Matrix and grid items are Next Generation NCLEX questions that present a set of findings, interventions, or client data as rows, with the same set of response columns applied to every row. You evaluate each row independently and, in the matrix multiple choice format, select exactly one column for it, so partial credit is possible and one wrong row does not invalidate the rest. The eight practice items below cover common clinical situations — COPD exacerbation, hyperkalemia, pressure injury staging, tuberculosis precautions, digoxin toxicity, thyroid disorders, newborn assessment, and delegation — with full rationales for every row. New to these formats? See our complete guide to NGN question types, or practice all six NGN item types.
Matrix & Grid NCLEX Practice Questions
Item 1 · Matrix / Grid · COPD Exacerbation: Expected Findings vs. Findings Requiring Immediate Follow-Up
A 68-year-old client with a 40-pack-year smoking history and stage 3 chronic obstructive pulmonary disease is admitted to the medical unit with an acute exacerbation triggered by a respiratory infection. The client is receiving oxygen at 2 L/min by nasal cannula, scheduled bronchodilators, and IV methylprednisolone. The nurse completes a focused respiratory assessment 6 hours after admission.
For each assessment finding, click to specify whether the finding is an expected finding in a COPD exacerbation or a finding that requires immediate follow-up.
Show answer & rationale
Barrel-shaped chest with increased anteroposterior diameter: Expected finding
Oxygen saturation 91% on 2 L/min nasal cannula: Expected finding
Pursed-lip breathing while ambulating to the bathroom: Expected finding
New somnolence, confusion, and asterixis: Requires immediate follow-up
Absent breath sounds over the right upper lobe with tracheal deviation to the left: Requires immediate follow-up
Chronic air trapping and hyperinflation remodel the thorax, so a barrel chest with an anteroposterior-to-lateral diameter approaching 1:1 is a hallmark chronic finding, not an emergency. Pursed-lip breathing is a learned, protective maneuver that creates back-pressure, splints collapsible small airways open during exhalation, and improves emptying; it should be encouraged rather than treated. An oxygen saturation of 91% is acceptable because the target saturation range in COPD is 88% to 92%. Driving the saturation higher risks CO2 retention by blunting hypoxic respiratory drive, by worsening ventilation-perfusion mismatch as hypoxic pulmonary vasoconstriction is inhibited, and through the Haldane effect, so 91% on low-flow oxygen indicates appropriate titration. New somnolence, confusion, and asterixis are classic signs of acute hypercapnia and CO2 narcosis. A client who becomes drowsy while working hard to breathe is decompensating, not resting; this warrants immediate provider notification and arterial blood gas measurement, because a rising PaCO2 with a falling pH signals impending respiratory failure and possible need for noninvasive positive pressure ventilation. Absent breath sounds in one lung field with contralateral tracheal deviation suggests a tension pneumothorax, a recognized complication of bullous emphysema and positive pressure ventilation. This is a life-threatening emergency requiring immediate escalation for needle decompression and chest tube placement. Distinguishing chronic structural changes and adaptive breathing patterns from acute neurologic and mechanical deterioration is the core reasoning skill this item tests.
Item 2 · Matrix / Grid · Severe Hyperkalemia: Indicated vs. Contraindicated Interventions
A 59-year-old client with stage 4 chronic kidney disease presents to the emergency department with generalized weakness. Vital signs are blood pressure 148/86 mm Hg, heart rate 52/min, respirations 18/min. Laboratory results show serum potassium 6.9 mEq/L, sodium 138 mEq/L, creatinine 4.2 mg/dL, and calcium 8.6 mg/dL. The 12-lead ECG shows tall peaked T waves and a widening QRS complex.
For each intervention, click to specify whether the intervention is indicated or contraindicated for this client at this time.
