Clinical judgment, step by step
The Next Generation items are built on NCSBN’s clinical judgment measurement model: recognize the cues in a client’s situation, analyze them, form hypotheses, decide on actions, take them and evaluate the outcome. Case studies walk through those steps in order; stand-alone items test one or two of them at a time.
Case studies
Every NCLEX-RN includes 3 case studies of six items each (18 items), within the 85-item minimum. Each case gives you a client record (notes, vital signs, laboratory values, orders) that changes as the case moves forward, and each of the six items asks for a different step of the judgment model. Read the record for what is new or different from the last screen; that is usually what the next item is about.
How partial credit works
- 0/1: one point for the right answer, none otherwise. Classic multiple choice is scored this way.
- Plus/minus: a point for each correct choice and a point taken away for each incorrect one, never below zero. Select-all-that-apply items are scored this way, so guessing extra options costs you.
- Rationale scoring: some paired choices earn a point only when both parts are right, because the second part is the reason for the first.
Partial credit means a hard item is never all or nothing. Answer every part you are sure of, and on select-all items leave out the ones you are guessing.
Multiple response: select all that apply
Several options can be right; the stem tells you whether to choose a set number or all that apply. Judge each option on its own, as if it were a true-or-false question.
Pharmacology · Try it
An older adult takes digoxin 0.125 mg daily. Which findings suggest digoxin toxicity? Select all that apply.
Select all that apply. 0 selected.
Matrix (grid)
A table of findings or actions, each to be placed in a column: expected or unexpected, indicated or contraindicated, effective or ineffective. Each row is its own decision and its own point.
Safety · Try it
The nurse reviews three new medication orders. For each order, indicate whether it can be carried out as written or needs clarification first.
For each row, choose one column. 0 of 3 answered.
| As written | Needs clarification | |
|---|---|---|
| Morphine 1.0 mg IV every 4 hours as needed for pain | ||
| Metoprolol tartrate 25 mg by mouth twice daily | ||
| Insulin lispro 10 u subcutaneously before breakfast |
Drop-down cloze
A sentence with one or more lists inside it. Read the whole sentence before choosing; the blanks often depend on each other, the first naming what is happening and the second what to do about it.
IV therapy · Try it
A client's peripheral IV site is cool, pale and swollen, and the infusion has slowed. Complete the sentence.
Complete the sentence by choosing from each list.
The findings are most consistent with , so the nurse should first .Bow-tie
The whole judgment in one picture: the condition in the middle, two actions on one side and two parameters to monitor on the other. Start with the condition; the actions and parameters follow from it.
Physiological Adaptation · Try it
A 72-year-old client admitted with a urinary tract infection now has a temperature of 39.2 °C (102.6 °F), heart rate of 118, respiratory rate of 26, blood pressure of 86/50 mm Hg and new confusion. Serum lactate is 4.1 mmol/L. Complete the diagram: the condition the client is most likely experiencing, two actions the nurse should take, and two parameters to monitor.
Choose two actions to take, the condition the client is most likely experiencing, and two parameters to monitor.
Actions to take · choose 2
Condition · choose 1
Parameters to monitor · choose 2
Other formats
The exam also uses drag-and-drop ordering, highlighting text in a client record, and trend items that show findings over time. The same habits apply: read the record for what changed, decide what it means, then act on the most urgent problem. For the bigger picture, see how the NCLEX is scored.