Quick answer: The Next Generation NCLEX (NGN), launched April 1, 2023, tests clinical judgment with six question types: Extended Multiple Response (select all that apply), Matrix/Grid, Extended Drag-and-Drop/Cloze, Highlight, Bowtie, and Trend. Most earn partial credit: select-all-that-apply and matrix multiple-response items subtract a point for each wrong pick (an item never scores below zero), while bowtie and drop-down cloze items give a point per correct choice with no penalty.
The Next Generation NCLEX (NGN) rolled out in April 2023 and changed how the exam tests clinical judgment. If you’re studying for the NCLEX-RN right now, you need to understand these question types — not just what they look like, but how to think through them.
How are these scored? The NGN uses partial credit on most item types. See how the Next Generation NCLEX is scored.
Ready to practice? Try our Next Generation NCLEX practice questions — a worked example of every item type (bow-tie, matrix, cloze, highlight, extended response, and a trend-style data item) with a full rationale.
This guide breaks down every NGN item type you’ll encounter and the reasoning approach that works for each one, with a sample question or a link to worked practice questions for each type.
The six Next Generation NCLEX (NGN) item types at a glance:
| NGN item type | What it asks you to do | Quick approach |
|---|---|---|
| Extended Multiple Response (Select All That Apply) | Pick every correct option from a list. Uses the new partial-credit scoring. | Treat each option as its own true/false question. |
| Matrix / Multiple Response Grouping | Classify items in a grid (e.g., “expected” vs. “requires follow-up,” or which action fits each client). | Work each row independently; read the column headers first. |
| Extended Drag-and-Drop (Cloze) | Drag the correct terms, values, or phrases into blanks in a passage, from a word bank or dropdown. | Read the whole passage first — one blank often hints at another. |
| Highlight (Text or Table) | Highlight the relevant findings in a nurse’s note, lab report, or scenario. Tests Recognize Cues. | Read the question first; highlight only what’s relevant, not everything abnormal. |
| Bowtie | Choose the 1 likely condition (center), then 2 actions to take (left) and 2 parameters to monitor (right). | Identify the condition first, then work outward: condition → actions → monitoring. |
| Trend | Read data across several timepoints and identify how the client’s condition is changing. | Compare each value with the one before it — the direction of travel is the answer, not any single number. |
Why the NCLEX Changed
The National Council of State Boards of Nursing (NCSBN) redesigned the exam because multiple-choice questions alone couldn’t measure clinical judgment. In clinical practice, you don’t pick from four options — you synthesize data, identify patterns, prioritize, and act. The NGN question types are designed to test exactly that.
The new exam uses the NCSBN Clinical Judgment Measurement Model (NCJMM), which evaluates six cognitive skills:
- Recognize Cues — identify relevant information from the clinical scenario
- Analyze Cues — connect assessment data to possible conditions
- Prioritize Hypotheses — rank the most likely and most urgent explanations
- Generate Solutions — identify nursing actions that address the priority
- Take Action — implement the correct interventions
- Evaluate Outcomes — determine if interventions were effective
Each NGN question type maps to one or more of these skills. Here’s what you need to know about each.
1. Extended Multiple Response (Select All That Apply)
You’ve seen SATA before, but the NGN version uses partial-credit scoring instead of all-or-nothing. The rules are summarized under How NGN Questions Are Scored, below.
How to approach it
Treat each option as an independent true/false question. Don’t let one answer influence your thinking on another. Read the stem carefully — pay attention to qualifiers like “priority,” “first,” or “immediately.”
Show answer & rationale
(A) Ammonia odor on breath comes from urea breakdown.
(B) Decreased level of consciousness comes from uremic encephalopathy.
(C) Pruritus is multifactorial: uremic toxin and calcium-phosphate deposition, dry skin and neuropathy.
(D) Pericardial friction rub comes from uremic pericarditis.
(E) Hypokalemia with flattened T waves is not expected. The failing kidney cannot excrete potassium, so uremic CKD produces hyperkalemia (with peaked T waves), not hypokalemia.
(F) Asterixis indicates metabolic encephalopathy.
