NCLEX -Style Item...

NCLEX®-Style Item Writing

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Learning ObjectivesAfter completing this course, you will be better able to:▪Apply the NCLEX® Test Plan to writing test questions▪Demonstrate the ability to write questions at the various

cognitive levels of Bloom’s revised taxonomy▪Craft a question’s stem, answer options (correct and incorrect),

and explanation for student learning (rationale)▪Evaluate your questions for quality and adherence to the Test

Plan

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Agenda9:30 Welcome Message

9:45 Using the NCLEX-RN or NCLEX-PN Test Plan for Writing a Question: Client Needs

Category and Subcategory, Nursing Activity Statements, Integrated Processes, and

NextGen NCLEX Implications

10:30 Developing a Multiple Choice Question by Components:

Stem, Answer Options (correct and incorrect), Explanation/Rationale

11:30 Breakout Session: Question Writing Practice

12:30 Lunch

1:15 Applying Bloom’s Taxonomy to Question Writing:

Writing at the Higher Cognitive Levels

1:45 Writing in the Alternate Formats

2:30 Evaluating your Question for Quality and Adherence to the Test Plan

3:00 Breakout Session: Question Writing Practice

4:15 Wrap up


Basics of the NCLEX® Test Plan


Test PlanThe content of the NCLEX-RN Test Plan is organized into four major Client Needs categories on the basis of a practice analysis of registered nurses. Two of the four categories are divided into subcategories:

▪ Safe and Effective Care Environment

▪ Management of Care

▪ Safety and Infection Control

▪ Health Promotion and Maintenance

▪ Psychosocial Integrity

▪ Physiological Integrity

▪ Basic Care and Comfort

▪ Pharmacological and Parenteral Therapies

▪ Reduction of Risk Potential

▪ Physiological Adaptation

Plan specifies the scope and topics of each Client Needs category.

▪ Some are self-evident; others are not!

The complete test plan can be downloaded from

www.ncsbn.org/testplans.htm


What’s the Client Need?

Question about lab values?

Physiological Integrity: Reduction of Risk Potential

Question involving application of ice for inflammation?

Physiological Integrity: Basic Care and Comfort

Question about landmarking chest auscultation?

Health Promotion and Maintenance


What Is the Client Needs Category?

The pediatric nurse is caring for four clients. To which client could flavoxatebe safely and effectively given?A. A 1-year-old girlB. A 6-year-old boyC. A 10-year-old boyD. A 14-year-old girl (key)


What Is the Client Needs Category?A client is having pulmonary function studies performed. The client performs a spirometry test, revealing an FEV1/FVC ratio of 60%. How should the nurse interpret this assessment finding?A. The client probably has strong exercise tolerance.B. This client’s exhalation volume is normal.C. The client likely has a respiratory infection.D. The client likely has obstructive lung disease. (key)


The Category Is Not Always Obvious…A nurse mistakenly drew up a dose of liquid methadone for a client who was ordered liquid morphine. A root cause analysis (RCA) has consequently been ordered. The RCA should prioritize which consideration?A. The nurse admits to not assessing the client’s pain before administering

the medication.B. The incident was reported to the client promptly, but the client has

subsequently threatened legal action.C. The client experienced respiratory depression as a result of the

medication error.D. Morphine and methadone are stored in bottles with similar

appearances on the unit. (key)


…But, You Can Choose One

▪ Choose the Client Needs category that you believe best captures the essence

▪ Keep the list of Client Needs categories, subcategories, and activity statements at hand when you are writing questions


Nursing Activity Statements

Activity statements are addressed in each of the Client Need categories

Activity Statements provide the content covered in the categories

▪Management of Care – 25 activity statements▪ Safety and Infection Control – 14 activity statements▪Heath Promotion and Maintenance – 15 activity statements▪ Psychosocial Integrity – 14 activity statements▪ Basic Care and Comfort – 16 activity statements▪ Pharmacological and Parenteral Therapies – 15 activity statements▪ Physiological Adaptation – 23 activity statements▪ Reduction of Risk Potential – 16 activity statements

A full list is available in Appendix B of the NCLEX Style Question Writing Guidelines


Nursing Activity Statements: Examples

Safe and Effective Care Environment: Management of Care

Related activity statements from the 2017 RN Practice Analysis

▪ Integrate advance directives into client plan of care▪ Assign and supervise care provided by others (e.g., LPN/VN,

assistive personnel, other RNs) ▪ Organize workload to manage time effectively▪ Participate in providing cost effective care


Integrated ProcessesThese 5 processes fundamental to the practice of nursing are threaded through the Client Needs categories

▪ Nursing Process – Assessing, diagnosing/analyzing, planning, implementing, and evaluating

▪ Caring – Using compassion, respect, and support▪ Communication and Documentation – Verbal and nonverbal

activities associated with the client record▪ Teaching/Learning – Nurse's knowledge, behaviors, skills,

and attitudes▪ Culture and Spirituality –Recognizing the client-reported

unique and individual preferences when interacting with client and family


Integrated Processes: Example Questions

Test questions should relate to the nursing process: assessment, intervention, evaluation

Which statement by the nurse is caring?

Which statement by the client requires additional instruction?

Which statement by the nurse is appropriate?