Show answer & rationale
Administer IV calcium gluconate 1 g over 2 to 3 minutes: Indicated
Administer 10 units of regular insulin IV with 25 g of dextrose 50%: Indicated
Initiate continuous cardiac monitoring: Indicated
Administer spironolactone 25 mg orally: Contraindicated
Infuse lactated Ringer's solution at 150 mL/hr: Contraindicated
A potassium of 6.9 mEq/L (normal 3.5 to 5.0 mEq/L) with peaked T waves and QRS widening is a cardiac emergency. IV calcium gluconate is the first priority because it does not lower potassium but antagonizes its effect at the myocardial membrane, restoring the gradient between resting and threshold potentials and stabilizing conduction within minutes. Regular insulin drives potassium intracellularly through stimulation of the sodium-potassium ATPase pump, lowering serum potassium by roughly 0.5 to 1.2 mEq/L within 15 to 30 minutes; dextrose is co-administered to prevent iatrogenic hypoglycemia, and glucose must be rechecked because the effect of insulin outlasts the dextrose bolus. Continuous cardiac monitoring is essential, since untreated hyperkalemia progresses from peaked T waves to a widened QRS, a sine wave pattern, and then asystole or ventricular fibrillation. Spironolactone is a potassium-sparing aldosterone antagonist that blocks distal tubule potassium excretion and would worsen the hyperkalemia; potassium-sparing diuretics, ACE inhibitors, ARBs, and NSAIDs should be held. Lactated Ringer's contains approximately 4 mEq/L of potassium and is a poor choice when the goal is potassium removal; normal saline is preferred if volume is needed. Insulin, beta-2 agonists, and bicarbonate only shift potassium temporarily. Definitive elimination requires a binder such as patiromer or sodium zirconium cyclosilicate, a loop diuretic if urine output permits, or hemodialysis, which is the definitive therapy in advanced kidney disease.
Item 3 · Matrix / Grid · Pressure Injury Staging Using NPIAP Criteria
A wound care nurse is rounding on a long-term care unit and documents the characteristics of five pressure injuries. The nurse stages each injury according to current National Pressure Injury Advisory Panel definitions.
For each wound description, click to specify the correct pressure injury stage.
Show answer & rationale
Intact skin over the sacrum with localized nonblanchable erythema; area is warmer and firmer than surrounding tissue: Stage 1
Partial-thickness loss of skin with exposed dermis; wound bed is pink, moist, and viable with no slough or granulation tissue: Stage 2
Full-thickness loss with visible adipose tissue, rolled wound edges, and tunneling; no fascia, muscle, tendon, or bone visible: Stage 3
Full-thickness loss over the heel with directly palpable calcaneal bone in the wound bed: Stage 4
Full-thickness loss with the wound base completely obscured by thick yellow slough and adherent black eschar: Unstageable
NPIAP staging is determined by the deepest tissue layer that is visible or palpable. A stage 1 pressure injury has intact skin with nonblanchable erythema; temperature change, firmness, and pain often precede the visible color change and may be the only early clues in darkly pigmented skin, where erythema can be difficult to appreciate. Stage 2 is partial-thickness loss exposing viable dermis, presenting as a shallow open ulcer or an intact or ruptured serum-filled blister; slough, granulation tissue, and eschar are absent by definition, and this stage should not be used to describe moisture-associated skin damage, skin tears, or tape injuries. Stage 3 is full-thickness loss in which adipose tissue is visible; granulation tissue, epibole (rolled edges), undermining, and tunneling may be present, but fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. Depth varies by anatomic location because the bridge of the nose, ear, occiput, and malleolus lack subcutaneous tissue. Stage 4 involves exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone; osteomyelitis is a real risk. An injury is classified as unstageable when slough or eschar obscures the wound base, because the true depth cannot be determined until the nonviable tissue is removed. One important exception: stable, dry, adherent eschar on an ischemic heel functions as a biologic cover and should not be debrided. Deep tissue pressure injury, a separate category, presents as intact or nonintact skin with persistent deep red, maroon, or purple discoloration.
Item 4 · Matrix / Grid · Tuberculosis Airborne Precautions: Effective vs. Ineffective Nursing Actions
A 34-year-old client is admitted with a 6-week history of productive cough, night sweats, hemoptysis, and a 15-pound weight loss. Chest radiography shows right upper lobe cavitary infiltrates, and the provider orders sputum collection for acid-fast bacilli and initiation of airborne precautions for suspected pulmonary tuberculosis.
For each nursing action, click to specify whether the action is effective or ineffective in preventing transmission of tuberculosis.
