questions that the plans put at roughly 10 percent. Fifteen of your questions are unscored pretest items, and nothing on screen tells you which ones. Each exam's test plan, stopping rules and passing standard are covered in our NCLEX-RN guide and NCLEX-PN guide.

Three rules shape how you work every format below:

• You must answer to move on. There is no skipping. Try to continue with a question unanswered and the screen stops you with a prompt.
• You cannot go back. Once you submit, the answer is final, including inside a case study.
• There is no set mix of formats. NCSBN says it does not fix a percentage for each format, because the adaptive algorithm selects items by content and difficulty, not by type.

Every NCLEX question type at a glance

Case studies and stand-alone items

Many of the formats above can appear either inside a case study or on their own as a stand-alone item, and the newer NGN formats in particular are used in both. Bow-tie and trend items are different: they appear only as stand-alone items.

Case studies

A case study is a set of six questions about one client. The screen is split in two: the client's record sits on the left in tabs such as Nurses' Notes, Vital Signs, Laboratory Results or Diagnostic Results, and the question sits on the right, with a counter showing which of the six screens you are on. The six questions follow the six clinical judgment steps in order: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. The story moves forward as you go, so a later screen can add a new note, a new set of vital signs or a change in the client's condition.

Two details matter more than they look. Each of the six questions is scored on its own, so a wrong answer on screen two does not drag down screens three to six. And NCSBN writes the later screens so they do not give away earlier answers, which means you should not hunt through screen five for hints about screen two. You could not go back to change it anyway.

Stand-alone items

A stand-alone item is a single question with its own client information. Most use the same formats you see in case studies. Two kinds only ever appear as stand-alone items: the bow-tie, which covers every clinical judgment step in one screen, and the trend item, which asks you to read client data gathered over a period of time. Both are explained below.

The three scoring rules, with worked examples

Partial credit applies only to questions with more than one correct answer. A single-answer question is simply right or wrong. For everything else NCSBN uses one of three rules, and you can tell which one applies from what the screen lets you do.

0/1: you are told how many to choose

When the question fixes the number of answers, by naming a number, by asking for one choice per row, or by giving a set number of drop-downs or spaces, each correct choice earns a point and each wrong choice earns nothing. There is no penalty for a wrong choice, because you could not have hedged by choosing more. A select-3 question where you pick two correct options and one wrong one scores 2 of 3.

Plus/minus: you can choose as many as you like

When you are free to pick any number of options, as in select all that apply, the highlight items and the open drag-and-drop box, each correct choice earns a point and each wrong choice takes one away. The item total never goes below zero. This is the rule that stops a candidate from simply ticking everything.

On grids and grouped items, plus/minus runs separately on each column or each group, each one is floored at zero on its own, and the pieces are added up. A bad column cannot cancel out a good one.

Rationale: two answers that only count together

Some questions pair a conclusion with the reason for it, such as an action and the finding that calls for it, or a risk and the evidence for it. Choosing the right action for the wrong reason shows that you did not really understand the link, so the pair is scored as one unit: both halves right earns the point, and anything else earns zero.

NCSBN's published examples show this two-part pair. Some prep companies describe a three-part version worth more points; NCSBN's own scoring article does not describe one, so we leave it out here.

You never see any of these points. They feed the adaptive algorithm's estimate of your ability, and the result you receive is pass or fail.

Select all that apply, select N, and grouping

NCSBN groups these three under the name extended multiple response: the older multiple response question, widened to more options and given partial credit.

Select all that apply (SATA)

The familiar checkbox question, now with partial credit. The phrase "select all that apply" appears in bold in the question, and NCSBN says at least one option is correct without setting an upper limit. It is scored plus/minus, so the strategy changes from older advice: a doubtful extra tick now costs a point if it is wrong, and a correct option left unticked costs only its own point.

Select N

The question names the number, for example select the two findings, or select four actions. In NCSBN's tutorial a selection past that number brings up a message telling you that you have reached the maximum. It is scored 0/1 with no penalty, so always use every selection you are given: a wrong pick costs nothing, and an empty one cannot earn anything.

Multiple response grouping

Each row is a category, such as a body system, with its own short list of checkboxes, and every row needs at least one selection. Each row is scored plus/minus on its own, floored at zero, and the rows are added together.

