Next Gen NCLEX question types: Case Studies, bow-tie, SATA, and partial credit

The Next Generation NCLEX (Next Gen NCLEX or NGN) is the latest version of the NCLEX exam. Its new question types, such as Select All That Apply (SATA), bow-tie, matrix/grid, drag-and-drop, and drop-down (cloze) items, place greater emphasis on clinical judgment. Another key difference from earlier versions is the addition of case studies designed to better evaluate the decision-making skills of nurses preparing to enter the profession.

On the NCLEX-RN, the version of the NCLEX created for registered nurses, nursing graduates will encounter Case Study questions that test their clinical skills and ability to determine treatment options quickly. A complete study plan for the NCLEX includes preparing for both conventional multiple-choice items and Next Gen questions, which focus on applying nursing knowledge in practice.

What is the NCLEX-RN?

The NCLEX-RN, short for the National Council Licensure Examination for Registered Nurses, is a standardized, computer-adaptive exam that nursing school graduates, including those with a bachelor’s, associate’s, or certificate in nursing, must take. To become licensed as a registered nurse (RN) in the U.S. and Canada, and for some internationally qualified nurses in Australia, passing the NCLEX is mandatory.

Most NCLEX-RN questions are divided into four main Client Needs categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Although there is no fixed number of questions, candidates typically respond to 85 to 150 items within a testing window of up to five hours, including breaks.

Passing the NCLEX demonstrates that a nursing graduate is capable of delivering safe and effective care at the entry level. Preparing for the NCLEX-RN involves developing a structured study plan, reviewing key content, practicing questions, and identifying topics that require more focus. With a targeted approach, effective strategies, and familiarity with different question types, you can increase your likelihood of passing on your first attempt.

NCLEX NextGen question types (with practice questions)

The NCLEX includes standard multiple-choice questions as well as Next Generation NCLEX item types, such as Select All That Apply (SATA), bow-tie, matrix/grid, drag-and-drop, and drop-down (cloze). Case Study questions, a series of six questions corresponding to a specific client case, are presented either as standard multiple-choice or in one of the NGN formats.

Case Study questions

On the NCLEX, test-takers will encounter three groups of six Case Study questions that feature multi-step clinical scenarios tied to the same client presentation. In the field, nurses use iterative, multi-step processes to observe and assess the presenting situation, identify concerns, and develop solutions. Nurses must take what they know and apply it to a broad series of situations, using key facts and evidence-based approaches to address medical needs.

Case study items are structured as unfolding client information, allowing nursing candidates to gather the information they need to demonstrate clinical judgment. The NCSBN Clinical Judgment Measurement Model (NCJMM) highlights these key steps:

• Recognize cues: Identify relevant and important information from different sources (e.g., medical history, vital signs)
• Analyze cues: Organize and connect the recognized cues to the client’s clinical presentation
• Prioritize hypotheses: Evaluate and prioritize hypotheses (urgency, likelihood, risk, difficulty, time constraints, etc.)
• Generate solutions: Identify expected outcomes and use hypotheses to define a set of interventions
• Take action: Implement the solution(s) that address the highest priority
• Evaluate outcomes: Compare observed outcomes to expected outcomes

Just as in real nursing practice, nurses must use the information provided to make decisions quickly. Sometimes medical professionals work with limited information and must use as many details as are available (age range, lab values, extent of illness or injury, etc.) to figure out the next steps in treatment and care.

The structure of Next Gen questions can be either multiple-choice or one of the NGN question types (SATA, bow-tie, etc.), which prompts the test-taker to piece together multiple pieces of information to arrive at an answer.

Select All That Apply (SATA) questions

Select All That Apply (SATA) questions are self-explanatory: examinees are given a scenario and must select all responses that apply. The example below covers infant care and required interventions:

A nurse is attending to an infant diagnosed with pulmonary atresia. Suddenly, the infant develops cyanosis, and the oxygen saturation falls to 50%. Choose the interventions that the nurse should perform. Select all that apply.

1. Monitor vital signs.
2. Prepare to administer morphine sulfate.
3. Prepare to administer intravenous fluids.
4. Call a code blue.
5. Place the infant in a knee-to-chest position.
6. Prepare to administer 100% oxygen by face mask.

Answer: 1, 2, 4, 5, 6.

In this case, responses 1, 2, 4, 5, and 6 all apply. The child who is cyanotic with oxygen saturation dropping to 50% is having a hypercyanotic episode. Hypercyanotic episodes often occur in infants with pulmonary atresia and in those with heart defects that obstruct pulmonary blood flow and communication between the ventricles.