Show answer & rationale
Places the client in a single-occupancy negative pressure airborne infection isolation room with at least 12 air exchanges per hour: Effective
Dons a fit-tested N95 respirator before entering the room: Effective
Applies a surgical mask to the client for transport to the radiology department: Effective
Wears a surgical mask instead of a respirator when suctioning the client: Ineffective
Props the room door open to increase air circulation during care: Ineffective
Mycobacterium tuberculosis travels in droplet nuclei roughly 1 to 5 micrometers in diameter that remain suspended in air for hours, so CDC guidance requires a true airborne infection isolation room: single occupancy, negative pressure relative to the corridor, a minimum of 6 air changes per hour in older construction and 12 or more in renovated or new construction, and air exhausted outdoors or passed through a HEPA filter. Staff must wear a fit-tested N95 or higher-level respirator on every entry; the annual fit test and the seal check before each use are what make the respirator protective. A surgical mask does not form a seal and does not filter droplet nuclei, so it offers no reliable protection to staff, particularly during aerosol-generating procedures such as suctioning, sputum induction, nebulizer therapy, or bronchoscopy, which markedly increase airborne concentration. The direction of protection reverses for the client: when a client must leave the room for an essential test, the client wears a surgical mask to contain respiratory secretions at the source, and the client should never wear an N95, which increases work of breathing. Propping the door open defeats the negative pressure differential and allows contaminated air to escape into the corridor; the door must remain closed except during entry and exit. Care should be clustered and transport minimized. Airborne precautions continue until the client has completed at least two weeks of effective multidrug therapy, is clinically improving, and has three consecutive negative acid-fast bacilli smears from sputum collected 8 to 24 hours apart.
Item 5 · Matrix / Grid · Digoxin Toxicity: Findings Consistent vs. Not Consistent
A 77-year-old client with heart failure with reduced ejection fraction and chronic atrial fibrillation takes digoxin 0.125 mg orally daily and furosemide 40 mg orally daily. The client presents to the clinic reporting several days of feeling unwell. The nurse reviews the assessment findings and laboratory results.
For each finding, click to specify whether the finding is consistent or not consistent with digoxin toxicity.
Show answer & rationale
Apical heart rate 46/min with new nausea, vomiting, and anorexia: Consistent with digoxin toxicity
Reports of blurred vision with yellow-green halos around lights: Consistent with digoxin toxicity
Serum potassium 2.9 mEq/L: Consistent with digoxin toxicity
Serum digoxin level 2.8 ng/mL: Consistent with digoxin toxicity
Blood pressure 132/78 mm Hg with a serum magnesium of 2.0 mg/dL: Not consistent with digoxin toxicity
Digoxin has a narrow therapeutic index. The target serum level in heart failure is approximately 0.5 to 0.9 ng/mL, and levels above 2.0 ng/mL are generally considered toxic, so 2.8 ng/mL is clearly elevated. Early toxicity is often gastrointestinal and nonspecific: anorexia, nausea, vomiting, and abdominal pain. Because digoxin increases vagal tone and slows atrioventricular conduction, bradycardia below 60/min, heart block, and paroxysmal atrial tachycardia with block are classic, so an apical rate of 46/min paired with new gastrointestinal symptoms is a red flag. The nurse holds the dose and notifies the provider for an apical pulse under 60/min in an adult, counted for a full minute. Visual disturbances are the most recognizable neurologic clue: blurred or double vision, photophobia, and yellow-green or halo-tinted vision (xanthopsia), sometimes described as objects appearing snow-covered. Hypokalemia is the single most important modifiable risk factor. Potassium and digoxin compete for the same binding site on the sodium-potassium ATPase pump, so when potassium falls, digoxin binding increases and toxicity can occur even at a therapeutic serum level. A potassium of 2.9 mEq/L, well below the normal 3.5 to 5.0 mEq/L, is a predictable consequence of loop diuretic therapy with furosemide and directly potentiates toxicity. Hypomagnesemia and hypercalcemia have similar potentiating effects, but a magnesium of 2.0 mg/dL falls within the normal adult range of approximately 1.7 to 2.2 mg/dL, and a blood pressure of 132/78 mm Hg is unremarkable, so that row is not consistent with toxicity. Management includes holding digoxin, correcting electrolytes, continuous cardiac monitoring, and digoxin immune Fab for life-threatening dysrhythmias or severe hyperkalemia.
Item 6 · Matrix / Grid · Distinguishing Hypothyroidism from Hyperthyroidism
A nurse in an endocrinology clinic is reviewing findings from several adult clients being evaluated for thyroid dysfunction. None of the clients are pregnant or acutely ill.
For each finding, click to specify whether it is associated with hypothyroidism, hyperthyroidism, or neither condition.