2. Matrix / Multiple Response Grouping
Matrix questions present a table where you evaluate multiple conditions or interventions across categories. You might see a grid of clients and need to check which nursing action applies to each, or a list of assessment findings where you classify each as “expected” or “requires follow-up.”
How to approach it
Work through each row independently. Don’t rush — read the column headers first to understand what you’re classifying. Matrix questions test your ability to differentiate between similar-sounding conditions, which is exactly what you do in clinical triage.
| Item | Contributing medication | Priority intervention | Neither |
|---|---|---|---|
| Tramadol started 2 days ago for back pain | ○ | ○ | ○ |
| Phenelzine discontinued 5 days before sertraline was started | ○ | ○ | ○ |
| Hold all serotonergic medications | ○ | ○ | ○ |
| Administer the prescribed benzodiazepine | ○ | ○ | ○ |
| Apply physical restraints to control agitation | ○ | ○ | ○ |
| Amoxicillin started yesterday for sinusitis | ○ | ○ | ○ |
Show answer & rationale
Priority interventions: Discontinue serotonergic agents immediately (stops further serotonin buildup) and administer benzodiazepines for symptom control (manages agitation, muscle rigidity, and autonomic instability while serotonin levels normalize).
Neither: amoxicillin (not serotonergic) and physical restraints (isometric muscle contraction against restraints worsens hyperthermia and lactic acidosis).
3. Extended Drag-and-Drop (Cloze)
These questions give you a passage with blanks — you drag the correct term, value, or phrase into each blank from a dropdown or word bank. Think of it like a clinical fill-in-the-blank. You’re completing a clinical statement, nursing note, or priority action plan.
Ordering and sequencing items live here too. NCSBN folded the older ordered-response format into extended drag-and-drop, so when you are asked to put nursing actions in the right sequence, you will be dragging them into position rather than numbering them.
How to approach it
Read the entire passage first before filling anything in. Context matters — one blank often gives clues about another. Focus on clinical logic: what assessment finding leads to what condition leads to what intervention?
The nurse expects [flank pain with clear, dilute urine and a normal CK / muscle pain and weakness with dark tea-colored urine and elevated CK / joint swelling with a butterfly rash].
The most critical laboratory value to monitor is [serum sodium / hemoglobin A1c / serum potassium].
The priority intervention is [fluid restriction to 1 L per day / oral potassium supplements / aggressive IV fluid resuscitation with normal saline].
A common cause is [crush injury or prolonged immobilization / iron-deficiency anemia / chronic constipation].
Each set of brackets is one drop-down: choose one option per blank.
Show answer & rationale
4. Highlight (Text or Table)
You’re given a block of text — a nurse’s note, lab report, or clinical scenario — and you highlight the findings that are relevant to the question. This directly tests Recognize Cues, the first step in clinical judgment.
How to approach it
Read the question first, then the passage. Know exactly what you’re looking for before you start highlighting. Don’t highlight everything that seems abnormal — only what’s relevant to the specific question being asked.
For worked examples, see our highlight practice questions.
5. Bowtie
The bowtie tests multiple layers of clinical reasoning in one question. You’re typically given a clinical scenario and asked to identify:
- Left side: Actions to take (2 selections)
- Center: The client’s condition or problem (1 selection)
- Right side: Parameters to monitor (2 selections)
This mirrors real clinical thinking: What is going on with this client? → What do I do about it? → What do I watch to know whether it is working?
How to approach it
Start with the center — what condition explains this picture? Then work outward. Which two actions address it most directly (left)? Which two parameters tell you whether it is improving (right)?
For worked examples, see our bow-tie practice questions.
6. Trend
A trend item gives you the same client at several points in time — serial vital signs, repeated labs, or a flow sheet across a shift — and asks what is changing. The data is usually spread across tabs or rows you have to read together.
NCSBN lists trend among the NGN item types, but what makes it distinct is the presentation rather than a new way of answering. A trend item borrows its response format from the others: extended multiple response, matrix/grid, cloze drop-down, highlight, or extended drag-and-drop.
The one exception is the bowtie. Although a bowtie is itself a drag-and-drop item, a trend item is never presented as one.
How to approach it
Do not judge any single reading on its own. Read down each column and ask which direction it is moving. A temperature of 38.1°C means little in isolation; a temperature climbing while the heart rate climbs and the blood pressure falls is a trajectory, and the trajectory is what the item is testing. Name the pattern before you look at the options.