Next Generation NCLEX

What we know

▪Testing of new question types began July 2017

▪ over 135,000 NCLEX-RN candidates have participated to yield a 80% participation rate

▪ 446 items have been reviewed

▪ each question required 19 minutes on average for the student to respond

▪NCSBN is exploring scoring methods

NCSBN has released prototype items (coved in Alternate Formats)


NCSBN Clinical Judgement Model

What does the student need to know?

▪Recognize cues▪View a variety of sources and determine relevant or

irrelevant information or what is most important or what is an immediate concern

▪Analyze cues

▪Organize and link the cue to the client’s clinical presentation

▪Consider multiple things that could be happening

▪Prioritize hypotheses

▪Evaluate and rank hypothesis based on priority

▪“Why is this occurring


From: NCSBN, (2018). NCLEX Conference. Charlotte, NC.

NCSBN Clinical Judgement Model

What does the student need to know?

▪Generate solutions

▪ Identify expected outcomes and using hypothesis to define a set of interventions for the expected outcomes

▪Take action

▪ Implementing the solution that addresses the highest priorities

▪Evaluate outcomes

▪Comparing observed outcomes against expected outcomes


From: NCSBN, (2018). NCLEX Conference. Charlotte, NC.

Additional Considerations

NCLEX questions should be free from bias▪Questions should not unfairly represent any group nor trend

toward preconceived notions of any group

The NCLEX is the licensure examination for all US and Canadian nurses▪Questions that appear on the NCLEX are applicable to nursing

practice in both nations▪WK products aim to offer questions applicable to both nations;

however, some questions may not meet this goal when the subject matter of the parent text covers nation-specific activities


Principles of Item Writing


The BasicsNCLEX-style questions include the stem, the correct (key) and incorrect (distractors) options, and a rationale explaining why the key is correct and the distractors are incorrect

Use the Nursing Activity Statements to Prompt Your Scenario

▪When creating questions based on particular content (course content; publication manuscript):

1. Choose a Client Needs category

2. Choose a Nursing Activity Statement from the list of related content area

3. Remember to address one of the Integrated Processes


Question Characteristics

Good Questions ...▪ differentiate between students who are learning and those

who are not.▪ address important nursing knowledge, skills, and attitudes.▪ clearly present expectations to the student (“What are they

asking me to know or do?”).▪ are accurate, both internally (in the context of the question

itself) and externally (in the context of broader nursing practice).


Writing Good Multiple Choice Questions

Requires you to synthesize several different considerations:

▪ Client Needs Category

▪ Learning Objective

▪ Nursing Activity Statement

▪ Cognitive Level – Bloom's Revised Taxonomy

Stem

Client NeedsNursing Activity

StatementLearning

ObjectivesCognitive Level


High-Quality Stems

A clearly described question, problem, or task that is within the scope of nursing practice

Decontextualized information Contextualized application

▪ When looking at content, ask yourself prompt questions:▪ When would this matter?▪ In what situation might this apply?

▪ Don’t reiterate the content you’re trying to cover▪ It can be helpful to think of the prompt question first, and then

“reverse engineer” a stem▪ What is the nurse’s best action?▪ What finding should the nurse prioritize?▪ What should the nurse do next?▪ What is the nurse’s priority?


Decontextualized InformationWhat is the most appropriate dose and timing of administration of codeinefor adjunctive pain relief?A. Codeine 5 mg PO every 6 hoursB. Codeine 10 mg PO every 4 hoursC. Codeine 15 mg PO every 2 hoursD. Codeine 20 mg PO every 4 hours (key)

▪Not linked to a Nursing Activity Statement▪No nurse; no client; no scenario

Ask:▪When would this matter?▪ In what situation might this apply?


Contextualized ApplicationThe nurse is providing care for an older adult client who has knee pain resulting from osteoarthritis. The health care provider prescribes codeine 20 mg PO q4h as an adjunctive therapy to the client’s NSAID. What is the nurse’s best action?A. Contact the health care provider to question the use of codeine in an

older adultB. Perform a focused respiratory assessment one hour before and one

hour after administrationC. Contact the health care provider to question concurrent use of an

NSAID and codeineD. Administer the medication as prescribed and monitor the client’s pain

(key)


Use the Nursing Activity Statements to Prompt Your Scenario▪When creating questions based on particular content (course

content; publication manuscript), ask:▪Which Integrated Process does this most naturally align with?▪What Nursing Activity Statements address this content?


Question Characteristics Good Questions ...▪ are based on a scenario (grounded in a situation or interaction).

▪ contain a maximum of 3 sentences; 2 is preferable.

▪ only include age if integral to the question.

▪ can include “adult,” “older adult,” “school-aged child,” “adolescent” if necessary

▪ maintain gender neutrality unless required by the content of the question

▪ for the client, the nurse, the health care provider, and unlicensed assistive personnel.

▪ contain only generic names for medications.

▪ offer grammatically-correct and logical key and distractors

▪ usually end with a question mark.

