Next Generation NCLEX® (NGN) Exam Format: A Comprehensive Guide

Nov 06, 2025 0

The National Council of State Boards of Nursing (NCSBN®) introduced a new format for the NCLEX-RN® and NCLEX-PN® exams in April 2023. This updated format, known as the Next Generation NCLEX® (NGN), includes innovative item types designed to assess students’ knowledge in more interactive and comprehensive ways. These new question formats go beyond traditional multiple-choice questions to evaluate a candidate’s sense of clinical judgment.

To successfully train nurses, nursing programs need to equip their candidates with both medical and clinical judgment knowledge, as well as the exam-taking skills needed to confidently navigate licensure exams like the NGN.

Students unfamiliar with the new NGN item types may experience stress, anxiety, and confusion on exam day. Therefore, understanding the format and types of items significantly enhances performance.

Overview of NGN Exam Features

Here’s a summary of key features and rules of the NGN exam:

Time Allotment: You have up to 5 hours to complete the NGN.
Number of Questions: You can expect to receive a minimum of 85 and a maximum of 150 questions. The number of scored questions ranges from 70 to 135.
Time Per Question: You have about 2 minutes to answer each question.
Breaks: You can take a break after 2 hours of testing and another after 3.5 hours.
Computerized Adaptive Testing (CAT): The computer stops delivering new questions when the algorithm determines with 95% confidence that you have achieved competency.

Computerized Adaptive Testing (CAT)

Computerized Adaptive Testing (CAT) customizes your exam to match your ability level, making each test unique. An algorithm adjusts the difficulty of each question based on your response to the previous one. You’ll start with a question near the passing level. If you answer correctly, the next question will be slightly harder. If you answer incorrectly, the next question will be easier.

The computer ends the exam based on the following rules:

Confidence Interval Rule: The computer ends the exam when it is 95% certain that your ability is clearly above or below the passing standard. This is the most common scenario.
Run-Out-of-Time Rule (ROOT): If you run out of time and haven’t answered the minimum number of questions, you will fail.

New Scoring Method: Polytomous Scoring

The NGN introduces polytomous scoring, a new partial scoring method. You can now receive partial credit for correct responses on questions with more than 1 correct answer. The polytomous scoring method allows for a more accurate assessment of your abilities, as it considers the level of proficiency demonstrated by each response.

Here’s how the scoring works:

Traditional Scoring: Your answer is either correct or incorrect, earning you 1 point for a correct response and no points for an incorrect one.
Plus/Minus Scoring: You earn points for selecting correct options but lose points for selecting incorrect ones. Your score is calculated by adding points for correct answers and subtracting points for incorrect ones.
Rationale Scoring: The rationale scoring rule applies to questions that assess relational or paired information. To earn 1 point, both of your selected answers must be correct.

NEXT GENERATION NCLEX Case Study/Cardiovascular/Respiratory Part I

New NGN Item Types

The Next Generation NCLEX (NCLEX-NGN) introduces new types of test items to evaluate your ability to use the NCSBN Clinical Judgment Measurement Model (NCJMM) when providing safe care for clients.

The new types of test items that are part of the case studies are described here.

Read also: Overcoming NCLEX disappointment

NCJMM Measures Six Essential Clinical Skills:

Recognize cues: Client findings from assessments, history, medical records, and other sources that provide information for the nurse to make preliminary decisions.
Analyze cues: The nurse examines the cues to determine what they can mean. Analysis requires knowledge of medical conditions, pathophysiology, and signs/symptoms.
Prioritize hypotheses: After considering the data and cues, the nurse evaluates what the client most likely needs and what is necessary for a safe recovery.
Generate solutions: Now the nurse thinks about all possible ways to address and resolve the client’s needs or problems. The nurse lists expected or desired outcomes first.
Take action: Interventions that will result in positive outcomes are included. The nurse must also act to intervene when complications develop.
Evaluate outcomes: Now the nurse determines if the interventions were successful or what else needs to be done for a positive outcome.