Show answer & rationale
TSH 12.4 microunits/mL with free T4 of 0.4 ng/dL: Hypothyroidism
Heat intolerance with a 12-pound unintentional weight loss over 2 months despite increased appetite: Hyperthyroidism
Constipation, cold intolerance, and dry coarse skin with periorbital edema: Hypothyroidism
Fine tremor of the outstretched hands, heart rate 118/min, and exophthalmos: Hyperthyroidism
Hemoglobin A1C of 5.2% with a fasting blood glucose of 88 mg/dL: Neither
Thyroid hormone sets the basal metabolic rate, so nearly every finding follows from whether metabolism is running slow or fast. In primary hypothyroidism the thyroid gland fails, T4 falls, and the pituitary compensates by raising TSH; a TSH of 12.4 microunits/mL (normal roughly 0.4 to 4.0) with a low free T4 of 0.4 ng/dL (normal roughly 0.8 to 1.8) is the diagnostic pattern. Slowed metabolism produces cold intolerance, weight gain, constipation, fatigue, bradycardia, dry coarse skin and hair, menorrhagia, hyperlipidemia, and delayed relaxation of deep tendon reflexes. Nonpitting periorbital and facial puffiness reflects mucopolysaccharide deposition in the dermis, the myxedema of severe deficiency. Untreated, this can progress to myxedema coma with hypothermia, hypotension, hypoglycemia, hyponatremia, and hypoventilation. Hyperthyroidism produces the mirror image: heat intolerance, diaphoresis, weight loss despite increased appetite, diarrhea, insomnia, anxiety, fine tremor, and tachycardia with atrial fibrillation in older adults. In primary hyperthyroidism the TSH is suppressed below 0.4 microunits/mL while free T4 rises. Exophthalmos is specific to Graves disease, an autoimmune condition in which thyroid-stimulating immunoglobulins drive both hormone overproduction and retro-orbital tissue infiltration; it does not occur with toxic nodular goiter or thyroiditis. Thyroid storm is the emergency extreme, marked by fever above 38.5 degrees Celsius, severe tachycardia, and altered mentation. A hemoglobin A1C of 5.2% (normal below 5.7% per ADA criteria) with a fasting glucose of 88 mg/dL is normal glycemic data and reflects neither thyroid state, making it the correct choice for the neither column.
Item 7 · Matrix / Grid · Newborn Assessment: Expected Findings vs. Findings Requiring Follow-Up
A nurse is caring for a term newborn born at 39 weeks gestation by vaginal delivery to a mother with gestational diabetes. Birth weight was 4,300 g (9 lb 8 oz). The nurse performs serial assessments during the first hours of life.
For each finding, click to specify whether the finding is expected or requires follow-up.
Show answer & rationale
Acrocyanosis of the hands and feet at 4 hours of age with a pink trunk: Expected finding
Axillary temperature 36.7 degrees Celsius (98.1 degrees Fahrenheit): Expected finding
Flat blue-gray macular pigmentation over the sacrum and buttocks: Expected finding
Respiratory rate 68/min with grunting, nasal flaring, and intercostal retractions at 6 hours of age: Requires follow-up
Point-of-care blood glucose 32 mg/dL at 2 hours of age: Requires follow-up
Acrocyanosis, bluish discoloration limited to the hands and feet with a pink trunk and mucous membranes, results from immature peripheral circulation and vasomotor instability. It is normal in the first 24 to 48 hours; central cyanosis of the lips, tongue, and trunk is never normal. The expected axillary temperature range is 36.5 to 37.5 degrees Celsius (97.7 to 99.5 degrees Fahrenheit), so 36.7 degrees Celsius is within normal limits. Congenital dermal melanocytosis, formerly called Mongolian spots, is a benign collection of melanocytes in the dermis seen most often in newborns with darker skin tones; it must be documented on admission with location and size so it is not later mistaken for bruising. The expected newborn respiratory rate is 30 to 60 breaths per minute, and brief periodic breathing with pauses under 20 seconds is normal. A sustained rate of 68/min accompanied by grunting, flaring, and retractions indicates respiratory distress and requires immediate evaluation for transient tachypnea of the newborn, respiratory distress syndrome, sepsis, or congenital heart disease; grunting represents the infant creating auto-PEEP against a partially closed glottis to keep alveoli open. Infants of diabetic mothers are at high risk for hypoglycemia because maternal hyperglycemia drives fetal hyperinsulinemia that persists after the placental glucose supply is cut. A glucose of 32 mg/dL is below the commonly used 40 mg/dL intervention threshold in the first 4 hours of life and requires feeding or IV dextrose with a recheck, since untreated hypoglycemia risks neurologic injury. Macrosomia also warrants assessment for birth trauma such as clavicular fracture and brachial plexus injury.