▪ Questions may end with a colon, if it will eliminate repetition in the answer options


Let’s Fix This Question’s Structure …

The nurse is providing care for a client who has limited mobility after a stroke. What should the nurse do to assess the client for contractures?A. Assess the client's deep tendon reflexes (DTRs).B. Assess the client's muscle size.C. Assess the client for joint pain.D. Assess the client's range of motion. (key)


The nurse is providing care for a client who has limited mobility after a stroke. What should the nurse do to assess the client for contractures? When assessing the client for the development of contractures, the nurse should assess the client’s:A. Assess the client's deep tendon reflexes (DTRs).B. Assess the client's muscle size.C. Assess the client for location and severity of joint pain.D. Assess the client's range of motion. (key)

… to be More Succinct


Question Characteristics

Good Questions▪ Bold key words in the stem, such as best and most

(“prioritizing-type” cues)▪ Avoid negatives

▪ “The nurse should not ...”▪ “All of the following are correct except …”

▪ Avoid teaching in the stem▪ Skip irrelevant information


Teaching in the Stem…

Clients with chronic renal failure are susceptible to anemia. The nurse is assessing a client who has chronic renal failure and who reports worsening fatigue. What is the nurse’s best action?


“Clients with chronic renal failure are susceptible to anemia. The nurse is assessing a client who has chronic renal failure and who reports worsening fatigue. What is the nurse’s best action?”

… Should Be Avoided


Irrelevant Information

▪Many writers attempt to write a case study instead of a question.

▪Typically 2 to 3 sentences is the limit

▪To present more information, think about adding a client chart or laboratory results

▪ Irrelevant information in the question does not validate the question

▪Distracters validate the question!


Irrelevant Information …

A female client, age 71, has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The client has recently been transferred from acute care to a rehabilitation setting. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?A. Collaborating with the client's insurer to describe the client's successesB. Teaching the client about the pathophysiology of her functional deficitsC. Eliciting ways to get the client to express a positive attitudeD. Appraising the family's involvement in the client's ADLs (key)


… Should Be Deleted

A female client, age 71, has been achieving significant improvements in heractivities of daily living (ADLs) since beginning rehabilitation from the effects of a brain hemorrhage. The client has recently been transferred from acute care to a rehabilitation setting. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?A. Collaborating with the client's insurer to describe the client's successesB. Teaching the client about the pathophysiology of her functional deficitsC. Eliciting ways to get the client to express a positive attitudeD. Appraising the family's involvement in the client's ADLs (key)


What Do You Think of These Stems?▪ Which of the following manifestations of infections are common in the

older client?

▪ A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The client states, “They tell me my cancer is malignant, while my coworker's breast tumor was benign. I just don't understand at all.” When preparing a response to this client, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type?


Stem PitfallsAVOID:

▪ Negative questions▪ “all of the above” or “none of the above”▪ Gender - unless gender specific▪ Age - unless developmental or pediatric/gerontology

considerations▪ Stereotyping - nurse is not always a female - avoid “she”▪ Sensitive terminology (handicapped, crippled)▪ Slang▪ Elitism (yacht, polo)▪ Roles: women cook, men lead▪ Giving the client a name


Key (The Correct Answer)

Write the correct response with no irrelevant clues

▪A common mistake when designing multiple-choice questions is to write the correct option with more elaboration or detail, using more words, or using technical terminology rather than general terminology

▪Remember: A good question enables students to choose the correct answer because they have learned the information and can apply it


DistractorsWriting the key is usually easy; writing distractors is more challenging!

▪ Good distractors must be:

▪ Unequivocally wrong, but still plausible

▪ Parallel to the key in terms of length, tone, grammar and specificity

▪ Distractors should not contain never language - verbs that are always inconsistent with nursing practice (“force,” “insist,” "punish", “interrupt,” etc.). For example:

▪ Avoid discussing the client's feelings.

▪ Make the client participate in the therapy session.

▪ Distractors are best created using common errors or misunderstandings about the concept being assessed


Creating Distractors

▪ It can be helpful to think of an option that is a good action but not the best option:

▪An unwarranted referral

▪Giving client education when prompt action is the priority

▪Addressing psychosocial concerns when physiology is at risk

▪Doing the right action but with the wrong:

▪ Client

▪ Technique

▪ Sequence

▪ Specificity

▪ Priority

▪ Phrasing (if speaking to the client)

▪ Frequency

▪ Timing


What Do You Think of These Distractors?

Which action is most appropriate for a nurse to take when administering anew blood pressure medication to a client?A. Administer the medication to the client without explanationB. Inform the client of the new drug only if the client asks about itC. Inform the client of the new medication, its name and use, and the

reason for the medication (key)D. Administer the medication, and inform the client that the provider will

later explain the medication


… and These?

A nurse notes a change in the voice and mannerisms of a client experiencing dissociative identity disorder (DID) after learning that the spouse has filed for divorce. What is the most appropriate nursing intervention?A. Avoid discussing the client’s feelingsB. Force the client to discuss feelingsC. Challenge the client’s feelingsD. Encourage the client to verbalize feelings (key)


Distractors (cont’d)▪ Avoid the temptation to create distractors by simply flipping the correct

answer▪ The results are usually simplistic or nonsensical, even though they

meet the criterion of being incorrect▪ Savvy students can easily spot these, and rule them out

Which assessment findings of an older adult should the nurse attribute to age-related changes? Select all that apply.A. Reduced vision (key)B. Reduced hearing (key)C. Increased [rather than decreased] taste D. Reduced Smell (key)E. Increased [rather than decreased] short-term memory


Distractors (cont’d)▪ Avoid creating difficulty through minutiae▪ Difficulty should arise through the sophistication and depth of

thinking that is needed to arrive at the correct answer, not through recall of minute detail

The nurse is participating in a committee that is allocating resources based on future projection. By 2030, the number of persons over the age of 85 is expected to increase by:A. 80%B. 90%C. 100% (key)D. 110%

Remember, all information in a text does not directly affect nursing care. Ask yourself: When would this matter?


