NCLEX question types, worked
Four of the new question formats, with one real item each. The answer, how to work it out, and what makes the wrong options look right.
Most guides tell you what the new NCLEX question types look like. This one works through four of them properly. For each format you get a real item, the answer, and an explanation of how to get there.
Try each question before you read the answer. Pick an option and commit to it, even if you are not sure. You learn far more from getting one wrong on purpose than from reading an explanation you already agreed with.
If you have not read why the exam changed shape in 2023, start with what changed in the Next Generation NCLEX and come back to these.
Bow-tie
A bow-tie item has three parts. You put the client's condition in the middle, two nursing actions on the left, and two things you would monitor on the right.
All the options come from one shared word bank, so the wrong answers for one part sit right next to the right answers for another. The whole item is marked together. Name the condition correctly but pick the wrong actions and you still lose most of the marks.
The chart. A 68-year-old client admitted with a two-day history of breathlessness. Sitting upright. Respirations 28 and laboured, SpO2 88% on room air, heart rate 112, blood pressure 158/94, temperature 36.9°C. Crackles to mid-zones bilaterally, pitting oedema to both shins, jugular venous distension. Gained 3 kg since last week. Reports sleeping on three pillows.
The task. From the word bank, select the condition the client is most likely experiencing, two actions the nurse should take, and two parameters to monitor.
Word bank: pneumonia · acute decompensated heart failure · pulmonary embolism · COPD exacerbation · administer prescribed IV furosemide · position upright and apply supplemental oxygen · administer a 500 mL fluid bolus · begin chest physiotherapy · obtain blood cultures · daily weight and fluid balance · oxygen saturation and respiratory rate · serum potassium · white cell count
Condition: acute decompensated heart failure. Actions: position upright and apply supplemental oxygen; administer prescribed IV furosemide. Monitor: oxygen saturation and respiratory rate; daily weight and fluid balance.
How to get there. Look at the findings as a group. The client sleeps on three pillows, has a raised JVP, crackles in both lungs, swollen shins, and has put on 3 kg in a week. Any one of those on its own could be several different things. All of them together mean the client is carrying too much fluid.
What makes the wrong options tempting. A fluid bolus is the right move when blood pressure is low. This client’s is high, so that option is there to catch anyone answering on reflex. Pneumonia fits the crackles and the fast heart rate, but the temperature is normal, and pneumonia does not explain swollen legs or 3 kg of weight gain. Serum potassium is worth watching once furosemide is running, but that is about giving the drug safely. The item asks what would show you the client is getting better, and that is the breathing and the fluid balance.
Trend
A trend item gives you the same measurements taken at three or more times. If you are used to questions that show one set of observations, it is tempting to read the most recent column and answer from that. The answer is usually in how the numbers are changing rather than where they have ended up.
The chart. A 24-year-old client, first post-operative day after an appendicectomy.
| 08:00 | 12:00 | 16:00 | |
|---|---|---|---|
| Temperature | 37.1°C | 37.8°C | 38.4°C |
| Heart rate | 82 | 98 | 118 |
| Blood pressure | 122/78 | 114/70 | 98/56 |
| Respirations | 16 | 20 | 26 |
| Urine output | 60 mL/h | 40 mL/h | 18 mL/h |
The question. Which action should the nurse take first?
- AAdminister the prescribed antipyretic and reassess the temperature in one hour.
- BNotify the provider of the trend and prepare for sepsis assessment and fluid resuscitation.
- CEncourage oral fluids and continue four-hourly observations.
- DDocument the findings and reassess at the next scheduled observation round.
How to get there. Every row is heading the same way across eight hours. Temperature, heart rate and breathing are all climbing. Blood pressure and urine output are both falling. If you only read the 16:00 column, a heart rate of 118 and a blood pressure of 98/56 are worrying but not dramatic. Read as a sequence, this is early sepsis in someone who had surgery yesterday, and the falling urine output is already telling you the kidneys are not getting enough blood.