0800 — T 37.2°C, HR 88, RR 18, BP 122/74
1200 — T 38.1°C, HR 104, RR 22, BP 112/68
1600 — T 38.8°C, HR 118, RR 26, BP 98/56
Which conclusion and nursing action are best supported by these data?
Shown here in a simplified single-answer format; on the exam this stem would carry one of the NGN response formats described above.
Show answer & rationale
(B) Expected post-operative fever is common in the first 48 hours and reflects the inflammatory response to surgical tissue injury (not atelectasis, despite the traditional teaching). But fever on its own raises the heart rate without dropping the blood pressure — roughly 8 to 10 beats per minute for each degree Celsius, and the 30-beat rise here is about double what this fever alone would explain. The falling systolic pressure is what separates this from a benign post-op fever. An antipyretic here treats the number and masks the trend.
(C) Dehydration can raise the heart rate and lower the blood pressure, but it does not account for a climbing fever — and a client 2 days post bowel resection is unlikely to be taking enough by mouth for oral fluids to matter. Encouraging PO intake is far too slow a response to this trajectory.
(D) Pain raises the heart rate and respiratory rate, but it does not cause fever, and it typically raises blood pressure rather than dropping it.
Key concept: On a trend item, read the direction of travel before you look at the options. The answer is almost always the pattern across timepoints, not the single worst value. Here the nurse would also check level of consciousness and urine output, and anticipate blood cultures before antibiotics, a lactate level, and IV fluid resuscitation.
How NGN Questions Are Scored
The biggest change is partial credit. Under the old NCLEX, SATA questions were all-or-nothing. The NGN scoring model gives you credit for what you get right:
- +1 point for each correct selection.
- -1 point for each incorrect selection, but only on plus/minus items: select-all-that-apply, matrix multiple-response and multiple-response grouping. A negative item score is rounded up to zero.
- No penalty on bowtie, drop-down cloze, select-N and matrix multiple-choice items. These use 0/1 scoring: 1 point per correct choice.
An educated partial answer beats a random guess: if you can confidently identify 3 of 5 correct selections, those 3 points count. For the full breakdown by item type, see how the Next Generation NCLEX is scored.
Study Strategy for NGN Questions
Knowing the question format is only half the battle. Here’s how to actually prepare:
- Practice all types. Don’t just do multiple choice. You need reps with every NGN format so nothing surprises you on exam day.
- Read rationales. Every single one. The rationale teaches you the clinical reasoning pattern, not just the answer.
- Focus on clinical judgment, not memorization. The NGN rewards you for thinking like a nurse. When you practice, ask yourself: What cues am I recognizing? What’s my priority hypothesis? What action addresses it?
- Time yourself. You get roughly 1-2 minutes per question. Practice under time pressure so you build speed without sacrificing accuracy.
- Track your weak areas. If you consistently miss pharmacology bowtie questions, that’s where your study time should go.
What to Expect on Exam Day
On the actual NCLEX, NGN questions are mixed in with traditional items. You won’t know which ones are scored and which are experimental (NCSBN uses unscored pretest items for research). Treat every question the same.
The exam is still computer adaptive — it adjusts difficulty based on your performance. NGN items follow the same adaptive logic: correct answers push the algorithm toward harder items. But NCSBN notes candidates can’t reliably tell easy items from hard ones, so don’t try to read the exam.
The question count range is 85 to 150 items, with a maximum time of 5 hours. Most candidates finish in 2-4 hours. The CAT algorithm can stop the exam at 85 questions if it has enough data to determine pass or fail with 95% confidence.
Bottom Line
The NGN isn’t harder — it’s different. It tests clinical thinking instead of rote recall, which is closer to how you’ll practice as a nurse. If you can look at a set of assessment findings, identify the priority problem, and choose the right intervention, you have the core skill these questions test.
The students who struggle tend to be the ones who only practice multiple choice, so work every item type using the study strategy above.
Frequently Asked Questions
How many NGN question types are on the NCLEX?