If a hypercyanotic episode occurs, the infant is immediately placed in the knee-chest position, which improves systemic arterial oxygen saturation by reducing venous return. Throughout treatment, vital signs must be continuously monitored to ensure that oxygen levels do not fall further, and a code blue notifies the primary care provider of an emergency.

Morphine sulfate and oxygen via face mask are prepared to relax breathing and, if needed, regain consciousness. This example shows how several factors (the condition, oxygen level, and age) all play a role in interventions.

Bow-tie questions

Bow-tie questions are structured as charts in which a central “potential condition” points to two actions to take on the left and two parameters on the right, mimicking a bow-tie shape. The example below presents five potential conditions with a set of actions and parameters to be chosen based on context clues:

Answer:

• Potential condition: Gestational diabetes with persistent hyperglycemia
• Actions to take: Monitor the fetus’s growth over time; Monitor blood glucose levels
• Parameters to monitor: Fasting blood glucose level; Fetal growth (fundal height or ultrasound for macrosomia)

A nursing graduate should be able to recognize the “actions to take” and “parameters” which both address two main concerns related to gestational diabetes: the health of the birthing parent (glucose levels) and the health of the fetus (fetal growth and development). The other options are either irrelevant (pregnancy-induced hypertension, post-partum depression) or incomplete (diabetes mellitus).

Matrix/grid questions

Matrix or grid questions present a client scenario and pieces of client information that allow a nurse to determine whether the client is at high risk of infection, identify steps in a treatment plan, or determine other procedures related to clinical practice. Elements are presented in a matrix, and test-takers select the correct answer from the table using checkboxes or tick marks. Here’s an example focusing on an older patient preparing for a surgical procedure:

A nurse cares for an older adult on a medical-surgical unit who is scheduled for a transurethral incision of the prostate (TUIP). For each perioperative step or piece of client data, determine whether it increases, decreases, or has no effect on the client’s infection risk.

Answer:

The first four factors would each increase the risk of infection post-surgery, particularly after transurethral surgery. Normal blood sugar levels indicate either that the patient does not have diabetes or is well-managing their diabetes, which decreases the risk of infection. A heart murmur, though sometimes indicative of more serious cardiovascular issues, is unlikely to affect infection risk on its own.

Drag-and-drop questions

Drag-and-drop questions also describe how they function: the exam’s interface lets the test-taker reorder a series of choices.

For example, take this question on PPE protocol:

A patient being treated for Hand, Foot, and Mouth Disease requests assistance with using the bathroom. Before entering, you must put on personal protective equipment. Arrange the correct order for donning PPE:

1. Don gloves
2. Don gown
3. Don N95 Mask (respirator)
4. Perform hand hygiene

Answer:

1. Perform hand hygiene
2. Don gown
3. Don a N95 mask (respirator)
4. Don gloves

The first step to safely interacting with a patient is to wash your hands to avoid lingering bacteria from another case or contamination from spreading. Next, put on the personal protective equipment in the order that makes sense: gown first, since it usually goes over your head and can get caught on the N95 mask if that’s on first, then the mask, and finally the gloves to minimize touching other objects with them on. For help on this kind of sequential question, consider the inverse procedure (in this case, doffing equipment) and what the reverse order of those steps would be.

Drop-down or cloze questions

Drop-down questions on the NCLEX are presented in one of three ways:

1. Drop-down cloze: A paragraph containing dropdown menus that present multiple options for completing the paragraph, with each dropdown offering three to five possible answers.
2. Drop-down rationale: A cause-and-effect sentence where you select the correct outcome and its supporting reason from dropdown menus.
3. Drop-down table: A table in which each cell contains a drop-down, letting you match causes to effects. Each drop-down menu offers three to five options.

Here’s an example of a cloze or “fill-in-the-blank” question:

A client was found to have a normal temperature, normal heart rate with a minimal heart murmur, and normal blood glucose levels. The client is at the lowest risk for developing _____ as evidenced by the client’s _____.

Option A:

1. myocardial infarction
2. dysrhythmias
3. hypoxia
4. influenza

Option B:

1. respiratory assessment
2. cardiovascular assessment
3. blood sugar levels
4. vital signs

Answer: Option A = 2 and Option B = 2

Based on the evidence, a nurse can deduce that the client is at low risk of developing a heart attack (myocardial infarction) based on their cardiovascular assessment, which found a small heart murmur but no other high-risk signs.

What about partial credit?

Unlike traditional multiple-choice questions, which are scored right or wrong, many Next Gen item types use partial-credit (polytomous) scoring. On SATA, matrix/grid, and bow-tie items, you can earn credit for the correct selections you make rather than losing all points for a single mistake.