Matrix (grid) questions

A matrix lists items down the side, such as findings or orders, and categories across the top, such as indicated or contraindicated, or indicated, nonessential and contraindicated. The grids in NCSBN's samples run from four to eight rows and two or three columns. NCSBN's name for both versions is matrix/grid.

Matrix multiple choice

Radio buttons: exactly one choice per row, and every row must be answered. Each row is worth one point under 0/1, so a grid with five rows is worth five points and a single wrong row costs only that row.

Matrix multiple response

Checkboxes: a row can belong to more than one column, and every column needs at least one tick. Each column is scored plus/minus on its own, floored at zero, and the columns are added together. Treat each column as its own select-all-that-apply question.

Drop-down questions: cloze, table and rationale

All three are what NCSBN calls cloze (drop-down) items: each drop-down asks you to pick one option from a list, whether it sits in a sentence or in a table.

Drop-down cloze

One or more drop-down lists sit inside a sentence or short paragraph, each showing "Select..." until you choose. NCSBN's tutorial says an item can carry one, two or three of them. Each drop-down is its own one-point multiple choice question, scored 0/1.

Drop-down table

The same idea laid out as a table, with a drop-down in each row, for instance a body system on the left and the matching nursing action to choose on the right. Every drop-down must be answered, and each is worth one point.

Drop-down rationale

A single sentence with two drop-downs that depend on each other, usually a conclusion and the evidence for it. It uses rationale scoring, as in the worked example above, and in NCSBN's sample case studies it is the format used at the prioritize hypotheses step.

Drag-and-drop questions

Drag-and-drop cloze

You drag words or phrases from a pool into blanks in a sentence. NCSBN's tutorial demonstrates the mechanics inside its bow-tie example rather than as a separate screen. Its scoring article does not list it on its own, but it has a fixed number of blanks, and NCSBN scores fixed-count items 0/1, so each blank is likely worth one point.

Drag-and-drop rationale

The drag-and-drop version of the cause and effect sentence: you drag tokens into a statement that pairs a conclusion with its reason. In NCSBN's published example, no token can be used twice. Like its drop-down twin, each pair uses rationale scoring.

Extended drag and drop

NCSBN describes this as a newer take on the old ordered response format, where not every option has to be used and there can be more options than spaces. In practice it comes in two shapes. In the open version you drag every finding that meets a condition, for example every finding that needs immediate follow-up, into a box on the right. You decide how many, so it is scored plus/minus, which NCSBN has shown with its own worked example. In the fixed version the question names a number, such as the top four, and you drag that many findings into a box that holds only that many, labelled Top 4 Findings in NCSBN's sample. By NCSBN's rule for fixed-count items, that version is likely scored 0/1.

Highlight questions

NCSBN's formal name is enhanced hot spot, but on screen it is highlighting. You read part of a client record, such as a nurse's note, a history or a set of lab results, and click the words or phrases that answer the question, for instance the findings that need immediate follow-up. Only some phrases are selectable: hovering over the others shows a no-entry symbol. Click a phrase again to remove its highlight.

The highlight table version works the same way inside a table. Highlighting text is scored plus/minus, as NCSBN's own worked example shows, because you choose how many phrases to mark, so highlighting a whole note to be safe can take your score to zero. The table version very likely follows the same rule for the same reason.

Bow-tie and trend items

Bow-tie

The bow-tie gets its name from the shape of the answer area. In the middle is one target for the condition the client is most likely experiencing. On the left are two targets for actions to take, and on the right two targets for parameters to monitor. Below the diagram are three columns of tokens, color matched to their targets, and in NCSBN's published samples the columns hold five actions, four conditions and five parameters.

You drag one token onto each target, and all five targets must be filled before you can move on. Tokens can only go to targets of their own kind, and the two action targets are interchangeable, as are the two parameter targets. Each target is scored 0/1, so a bow-tie is always worth five points, and each target counts on its own: naming the wrong condition does not cancel correct actions or parameters.

Trend

A trend item gives you client information gathered over time, such as vital signs across several hours or notes from successive assessments, and asks you to act on what has changed. It is not a format of its own: the answer area uses one of the newer NGN formats above, never a bow-tie, and is scored by that format's rule. Read the times as carefully as the values.

The traditional formats that are still on the exam

Multiple choice

Four options and one best answer, still the backbone of the exam. NCLEX puts key words such as first, priority, immediately, most and best in bold, and those words usually decide the question.