What makes the wrong options tempting. Option A does treat the fever, which is a real finding, but it brings the number down without touching the cause. Options C and D both sound sensible if you look at any single column, and that is the point. Nothing at 16:00 on its own forces you to act, so it is easy to talk yourself into waiting for the next round of observations. The question is checking whether you noticed the direction.
Matrix or grid
A matrix item is a table. Findings run down the side, categories run across the top, and you tick a box for each row. You gain marks for correct ticks and lose them for incorrect ones, so ticking everything that looks possible will score badly.
The chart. A client with type 1 diabetes is found drowsy and sweating at 06:00. Capillary blood glucose 2.9 mmol/L (52 mg/dL). The client is rousable and able to swallow.
The task. For each finding, indicate whether it is consistent with hypoglycaemia or consistent with hyperglycaemia.
| Finding | Hypoglycaemia | Hyperglycaemia |
|---|---|---|
| Cool, clammy skin | ✓ | |
| Tremor and palpitations | ✓ | |
| Fruity odour on the breath | ✓ | |
| Deep, sighing respirations | ✓ | |
| Polyuria and thirst | ✓ | |
| Irritability and confusion | ✓ |
How to get there. Low blood sugar sets off an adrenaline response, which is why the client is cool, clammy, shaky and aware of their heartbeat. The brain also runs short of glucose, and that produces the irritability and confusion. High blood sugar works differently. The extra glucose drags water out into the urine, so the client passes a lot of it and is thirsty, and once ketones build up you get deep sighing breaths and a fruity smell.
Where marks go missing. Confusion really does happen in both, so ticking it in both columns feels like the safe answer. In a matrix item it costs you. If you want one finding that separates them quickly, use the skin. Cool and clammy means low, warm and dry means high.
What you would do. The client is rousable and can swallow, so give 15 g of carbohydrate by mouth and check the blood glucose again after 15 minutes. Being drowsy on its own is not a reason to reach for intramuscular glucagon or IV glucose, as long as swallowing is safe.
Cloze
A cloze item is a sentence with dropdown menus in it. You choose an option for each gap, and the sentence only reads correctly if every choice is right. One wrong pick makes the whole sentence wrong, so this format checks whether your thinking holds together from start to finish.
The chart. A 30-year-old client, 34 weeks pregnant, presents with a headache unrelieved by paracetamol, visual "sparkles", and epigastric pain. Blood pressure 168/112 on two readings four hours apart. Urine protein 3+. Brisk reflexes with two beats of clonus. Platelets 96 × 109/L.
Complete the sentence. The client is most likely experiencing [1], and the nurse's priority action is to [2].
Option 1: gestational hypertension · pre-eclampsia with severe features · chronic hypertension · migraine in pregnancy
Option 2: administer prescribed magnesium sulfate and prepare for seizure precautions · encourage a dark quiet room and reassess in two hours · give the next dose of paracetamol · obtain a 24-hour urine collection
[1] pre-eclampsia with severe features. [2] administer prescribed magnesium sulfate and prepare for seizure precautions.
How to get there. High blood pressure plus protein in the urine is pre-eclampsia. What makes this the severe form is that four warning signs are present at once, and any one of them would be enough on its own: a systolic pressure of 160 or above, a platelet count below 100 × 109/L, disturbed vision, and pain in the upper abdomen. The clonus tells you the nervous system is already irritable.
What makes the wrong options tempting. Gestational hypertension means the same blood pressure without the protein and without any sign of organ damage. It sits one option away and is far less urgent, so choosing it changes everything about what happens next. The dark quiet room is sound advice for a migraine, and offered here it delays magnesium in someone who may be close to a seizure. The 24-hour urine collection is a real test, but events have moved past it. When the platelets are falling and vision is affected, you treat rather than investigate.
None of the wrong answers were silly. Every one was a real nursing action that would be correct in a slightly different situation, and in two of the four items a single changed detail would have made the wrong option the right one. That is deliberate. The exam is sorting people by which finding they gave the most weight to.
The exam itself is one step of seven on the way to a US licence. How to become a nurse in the USA from India sets out the other six.
Four items on a page. A dozen in the live hour.
Bring your own question and ask it on the call. Free to attend, Wednesdays and Saturdays, 6–7 PM IST.
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