Distractors (cont’d)▪ When working from a text, remember that a distractor is not necessarily

wrong just because it does not appear in the text▪ Situate your questions in the totality of nursing practice, not just in the

content/text from which you are working (externally accurate)

A client has just been diagnosed with gastric cancer and the health care provider has explained why the client has a poor prognosis for recovery. What is the nurse's best action?A. Assess the client for indications of disbelief (key)B. Educate the client about resources availableC. Assess the client for indications of fearD. Offer spiritual support

The fact that information does not appear in the text does not mean that it is wrong!


Aim for Diversity in Distractors

The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time?A. Only when neededB. Daily at bedtimeC. First thing in the morning, 30 minutes before eatingD. With each meal (key)

What does the student need to know to get this question correct?1. When phosphate-binders should be administered


Diversity in Distractors

The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has just been prescribed calcium acetate. to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time? What is the nurse's best action?A. Collaborate with the health care provider and perform a medication

reconciliation Only when needed B. Review the results of the client's most recent liver panel Daily at

bedtimeC. Assess the client's hourly urine output First thing in the morningD. Educate the client about the need to take the medication with food

With each meal (key)


Diversity in Distractors (cont’d)

What does the student need to know to get this question correct?1. When phosphate-binders should be administered2. Whether a single new medication warrants a medication reconciliation3. Whether the medication's safety is contingent on recent urine output4. The effect of calcium acetate on liver function (hepatotoxic?)5. Specific assessments that must precede calcium acetate

Multifactorial thinking is the goal


Key and Distractor PitfallsAVOID:

▪ Not matching the ending of the stem

▪ if stem ends with a colon (:), use lower case and end with a period.▪ if stem ends with a question mark (?), use upper case and end with

a period, if a complete sentence.▪ If numerical, randomly chosen numbers

▪ place options in order▪ keep ranges equal and do not overlap

▪ Nonsensical distractors▪ students should be familiar with the options

▪ Do not use synonyms▪ bradycardia and slow heart rate▪ polyuria and increase urinary output


Explanations (Rationales)

Every question must be followed by a few sentences that explain why the key is correct, and why the distractors are incorrect.

Good explanations:▪ should not simply state that the key is correct, or that the

distractors are wrong.▪ should be a prose piece of writing (not bullets, sentence

fragments or imperative statements) that can stand alone logically and grammatically.


Explanations (Rationales)Remember: Your rationale should meet the goals of a good explanation, even if your are working from your text.▪ Avoid copying large blocks or text that only address the

question in a general way▪ Ensure the explanation makes sense when removed from the

preceding and following text▪ Reformat to ensure it is a prose paragraph, not a list, table, or

chart ▪ Remove references


How Could This Explanation Be Improved?

(This explanation follows a question about the clinical characteristics of fetal alcohol spectrum disorder.)

Explanation: The distinctive pattern identified three specific findings: growth restriction (prenatal and postnatal), craniofacial structural anomalies, and CNS dysfunction. These distinctive findings were called fetal alcohol syndrome (FAS), characterized by physical and mental disorders that appear at birth and remain. The others do not apply to FAS.


Breakout Session 1: Question Writing Practice▪ The NCLEX Style Question Writing Guidelines in your binder contain:

▪ Step 1: Choose Content to Test ▪ Step 2: Choose Cognitive Level ▪ Step 3: Write the Question ▪ Step 4: Review Your Question

▪Appendix A: NCLEX Question Types▪Appendix B: Client Needs, Integrated Processes, and Nursing Activity

Statements▪Appendix C: Verbs for Each Cognitive Level ▪Appendix D: Question Templates


Writing at the Higher Cognitive Levels


Cognitive Levels on NCLEX®

To identify the level of your question, ask yourself:

▪ Can the student recall or recognize the information?

▪ Remember (Knowledge)

▪ Can the student explain, interpret, or summarize ideas or concepts?

▪ Understand (Comprehension)

▪ Can the student use the information to execute or implement a concept or idea?

▪ Apply (Application)

▪ Can the student distinguish between different issues or concepts?

▪ Analyze (Analysis)


Bloom’s Revised Taxonomy

x


Writing Questions with Bloom’s

Verb choice does not define the level

The nurse will assess which adult client first? The client with: A. an apical pulse of 76 bpm.B. a temperature of 97.8°F (36.5°C).C. a blood pressure of 110/70 mm Hg.D. an oxygen saturation of 80% (0.80 L). (key)


Remember Level Question

A 29-week gestation client is being assessed for preeclampsia. Which symptoms indicate the client has preeclampsia? Select all that apply. A. Proteinuria (key)B. Facial swelling (key)C. Fetal heart rate 158 bpmD. 3 lb (1.36 kg) weight loss fixE. Blood pressure 144/92 mm Hg (key)


Understand Level QuestionA 29-week gestation client is diagnosed with preeclampsia. The client asks “Why is my face so swollen?” How will the nurse reply?A. “Preeclampsia causes your body to produce too much cortisol, which

causes facial and extremity swelling.”B. “Many women with preeclampsia experience facial inflammation,

especially around the eyes and cheek bones.’C. “Preeclampsia causes fluid to shift from your vessels to your tissues,

causing swelling in your extremities and face.” (key)D. “Women with preeclampsia cannot excrete fluids adequately, leading

to a buildup of fluids in the circulatory system.”


