The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the exam that all nursing graduates must successfully pass to obtain their nursing license and become a registered nurse. The purpose of the NCLEX is to evaluate if a nursing graduate (i.e., candidate) is competent to provide safe, competent, entry-level nursing care. The NCLEX-RN is developed by the National Council of State Board of Nursing (NCSBN), an independent, nonprofit organization composed of the 50 state boards of nursing and other regulatory agencies.[1]

A new edition of NCLEX will be released in 2023 that includes “Next Generation” questions. (If you take the NCLEX before the new edition is released, you may be asked to voluntarily participate in a special research section that tests the accuracy of these new types of questions without your performance counting toward your final score.) The Next Generation NCLEX (Next Gen) uses evolving case studies and other types of test questions based on the new NCSBN Clinical Judgment Measurement Model (NCJMM). The NCJMM assesses how well the candidate can think critically and use clinical judgment when providing safe nursing care.[2]

Five new Next Generation test item types are called extended multiple response, extended drag and drop, cloze (drop-down), extended hot spot (highlighting), and matrix-grid[3]:

  • Extended Multiple Response: Extended Multiple Response items allow candidates to select one or more answer options at a time. This item type is similar to the current NCLEX multiple response item but has more options and uses partial credit scoring.
  • Extended Drag and Drop: Extended Drag and Drop items allow candidates to move or place response options into answer spaces. This item type is like the current NCLEX ordered response items but not all of the response options may be required to answer the item. In some items, there may be more response options than answer spaces.
  • Cloze (Drop – Down): Cloze (Drop – Down) items allow candidates to select one option from a drop-down list. There can be more than one drop-down list in a cloze item. These drop-down lists can be used as words or phrases within a sentence or within tables and charts.
  • Enhanced Hot Spot (Highlighting): Enhanced Hot Spot items allow candidates to select their answer by highlighting predefined words or phrases. Candidates can select and deselect the highlighted parts by clicking on the words or phrases. These types of items allow an individual to read a portion of a client medical record (e.g., a nursing note, medical history, lab values, medication record, etc.), and then select the words or phrases that answer the item.
  • Matrix/Grid: Matrix/Grid items allow the candidate to select one or more answer options for each row and/or column. This item type can be useful in measuring multiple aspects of the clinical scenario with a single item. In the example below, each of the eight rows will need to have one of the three answer choices selected.

View the following YouTube video[4] from NCSBN on Next Generation test items: The Right Decisions Come from the Right Questions

The NCJMM complements the nursing process but uses different terminology in exam questions while assessing the candidate’s clinical judgment. This terminology includes recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes. See Table 4.9 for a comparison of these terms and actions to the nursing process.[5], [6], [7]

Table 4.9 Comparison of the NCSBN Clinical Judgment Measurement Model to the Nursing Process

NCSBN Clinical Judgment Skill Description  Corresponding Step of the Nursing Process
Recognize Cues What data is clinically significant?

Determining what client findings are significant, most important, and of immediate concern to the nurse (i.e., identifying “relevant cues”).

Analyze Cues What does the data mean?

Analyzing data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for this client at this time according to their age, development, and clinical status.

Making a clinical judgment concerning the clients’ “human response to health conditions/life processes, or a vulnerability for that response,” also referred to as “forming a hypothesis.”


(Analysis of Data)

Prioritize Hypotheses What hypotheses should receive priority attention?

Ranking client conditions and problems according to urgency, complexity, and time.

Generate Solutions What should be done?

Planning individualized interventions that meet the desired outcomes for the client; may include gathering additional assessment data.

Take Action What will I do now?

Implementing interventions that are safe and most appropriate for the client’s current priority conditions and problems.

Evaluate Outcomes Did the interventions work?

Comparing actual client outcomes with desired client outcomes to determine effectiveness of care and making appropriate revisions to the nursing care plan.


It is important to note that NANDA Nursing Diagnoses are not specifically assessed on the NCLEX. However, the ability of a candidate to cluster client data, make hypotheses, prioritize hypotheses, and plan nursing interventions is based on a nursing knowledge base of potential human responses to health problems and life processes (otherwise known as nursing diagnoses).

Learning activities are incorporated throughout the chapters of this book to assist students in learning how to respond to NCLEX Next Generation-style test questions.

  1. NCSBN.
  2. NCSBN.
  3. NCSBN.
  4. NCSBN. (2019, December 17). The Right Decisions Come from the Right Questions. [Video]. YouTube. All rights reserved.
  5. NCSBN (n.d.) NCSBN Clinical Judgment Measurement Model.
  6. Ignativicius, V. & Silvestri, L. (2022). Preparing for the Next-Generation NCLEX (NGN): A “how-to” step-by-step faculty resource manual. Elsevier. 
  7. American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.


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Nursing: Mental Health and Community Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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