Item 8 · Matrix / Grid · Delegation and Scope of Practice on a Medical-Surgical Unit
A charge nurse on a 30-bed medical-surgical unit is planning assignments for the day shift. The team includes one registered nurse, one licensed practical/vocational nurse, and one assistive personnel. The charge nurse applies the NCSBN delegation framework and the state nurse practice act.
For each task, click to specify the least-skilled team member to whom the task may appropriately be assigned or delegated.
Show answer & rationale
Obtaining routine vital signs on a stable client on postoperative day 2: Assistive personnel
Assisting a stable client with ambulation in the hallway using a gait belt: Assistive personnel
Administering a scheduled oral dose of metoprolol to a stable client: Licensed practical/vocational nurse
Reinforcing an abdominal dressing with moderate serosanguineous drainage over a healing surgical incision: Licensed practical/vocational nurse
Performing the admission assessment and developing the plan of care for a newly admitted client: Registered nurse only
Delegation decisions rest on the five rights of delegation: the right task, circumstance, person, direction and communication, and supervision and evaluation. The registered nurse retains accountability for the outcome even when the task is delegated. Assistive personnel may perform standardized, predictable tasks on stable clients with predictable outcomes that do not require nursing judgment: vital signs, intake and output, hygiene, feeding a client without swallowing precautions, positioning, transfers, and ambulation with an assistive device. Assistive personnel may collect and report data but may not interpret it, so the delegating nurse must give explicit parameters and require that findings be reported back. Licensed practical/vocational nurses may administer most oral, subcutaneous, and intramuscular medications, perform sterile dressing changes and wound reinforcement, insert urinary catheters, provide tracheostomy care, and monitor stable clients with expected outcomes; scope varies by state, and LPN/LVNs generally may not push IV medications, hang blood, or manage titrated vasoactive or anticoagulant infusions. The registered nurse cannot delegate the nursing process itself. Initial and admission assessments, nursing diagnosis, care planning, evaluation of client responses, client education requiring teaching design, unstable clients, and titration of high-alert infusions such as heparin, insulin, or vasopressors all require RN judgment. A key exam pattern: assessment, teaching, evaluation, medication titration, and any unstable client stay with the RN, while stable, routine, repetitive tasks move down the ladder. Note that reinforcing an existing dressing differs from the first postoperative dressing change, which the surgeon or RN typically performs.
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Frequently Asked Questions
How are matrix and grid NCLEX questions scored?
Matrix items use partial credit scoring rather than all-or-nothing, and NCSBN assigns the rule by format. Matrix multiple response items (more than one answer allowed) use plus/minus scoring: each incorrect selection cancels out a correct one, and each column is scored separately, with a negative column total rounded up to zero. Matrix multiple choice items (one answer per row), like all eight above, use 0/1 scoring: each row is scored independently, each correct row earns one point, and a wrong row carries no penalty. Because of this, you should always answer every row rather than leaving one blank.
What is the difference between a matrix multiple choice and a matrix multiple response item?
In a matrix multiple choice item, each row has exactly one correct column, so the columns are mutually exclusive: a finding is either expected or unexpected, indicated or contraindicated. In a matrix multiple response item, a single row can have more than one correct column selected. Read the prompt wording carefully. Phrases like select one option in each row signal matrix multiple choice, while select all that apply in each row signals matrix multiple response. All eight practice items above are matrix multiple choice.
How do I avoid running out of time on matrix questions?
Work row by row instead of trying to hold the whole grid in your head. Read the scenario once for the client's diagnosis, acuity, and key lab values, then treat each row as its own true-or-false decision against that clinical picture. Avoid the trap of assuming the columns must be evenly distributed; a well-written item may have four rows in one column and one in another. If a row is genuinely unclear, make your best clinical judgment and move on, since partial credit means one uncertain row does not cost you the item.
Which column headings show up most often on the NCLEX?
The most common paired headings are expected versus unexpected, indicated versus contraindicated, effective versus ineffective, anticipated versus not anticipated, and increases risk versus decreases risk versus no effect. You will also see headings tied to nursing process steps, such as which findings require immediate follow-up, and headings that ask you to sort findings among competing diagnoses, such as hypothyroidism versus hyperthyroidism. The column labels tell you exactly what judgment is being tested, so read them before you read the rows.