Apply Level Question

The nurse is assessing a 29-week gestation client diagnosed with severe preeclampsia. The nurse will notify the health care provider for which finding?

A. Hemoglobin 12 g/dL (120 g/L) fixB. Platelet count 175,000 mm3 (175,000 × 109/L)C. Alanine aminotransferase (ALT) 40 units/L (0.67 µkat/L)D. Aspartate aminotransferase (AST) 100 units/L (1.67 µkat/L) (key)


Analyze Level Question

A 29-week gestation client reports right upper quadrant pain, being tired, severe headache, and seeing “white spots.” The client’s vitals are: T 99.2 (37.3), P 100, BP 144/90, and O2 sat 96% (0.96). Which nursing intervention is priority for this client?

A. Determine the intensity level of the headache.B. Administer meperidine 35 mg intravenously PRN.C. Evaluate liver enzymes and complete blood count. (key)D. Prepare to send the client for a gallbladder ultrasound.


NCLEX Passing Level

Remember to address the NCLEX passing level as you develop questions

▪Level of question difficulty

▪To pass NCLEX, the student must answer correctly the questions written at the apply and analyze levels


Higher-Level Thinking: Apply

▪ These questions require students to apply principles, rules, or facts in order to solve a problem.

▪ They answer the question “What should the nurse do?”

▪ The key to preparing questions at the apply level is to place the concept in a life situation or context that requires the student to first recall the facts and then apply or transfer the application of those facts into the situation.

▪ Example:

The nurse is caring for a client with (diagnosis) who had (a diagnostic test/procedure). Which statement, made by the client, would require immediate follow-up?


Higher-Level Thinking: Analyze

▪ These questions break information into parts to understand the larger context.

▪ They answer the question “What should the nurse consider/think about doing next?”

▪ The key to preparing questions at the analyze level is to determine a relationship among the concept(s), know the effects of the situation, identify patterns, and understand the meaning of information in a client or nursing practice situation.

▪ Example:

The nurse has received the following (client information/data) on two clients in the nurse’s care. Which client would the nurse assess first?


Practice: Which Question Level is This?

Which serum laboratory level will the nurse review to evaluate a client’s liver function?

A. Amylase

B. Troponin

C. Blood urea nitrogen (BUN)

D. Alanine transaminase (ALT) (key)


Practice:Which Question Level is This?

Which serum laboratory level will the nurse review for a client with hepatitis?

A. Amylase

B. Troponin

C. Blood urea nitrogen (BUN)

D. Alanine transaminase (ALT) (key)


Practice:Which Question Level is This?

Which laboratory test most concerns the nurse for a client scheduled to receive acetaminophen?

A. Amylase 50 U/L (0.83 µkat/L)

B. Troponin 0.02 ng/mL (0.02 µg/L)

C. Alanine transaminase (ALT) 90 units/L (1.50 µkat/L ) (key)

D. Blood urea nitrogen (BUN) 10 mg/dL (3.57 mmol/L)


Practice:Which Question Level is This?The nurse is caring for a client with congestive heart failure and notes the following lab results in the client’s chart:

Which nursing action is priority?

A. Determine the client’s temperature orally

B. Administer the client’s oral potassium dosage

C. Schedule for the client’s labs to be repeated tomorrow morning

D. Hold the client’s hydrocodone and notify the health care provider (key)


Sodium 135 mEq/L (135 mmol/L)Potassium 3.5 mEq/L (3.5 mmol/L)Alanine transaminase (ALT) 95 units/L (1.59 µkat/L)White blood cells (WBC) 14,500/mm3 (14.500 ×109/L)B-type natriuretic peptide (BNP) 90 pg/mL

A client presents with severe heartburn. What symptom will the nurse expect to assess in this client?

A. Increased blood pressure

B. Productive cough at bedtime

C. Persistent nausea and vomiting

D. Stomach pain in the upper abdomen (key)

Practice:What is required to increase the level of this question to apply or analyze?


The nurse is teaching a client about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.

A. Transient ischemic attacks (TIAs) (key)

B. Cerebrovascular disease (key)

C. Retinal hemorrhage (key)

D. Venous insufficiency

E. Right ventricular hypertrophy

Practice:What is required to increase the level of this question to apply or analyze?


Question Types


Question Types on the NCLEX®

The bulk of the questions on the NCLEX are four-option multiple choice questions

Since 2017, students have been involved in the NCSBN testing initiative to “explore new types of questions to expand or enhance of nursing clinical judgement.”*

The next generation question currently being tested are expected to be in use in 2022.

*https://www.ncsbn.org/next-generation-nclex.htm


Multiple Choice Items

MC questions require a learner to:

▪ Select the single correct response ▪ Four (4) options are listed


Multiple Choice Item: Example

An older adult client has come in to the clinic for the twice-yearly physical. The client tells the nurse that he or she is generally enjoying good health, but has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse firstsuggest?

A. Reduce stress levels and promote relaxation.B. Increase carbohydrate intake and reduce protein intake.C. Take herbal laxatives each night at bedtime.D. Increase daily intake of water. (key)


Why write in the alternate formats?

Alternate format questions:

▪ get students to think outside of the usual four option multiple choice (MC) question format.

▪ allow writers to create questions that address upper cognitive levels of learning.