Graphic options

A single-answer question where the options are pictures rather than words, or where an image is part of the question itself. It is scored 0/1.

Calculation (fill in the blank)

You type a number into a box. The unit is printed beside the box, so type only the number, and letters are rejected. The question says whether to answer as a whole number or to one or two decimal places. If decimal places are requested, enter the decimal point: NCSBN says an answer without it is not counted as correct. Round once, at the end of your working, never at intermediate steps. If an item asks for one decimal place and your working gives 1.666, enter 1.7, not 1.67 and not 2.

An on-screen calculator is provided, and in NCSBN's tutorial it is a basic model with the four operations plus percent, square root and memory keys. Handheld calculators are not allowed in the testing room, and you get an erasable noteboard for your working.

Ordered response

You drag options into the correct sequence, such as the steps of a procedure. NCSBN's 2026 list of alternate item formats still names it, so it is likely you could meet one, but its newer material describes extended drag and drop as building on it, and the current tutorial does not include an ordered response screen. NCSBN has not published how ordered response is scored, so do not count on partial credit for a sequence that is nearly right.

Chart and exhibit items

The question is answered from information in tabs: a medication record, intake and output, lab results. The software does not make you open every tab before answering, so it will not warn you that you skipped one. Open and read each tab in full. When a lab value appears, its normal reference range appears with it, so you do not need to have every range memorized.

What you will not see any more

Older review books and question banks still teach two formats that have dropped out of NCSBN's current materials:

• Audio items, where you listened to a clip such as heart or lung sounds through headphones and chose an answer. The 2019 RN test plan listed audio among the formats and said items could carry audio as multimedia. The 2026 RN and PN test plans name charts, tables and graphics as the multimedia an item may carry, with audio no longer in that list, NCSBN's current list of alternate formats does not name audio, and the 2026 candidate bulletin mentions earplugs but no headphones.
• Image hot spot items, where you clicked an area of a picture, for example the correct place to auscultate. The 2019 test plan and NCSBN's older FAQ described them. NCSBN's current list of alternate formats leaves them out, and so does the current tutorial. (The 2026 test plans no longer list item formats at all; they send candidates to the tutorial instead.)

NCSBN has not, as far as we can find, published a retirement notice for either, so the fair statement is that they are very unlikely to appear rather than impossible. Do not confuse the old hot spot with highlighting, whose formal name is enhanced hot spot and which very much is on the exam. If a question bank leans on audio clips or click-on-the-picture questions, it was probably written for the exam before 2023.

How to prepare for the formats

• Take NCSBN's tutorial early and again close to test day. It runs in a browser from the Prepare page of nclex.com, walks through eleven sample questions on the real exam software, and includes the on-screen calculator. Clicking through a matrix or a bow-tie once before the exam removes a source of stress you do not need.
• Read the scoring rule off the screen. If you choose how many, it is plus/minus: tick only what you would defend. If the question fixes how many, it is 0/1: use every selection. If two answers form a sentence with a because, it is rationale: get the link right, not just one half.
• Work case studies as a story. Read the whole record once, then re-read the tab that changed on each new screen. The six steps run in order, so ask what this screen's step needs from you.
• Practice reading exhibits, not just answering questions. Much of the NGN is finding the cue in a note or a table before any nursing knowledge applies.
• Use NCSBN's sample pack and exam preview. Both are on the Prepare page of nclex.com, and they show case studies and stand-alone items as NCSBN itself presents them.

Where this guide comes from

Everything above was checked on October 6, 2026 against NCSBN's own material: the 2026 NCLEX-RN and NCLEX-PN test plans, the 2026 candidate bulletin, the NCLEX FAQs, NCSBN's help center articles on scoring models and item formats, its Next Generation NCLEX News issues and 2022 webinar on scoring, and the candidate tutorial linked from the nclex.com Prepare page, with the 2019 NCLEX-RN test plan for the formats that have dropped out. Where NCSBN has not said something directly, this guide says so. If NCSBN changes a format, its material wins over ours.

Kalyta is an independent study tool and is not endorsed by or affiliated with NCSBN. NCLEX, NCLEX-RN and NCLEX-PN are registered trademarks of the National Council of State Boards of Nursing, Inc.