Stand-alone Test Items

Stand-alone test items target one or more of the 6 clinical skills. There is a short scenario that may include tabs with data, such as nurse’s notes, vital signs, lab results, medical-social history, medications, etc. Although they include steps from the NCJMM, they differ from the Ongoing Case Studies:

Feature	Stand-alone	Case Study
Number of Items	Single test item	Group of 6 progressive test items
Diagnosis	Has a stated diagnosis or an implied diagnosis	Diagnosis not known at the outset
Clinical Information	Contains clinical information for a specific client	Contains clinical information for 1 or more clients
Clinical Decisions	Has components that require an entry-level nurse to make 1+ clinical decisions	Entry-level nurse must make multiple clinical decisions throughout the case study

There are 2 types of stand-alone test items: Bow-tie and Trend.

Bow-Tie Test Items

Bow-tie items cover all 6 steps in the NCJMM at one point in time. You will read the scenario and available data, then decide:

which findings are relevant, normal or abnormal (Recognize cues);
understand possible medical conditions or complications (Analyze cues)
identify the client’s immediate needs and/or problems (Prioritize hypotheses)
determine possible solutions to take (Generate solutions)
implement appropriate interventions (Take actions)
monitor interventions for effectiveness (Evaluate outcomes)

Tips to answer a Bow-tie item on your exam:

ALWAYS read the entire test item carefully. Make sure you understand what the question is about.
Answer the middle well (Potential Condition) FIRST. This is the main question and will help you answer the Actions and Parameters columns more accurately. Identify the relevant information and apply it to the client’s condition. Now you can review the options and select the BEST choice. Drag it to the matching color target.
Now you can look at the nursing actions that will BEST manage and support the client. Select two and drag them to the matching color targets.
Finally, determine the parameters that will indicate if the actions effectively monitor those nursing actions. Select two and drag them to the matching color targets.
ALWAYS check your answers before moving to the next test item!

Trend Test Items

Trend items present a client scenario with information gathered over time. The time period can range from minutes to hours, days, or longer. The nurse must review the information and determine if the client’s condition is changing.

Read also: Understanding NGN Pass Rates

Unlike Bow-tie items, which include all 6 steps in order, Trend items address multiple steps, but they don’t follow the exact order.

Like Bow-tie items, tabs can include nurse’s notes, vital signs, lab results, medications, medical-social history, etc. The types of questions can be any that are found in Ongoing Case Studies.

Since trend items don’t follow the NCJMM 6-step order, you may get a question that covers Recognize Cues and then skips to Take Action. Or Generate Solutions, then Evaluate Outcomes. In order to answer correctly, you must know all the steps and be able to follow them, even if they aren’t part of that particular test item.

Additional NGN Item Types

The Next Generation NCLEX® (NGN) exam includes several new item types designed to assess students’ knowledge in interactive and comprehensive ways. Here are some of these item types:

Unfolding Case Studies: These are a series of questions based on a changing case study. The test taker must adapt as the scenario progresses due to new and unpredictable information.
Matrix Item Type: This is a closed-ended question that asks the test taker to evaluate a number of row items using the same set of column choices. Questions can have 4-10 rows and 2-3 columns, with each row requiring one response option.
Drag-and-Drop Cloze Item Type: This presents a sentence or short passage with two or more blanks. The test taker must complete the sentence by dragging the correct tokens into the appropriate blanks.
Drop-Down Cloze Item Type: This presents a paragraph with one or more drop-down menus within the text. Each drop-down contains three to five possible answer options, and the test taker must select the most appropriate choice.
Drop-Down Rationale Item Type: This presents a single sentence that illustrates a cause-and-effect relationship. The sentence may include one cause and one effect, or one cause and two effects.

Strategies for NGN Exam Readiness

To prepare for the NGN exam, consider the following strategies:

Familiarize Yourself with Item Types: Research indicates that understanding the format and types of items significantly enhances performance on exam day.
Practice with NGN Prep Items: Use resources that simulate the challenges posed by advanced question styles.
Understand Test Expectancy: Knowing the format of the test can help you adapt your study strategies and process information differently.
Utilize Available Resources: Take advantage of tools and materials designed to equip nursing candidates with the necessary knowledge and skills.