▪ address the need to evaluate visual and auditory assessment skills.

Plus…

▪ The NCLEX includes alternate format questions.

Alternate Format Questions


Multiple ResponseMR questions require a learner to:

▪ Select at least one response out of a field of 5 or 6 options▪ Select all options that apply to be awarded credit for the item▪ The Writer provides:▪ Item written similarly to a multiple-choice question▪ 5 or 6 options, of which at least 1 is correct

A multiple response item can be written at any level of Bloom’s revised taxonomy. Just because there is more than one correct answer, the question is not necessarily evaluating higher level or critical thinking.


Multiple Response: ExampleThe nurse is performing a morning assessment. Which assessments of a client would require immediate intervention? Select all that apply.

A. Ten respirations per minute by a sleeping clientB. Rattling sound in the pharynx of an unconscious client (key)C. Coughing and expectorating large amounts of thick mucusD. Slight shortness of breath after returning from the bathroomE. Vomiting of large amount of bright red hemoptysis (key)


Fill-in-the-BlankFIB items require a learner to:

▪Type number(s) into a calculation item with no proposed options

▪ Rounding may be indicated as necessary

▪ Unit of measure is provided and not typed by the student▪ The Writer provides:▪ Rationale should contain the formula and the calculation

FIB questions always test calculations (e.g., medication administration; fluid balance, etc.). The blank is always completed with a number, never a word.


Fill-in-the-Blank: ExampleA client is prescribed clozapine 250 mg by mouth daily. How many tablets will the nurse administer if each tablet contains 100 mg? Record your answer using one decimal place.

__________ tablets

Answer: 2.5

Rationale: The correct formula to calculate a drug dosage is:

𝐷𝑜𝑠𝑒 𝑜𝑛 ℎ𝑎𝑛𝑑 =𝐷𝑜𝑠𝑒 𝑑𝑒𝑠𝑖𝑟𝑒𝑑

𝑋In this example, the equation is:

100 𝑚𝑔/𝑡𝑎𝑏𝑙𝑒𝑡 =250 𝑚𝑔

𝑋

X = 2.5 tablets


Hot SpotHS questions require a learner to:

▪ Identify one or more area(s) on a graphic (figure, illustration, photo)

▪Use the computer's cursor to identify appropriate location

▪ No options are provided

▪ The Writer provides:

▪ Graphic and a box showing the area the student should identify

▪ Rationale should clarify why that area should have been chosen


Hot Spot: ExampleWhile assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by

lordosis.

Rationale: Lordosis is characterized by an accentuated curve of the lumbar area of the spine.


Chart/ExhibitC/E questions require a learner to:

▪ Read the information in the chart/graph/table to answer the question

▪ The question should refer to the exhibit but otherwise is not restricted

▪ Questions may be multiple choice, multiple response, hot spot, or ordered response

Data may be presented as chart “tabs” such as prescriptions/orders, history and physical, laboratory results, miscellaneous reports, imaging results, flow sheets, intake and output, medication administration record, progress notes, and vital signs or as a table or graph showing results of a series of tests


Chart/Exhibit: ExampleA preschooler requires isolation precautions. Based on the progress notes shown, for which isolation precautions would the nurse plan?

A. StandardB. DropletC. Airborne (key)D. Contact


Drag-and-Drop/Ordered Response

D&D questions require a learner to:

▪ Rank order or Move options to provide the correct answer using a numerical, alphabetical or chronological order

▪ Drag the statements into the proper order using the mouse/finger▪ The Writer provides:▪ 5 or 6 unordered terms or phrases▪ No answer choices are provided▪ Rationale should state why this is the correct order

D&D questions are used to rank the order of different items or data, but primarily are used to sequence a nursing task.


Drag-and-Drop/Ordered Response: ExampleThe nurse is instructing a client diagnosed with chronic obstructive pulmonary disorder how to do pursed-lip breathing. Place the statements in the order in which the nurse would the nurse explain the steps to the client? "Relax your neck and shoulder muscles."

"Breathe in normally through your nose for 2 counts (while counting to yourself: one, two)."

"Pucker your lips as if you were going to whistle."

"Breathe out slowly through pursed lips for 4 counts (while counting to yourself one, two, three, four).""Relax your neck and shoulder muscles."

"Breathe in normally through your nose for 2 counts (while counting to yourself: one, two)."

"Pucker your lips as if you were going to whistle."

"Breathe out slowly through pursed lips for 4 counts (while counting to yourself one, two, three, four)."


Audio-Based/Video-BasedAB/VB items require the learner to:

▪ Click to hear a brief audio file or see a brief video file, and identify the best response/action

▪ Make a nursing judgement or select a nursing action based on interpretation of the audio or video file

▪ The question should refer to the audio or video file but otherwise is not restricted

▪ Questions may be multiple choice, multiple response, hot spot, or ordered response

AB/VB items primarily relate to physical assessmentAB/VB items will not consist of statements or clips of conversations


Graphic Option

GO questions require a learner to:

▪ Evaluate graphics (figures, illustrations, photos)▪ Graphics are provided in place of text based options

▪ Select the appropriate graphic option to answer the question▪ The Writer provides:▪ Item written similarly to a multiple-choice or multiple-response

question▪ Often, these questions contain the answer option number/letter may

be used in the rationale

GO questions often test the knowledge of kinesthetic tasks.