There are six NGN item types you need to know: Extended Multiple Response (the new-scoring version of Select All That Apply), Matrix/Multiple Response Grouping, Extended Drag-and-Drop (Cloze), Highlight (text or table), Bowtie, and Trend. Each type maps to one or more of the six clinical judgment skills in the NCSBN Clinical Judgment Measurement Model, from Recognize Cues through Evaluate Outcomes. Practice every format so nothing surprises you on exam day.
Do NGN questions give partial credit?
Yes — partial credit is the biggest scoring change on the NGN. On select-all-that-apply, matrix multiple-response and multiple-response grouping items you earn +1 point for each correct selection and lose 1 point for each incorrect one, though the score can’t go below zero. Bowtie, drop-down cloze and matrix multiple-choice items use 0/1 scoring, with no penalty for a wrong choice. Under the old NCLEX, SATA questions were all-or-nothing. This means an educated partial answer is always better than a random guess: if you confidently identify 3 of 5 correct selections, those 3 points count.
How do you answer a bowtie question on the NCLEX?
Start with the center — identify the client’s likely condition or problem first — then work outward. On the left you select 2 actions to take that address that condition most directly, and on the right you select 2 parameters to monitor that tell you whether those actions are working. The bowtie mirrors real clinical thinking: what is going on with this client, what do I do about it, and what do I watch to know whether it is working. Name the condition before you touch the option tokens, and the rest of the selections fall into place.
What is the best strategy for Select All That Apply questions on the NGN?
Treat each option as its own independent true/false question, and don’t let one answer influence your thinking on another. Read the stem carefully for qualifiers like priority, first, or immediately. Because the NGN version uses partial-credit scoring, you earn points for each correct selection rather than needing a perfect answer, so select every option you can confidently support instead of guessing randomly.
Can the NCLEX end at 85 questions?
Yes. The exam ranges from 85 to 150 items with a maximum time of 5 hours, and the computer-adaptive algorithm can stop at 85 questions if it has enough data to determine pass or fail with 95% confidence. Most candidates finish in 2 to 4 hours. NGN items follow the same adaptive logic as traditional questions — correct answers move you toward harder items, but you can’t reliably judge item difficulty while testing, so don’t try to read the exam.
Is the Next Generation NCLEX harder than the old NCLEX?
The NGN isn’t harder — it’s different. It tests clinical judgment instead of rote recall, which is closer to how you’ll actually practice as a nurse. Instead of picking from four options, you synthesize data, identify patterns, prioritize, and act. The students who struggle are the ones who only practice multiple choice, so get reps with every item type, read every rationale, and focus on the reasoning process rather than just the answer.
Practice Each NGN Question Type
Reading about the item types is not enough — you have to work them. Here are free practice sets with full rationales for every Next Generation NCLEX format:
- Bow-Tie Practice Questions — Central condition linked to actions and parameters to monitor
- Matrix / Grid Practice Questions — Multiple-response grids scored per row
- Cloze / Drop-Down Practice Questions — Complete clinical sentences from drop-downs
- Highlight Practice Questions — Identify the relevant findings in the chart
- Trend Practice Questions — Interpret data changing across timepoints
- NGN Case Study Practice Questions — Full six-question unfolding case studies
Practice questions like these
Put it to the test with NCLEX-style practice questions — free, full rationale on every answer. No credit card.
Start Practicing FreeSources
- NCSBN Help Center — What is the current format and item types for the NCLEX? — NGN clinical-judgment item types defined; 85-150 items; SATA uses partial (polytomous) credit
- NCSBN Help Center — What are the current scoring models? — +/- for SATA and matrix MR (floored at zero); 0/1 for bowtie (max 5), cloze, matrix MC, select N
- NCSBN NCLEX — Computerized Adaptive Testing (CAT) — Exam stops when the computer is 95% certain ability is above or below the passing standard
- NCSBN Help Center — Is it true that candidates who receive the minimum number of items and the last item is easy will fail? — Candidates cannot reliably identify which items are easy or difficult
- NCSBN NCLEX — Next Generation NCLEX — The Next Generation NCLEX launched April 1, 2023 to measure clinical judgment
- NCSBN Help Center — Are items in case studies dependent on the correct response to a prior item? — Case studies follow NCJMM Layer 3 from Recognize Cues through Evaluate Outcomes
Sources checked September 2026.