Common scoring approaches include the +/- method (each correct choice earns a point and each incorrect choice deducts one, with no negative overall score). All-or-nothing rationale scoring, however, is used for cause-and-effect items, which means you will not receive partial credit for wrong responses on these questions. In practice, partial credit rewards partial clinical judgment, so it’s worth attempting every part of an NGN item even when you’re unsure of one piece.

Additional questions about the NCLEX

Is the NCLEX hard?

The NCLEX is considered a moderately challenging exam, but completing an accredited nursing program should prepare you well. Although it covers a wide range of topics and requires deliberate preparation, the first-time NCLEX pass rate is relatively high. According to NCSBN, in 2025, first-time U.S.-educated candidates achieved an 86.7% pass rate on the NCLEX-RN. Success on the exam demands effort, but it is definitely possible to pass soon after finishing your educational program.

What makes the NCLEX tough is both the extensive content it covers and the need to apply nursing knowledge in practical situations. Test-takers are evaluated not only on their knowledge of medication names or procedures but also on their ability to determine when and how to use that information appropriately. As in real nursing practice, candidates must translate their coursework knowledge into safe and effective patient care.

How do you study for the NCLEX?

Preparing for the NCLEX resembles preparing for other standardized tests because the exam has distinct content and format, and relying solely on prior knowledge is usually insufficient. Nursing graduates should dedicate time to studying for the NCLEX and get comfortable with its unique question styles and Case Studies.

1. Review the NCLEX test plan and structure your study plan accordingly.
2. Practice under real NCLEX exam conditions.
3. Summarize each section in your own words after studying.
4. Use spaced repetition systems for memorization-heavy material.
5. Work through practice problems soon after learning new content.
6. Finish each session by testing yourself rather than re-reading material.

Practicing with a variety of realistic questions that mimic the different styles of NCLEX content will help prepare you for the official test day. Make sure always to read each question carefully and in its entirety: NCLEX questions often include details designed to distract or misguide test-takers, so double-check that you understand what’s being asked.

What score do I need to pass the NCLEX?

There is no set NCLEX passing score. The exam allows candidates to answer between 85 and 150 questions. The computer-adaptive software continuously assesses performance, adjusting question difficulty as the test-taker progresses. Once the system has enough information to determine, with 95% confidence, whether an examinee will pass or fail, the exam ends immediately. You won’t know your result right away; official results are typically released within about two to six weeks (often sooner) through your nursing regulatory body. NCSBN also offers an unofficial “Quick Results” service that provides a pass/fail indication about 48 hours after your exam for a small fee.

To help ensure you pass the first time and avoid signing up for a retake, practice with full-length tests and aim to answer as many questions as possible. Practice exams will help you develop time management, pattern recognition, and other test-taking strategies for the official test day, even without a specific score to aim for.

How do you register for the NCLEX?

Well ahead of your exam, double-check that you have a valid government-issued ID for admission at your testing center and that you’ve followed all required steps to sit for the test:

1. First, complete a state-approved nursing education program. This may include a bachelor’s degree in nursing (BSN), an associate degree in nursing (ADN), or a hospital-based diploma program.
2. Apply for licensure or registration with the nursing regulatory body (NRB) in the state or jurisdiction where you intend to practice. Depending on the location, this may be the state board of nursing, an office within the state education department, or another designated regulatory authority.
3. Register with Pearson VUE, the organization that delivers the exam.
4. Pay the $200 registration fee.
5. Receive your Authorization to Test (ATT) email, which confirms your eligibility to test.
6. Schedule an appointment to take the NCLEX at your local testing center. Have your ATT email prepared for your appointment.

The night before the NCLEX should be about mental preparation, not last-minute cramming. Make sure you have all your materials in order (a government ID with a photograph and the ATT email to confirm entry). Dress comfortably, but avoid bringing hats or scarves into the test room (religious exceptions apply).

Always plan to arrive at your testing site at least 30 minutes early, as late arrivals may not be admitted. Remember that you cannot bring your own calculator; one will be provided for you.

Conclusion

The NCLEX exam is essential for becoming a nurse and is required in all U.S. states and territories and in all Canadian provinces. The Next Gen NCLEX features case study questions that mimic real clinical situations, rewarding quick thinking and expert judgment. Studying not only prepares you for the exam but also gives you an advantage in developing the clinical skills and critical thinking necessary for success in practice.

After completing your nursing program, passing the NCLEX remains the final hurdle to licensure. To improve your chances, create a thorough study plan, get comfortable with NGN questions, and take practice tests regularly. An organized approach and understanding of different question types will ease stress on the test day and boost your overall results.