Graphic Option: ExampleWhich illustration indicates the position in which the nurse would place the newborn to assess for incurving of the trunk?

A. B. C. D.

(key)


Next Generation Question Types


Next Generation NCLEX-RN®

Prototype questions:

▪Extended Multiple Response Item

▪Matrix Item

▪Highlight Item

▪Cloze (DropDown) Item

▪Extended Drag-and-Drop Item

NCSBN, (2018). NCLEX Conference. Charlotte, NC.


Next Generation NCLEX-RN®

What the writer needs to know▪ NCSBN is exploring question types and scoring▪ No final decision on question type specifics are currently

available

▪ NCSBN is committed to the Clinical Judgement Model▪ A robust clinical case study is the backbone of writing

questions that focus on clinical judgement▪ And…

▪ provides the flexibility to rework any item as the question types evolve


Extended Multiple Response

EMR questions require the learner to:

▪ Select at least one response out of a field of up to 10 options

▪ Select all options that apply to be awarded credit for the item

Writing implications:

▪ Item written similarly to current multiple-response question but with more (up to 10) options


Example from: NCSBN, (2018). NCLEX Conference. Charlotte, NC.


The nurse is caring for a 54-year-old client who

travels frequently. The client was seen in the

emergency department at 1300 for reports “chest

pain, sweating, and trouble breathing.”

VITAL SIGNS

● Blood Pressure 130/86 mmHg

● Heart Rate 104 bpm

● Respirations 24 breath/min

● Oxygen Saturation 93% (0.93) on room air

● Temperature 98.9ºF (37.2°C)

Which nursing actions are a priority for the nurse to

provide at this time? Select all that apply.

A. Obtain an electrocardiogram (ECG)

B. Obtain the client’s weight

C. Apply cardiac monitoring

D. Apply oxygen at 4L/min via nasal cannula

E. Administer nitroglycerin 0.4 mg sublingually

F. Obtain a urinalysis

Answer: A, C, D, E

Rationale: The client is experiencing chest pain and should have an ECG to determine the presence

of a cardiac event. Application of the cardiac monitor would assist with identifying any changes to the

rate or rhythm of the heart for early intervention. Application of oxygen is indicated due to a decrease

in oxygen saturation to 93% (0.93). Administration of nitroglycerin is an intervention that is beneficial

for dilation of the coronary arteries in the event of coronary vasospasm or occlusion. A urinalysis may

be done at a later time if indicated but does not relate to current clinical findings. The client’s weight

may be obtained at a later time; stabilization of the client is the priority.

Extended Multiple Response


Matrix

Matrix questions require the learner to:

▪ Complete a grid identifying a nursing action or analysis

▪ Select a choice for all actions/analyses included


▪ Instead of standard options, the actions/analyses will need to be qualifiable

▪ Item should define the choices in the grid


MatrixA client has undergone cholecystectomy. The nurse assesses the client and records the findings. For each finding listed, select whether it indicates high risk, low risk, or no risk for postoperative complications.


Assessment Finding High Risk Low Risk No Risk

Incision redness, no

drainage

X

Received morphine

sulfate 4 hours ago

X

C/O unilateral leg

pain

X

D-dimer: positive X

White Blood Cell

count: 7200/µL (7.2

×109/L)

X

Platelets: 190 ×103/µL

(190 ×109/L)

X

Abdomen tender,

bowel sound present

X

Highlight

Highlight questions require the learner to:

▪Read a case study

▪Highlight all information that answers the question asked


▪Create a case study chart with at least two columns, and ask a question that directs student to what information to highlight

▪This format may be difficult to duplicate, depending on the LMS in use


Cloze (DropDown)Cloze questions require the learner to: ▪ Complete the sentence(s) using the selection menus (drop-

down lists)▪ There will be several selections within one question

Writing implications:▪ Create a case study or client chart▪ For the case study (example 1), the case is followed by a

client chart that is missing information.▪ For the client chart (example 2), the client chart is

followed by a multi-tier question▪ For each type, write a list of options for the drop-down lists▪ This format may be difficult to duplicate, depending the LMS

in use


Extended Drag-and-DropExtended D&D questions require a learner to:

▪Move options to answer the question asked

▪Drag the statements into the proper order using the mouse/finger


▪Create a clinical situation that includes the list of options for the student to move

▪Create a second situation that provides enough information for the student to move the first set of options

Extended D&D questions are used to apply clinical judgement for the situation described.


New Information about Next Generation NCLEX® available Quarterly


Evaluating Your Questions


Evaluate Your Question

Step 1: Educational Objective

▪Can you easily identify what you are trying to assess?

▪ Is this objective the focus of the question within the stem?



Step 2: Relevance to Practice

▪Does your scenario depict current nursing practice?

▪ Is your question relevant to clinical practice?

▪That is, does your question address nursing knowledge, skills, and attitudes your students will need when they begin to practice nursing?



Step 3: NCLEX Test Plan

▪Can you easily identify:▪ the Nursing Activity Statement?▪ the Client Needs category?▪an Integrated Process?



Step 4: Cognitive Level

▪ Is the nurse in the scenario taking an action or making a decision regarding care?

▪Does the question promote critical thinking?



Step 5: Question Construction—Stem

▪ Is the scenario plausible?▪ Is the stem concise, free of details unnecessary for answering

the question correctly?▪ Is the stem stated positively and directly?



Step 5: Question Construction—Options

▪ Is the correct answer option stated simply, free of leading information?

▪Are the distractors plausible for the scenario?▪Are the answer options similar in grammar, length, and amount

of detail?▪Do any answer options cancel out any other answer options?▪Do any answer options repeat information from any other

answer options?

Work backward, view the answers first then review the question.



Step 5: Question Construction—Explanation

▪Does the explanation instruct readers on why the key is correct and on why the distractors are incorrect?

▪Does the information have context with the stem and options, rather than generalized learning?


Evaluating: Let's Practice

Using the steps 1 through 5, let‘s break down the questions on the next two slides

Remember:▪ Identify strengths▪ Identify concerns or issues▪Develop a rationale


Evaluate This Question

A client is admitted to the emergency room with right lower quadrant pain. Acute appendicitis is suspected. Which health care provider order should the nurse implement first?A. Administer 5-325 hydrocodone/acetaminophen PO for painB. Draw blood for complete blood count and electrolyte levelsC. Obtain urine specimen for urinalysisD. Start Intravenous (IV) line with normal saline 100 mL/hr (key)


Evaluate This Question

The Registered Nurse (RN) on a medical-surgical unit is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which actions are appropriate to assign to the LPN? Select all that apply.A. Administer a scheduled analgesic to a client with chronic back pain

(key)B. Assess fluid volume status of a client with heart failure who is

scheduled for dischargeC. Assist with bathing, feeding, and dressing a client with multiple

sclerosisD. Perform wound care and sterile dressing change for a client with a

stasis ulcer (key)E. Provide incontinence care and linen change for a client with Clostridium

Difficile


Breakout Session 2: Question Writing Practice▪ The NCLEX Style Question Writing Guidelines in your binder contain:

▪ Step 1: Choose Content to Test ▪ Step 2: Choose Cognitive Level ▪ Step 3: Write the Question ▪ Step 4: Review Your Question

▪Appendix A: NCLEX Question Types▪Appendix B: Client Needs, Integrated Processes, and Nursing Activity

Statements▪Appendix C: Verbs for Each Cognitive Level ▪Appendix D: Question Templates


References

▪ Birkhead, S., Kelman, G., Zittel, B. & Jatulis, L. (2018). The Prevalence of Multiple-Choice Testing in Registered Nurse Licensure-Qualifying Nursing Education Programs in New York State. Nursing Education Perspectives, 39, 139-144. doi:10.1097/01.NEP.0000000000000280

▪ Hicks, N. A. (2011). Guidelines for Identifying and Revising Culturally Biased Multiple-Choice Nursing Examination Items. Nurse Educator, 36, 266-270. doi:10.1097/NNE.0b013e3182333fd2

▪ Killingsworth, E., Kimble, L. & Sudia, T. (2015). What Goes Into a Decision? How Nursing Faculty Decide Which Best Practices to Use for Classroom Testing. Nursing Education Perspectives, 36, 220-225. doi:10.5480/14-1492

▪ Kim, D. (2018) Next Generation NCLEX (NGN) Update. Presented September 2018, NCSBN NCLEX Conference, Charlotte, N. C.

▪ Haladyna, T.M. (1999). Developing and validating multiple-choice test items. (2nd edition). Lawrence Erlbaum Associates, London.

▪ Haladyna, T.M. & Rodriguez, M.C. (2013). Developing and validating test items. Routlage Taylor and Francis Group. New York.

▪ Haladyna, T.M. (2011). Developing and validating multiple-choice test items. (3rd edition). Routledge Taylor and Francis Group. New York.

▪ Oerman, M.H. & Gaberson, K.B. (2014). Evaluation and testing in nursing education (4th edition). Springer. New York.

▪ Miller, K. (2018) Using an Integrated Clinical Judgment Model in Education. Presented September 2018, NCSBN NCLEX Conference, Charlotte, N. C.

▪ NCLEX-RN® Examination Detailed Test Plan for the National Council Licensure Examination for Registered Nurses NCLEX-RN® DETAILED TEST PLAN Item Writer/Item Reviewer/Nurse Educator Version. (2019). National Council of State Boards of Nursing, Inc. (NCSBN®). Chicago.

▪ Item samples provided by NCSBN Retrieved @ www.nursingsummit.com/wp-content/uploads/presentations/NCSBN%20research%20on%20NCLEX%20examination%20redesign%20a


InstructorsNCLEX Editorial Advisory Board

Vicki Moran, PhD, MPH, RN, CNE, APHN-BC

Saint Louis University

Saint Louis, Missouri

[email protected]

Leigh W. Moore, MSN, RN, CNOR, CNE

Southside Virginia Community College

Alberta, Virginia

[email protected]

Monica Buchanon, PhD, RN, CRRN Argosy UniversityDenver, [email protected]

Jeff Dyck, BA, BSN, MSN, CNE

British Columbia Institute of Technology School of Health Sciences

Burnaby, British Columbia

[email protected]

Wolters Kluwer Staff ContactsDawn Lagrosa

Content Strategist

(215) 521-8353

[email protected]

Health Learning, Research & Practice

Wolters Kluwer

Two Commerce Square

2001 Market St.

Philadelphia, PA 19103

Michael Marino

Supervisory Content Strategist

(410) 528-4371

[email protected]

Health Learning, Research & Practice

Wolters Kluwer

351 West Camden Street

Baltimore, MD 21201


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