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What NGN items are really testing
The Next Generation NCLEX (in place since April 2023) is built on the NCSBN Clinical Judgment Measurement Model. Instead of asking "what's the normal potassium?", NGN items hand you a messy chart and ask what matters, what it means, what you'd do, and whether it worked.
On every NCLEX-RN and NCLEX-PN under the 2026 test plans, you get:
- 3 case studies — 18 items total, six per case.
- Stand-alone clinical judgment items — about 10% of the exam, depending on its length. These are the bowtie and trend items.
- Traditional items (multiple choice, select all that apply, calculations, and so on) for the rest.
Case study items are counted separately from the Client Needs content percentages, so you can't "skip" clinical judgment by being strong in one content area.
The six clinical judgment steps
Each case study has one item for each step, in this order. Knowing which step an item targets tells you what kind of answer it wants.
| Step | What you're doing | How the item usually reads |
|---|---|---|
| 1. Recognize cues | Pick out the relevant, important data | "Which findings require follow-up?" |
| 2. Analyze cues | Connect the cues to the client's condition | "These findings are consistent with ___" |
| 3. Prioritize hypotheses | Rank problems by urgency, likelihood, and risk | "The client is at highest risk for ___" |
| 4. Generate solutions | Define outcomes and the interventions that reach them | "Which interventions should the nurse anticipate?" |
| 5. Take action | Carry out the highest-priority interventions | "Which actions should the nurse take?" / indicated vs. contraindicated |
| 6. Evaluate outcomes | Compare what happened with what you expected | "Which findings show the treatment is effective?" |
The trap in step 1 is picking every abnormal value. The item asks what needs follow-up for this client right now — a slightly low hemoglobin in a client with chronic kidney disease may be expected and not the point.
The item formats, with quick examples
All examples below are original. Practice the real interface in the free candidate tutorial, and try NCSBN's own case studies in the free Sample Pack.
Extended multiple response
Select-all-that-apply with more options than you're used to, plus variations: "select N" (choose exactly a stated number) and grouping (select all that apply within each group).
Example: A client taking furosemide reports leg cramps. Which findings are consistent with hypokalemia? Select all that apply: muscle weakness · U waves on the ECG · peaked T waves · leg cramps · hyperactive reflexes.
Answer: muscle weakness, U waves, leg cramps. Peaked T waves point to hyperkalemia; low potassium decreases reflexes.
Drop-down (cloze, rationale, table)
Choose a word or phrase from a menu inside a sentence or table. A drop-down rationale links a choice to its reason.
Example: After an EGD with throat spray, the client is at risk for [aspiration ▾] because of [a suppressed gag reflex ▾].
Drag-and-drop (cloze, rationale)
Same idea as drop-down, but you drag answer tokens into blanks. Some tokens are never used.
Example: After a percutaneous liver biopsy, position the client on the [right side] to [put pressure on the puncture site]. Unused tokens: left side · prone · promote drainage.
Highlight (enhanced hot spot)
Click words or rows in a nurses' note or table to mark the findings that answer the question.
Example: Highlight the findings that require follow-up in an older adult 1 day after hip surgery: "Temp 38.9°C (102°F). HR 88. BP 128/76. New confusion since 0400. Lungs clear. Pain 3/10."
Answer: the fever and the new confusion — together they suggest infection or delirium.
Matrix/grid
A table of rows and columns. Multiple choice matrices allow one selection per row; multiple response matrices allow one or more per row or column.
Example: For each finding, choose DKA, HHS, or both: Kussmaul respirations (DKA) · glucose above 600 mg/dL with no ketones (HHS) · severe dehydration (both).
Bowtie (stand-alone)
A diagram with the condition in the middle, actions to take on one side, and parameters to monitor on the other. You pick one condition, two actions, and two parameters.
Example: A client with diabetes is shaky and sweaty with a glucose of 58 mg/dL. Condition: hypoglycemia. Actions: give 15 g of fast-acting carbohydrate; recheck glucose in 15 minutes. Monitor: blood glucose; level of consciousness.
Trend (stand-alone)
Data across several time points — vital signs, labs, intake and output. The item can use any response format, but it always asks you to judge direction: better, worse, or unchanged.
Example: Over 24 hours of diuresis, weight falls 2 kg and crackles clear, but potassium drops from 4.2 to 3.2 mEq/L. Improving overall — and the potassium needs follow-up.
How NGN partial credit works
The test plan confirms three partial-credit methods for items with more than one correct response. Which one applies depends on the item format.
- Plus/minus (+/−): +1 for each correct option you select, −1 for each incorrect option you select. The item score can't drop below zero. Example: 6 options, 3 correct. You pick 4 — the 3 right ones and 1 wrong — so you earn 3 − 1 = 2 points. Pick all 6 and you earn 3 − 3 = 0.
- Zero/one (0/1): +1 for each correct response, 0 for each incorrect one, with no deductions. Example: a 5-row matrix where you get 4 rows right earns 4 points.
- Rationale: linked answers must both be right to earn the point. Example: "The client is at risk for ___ because of ___." Right risk, wrong reason = 0 for that pair.
What this means for you: on plus/minus items, guessing extra options costs you, so select only what you'd defend. On zero/one items, there's no penalty, so answer every row. On rationale items, make sure your "because" actually explains your "what."
The practice test on this site scores every multi-part item all-or-nothing, which is stricter than the real exam — treat "2 of 3 correct" in review as the partial credit you'd likely have earned.
Strategies and common traps
- Read the stem before the chart. Know which step you're on and what you're hunting for, then scan the notes, vitals, and labs.
- Watch for new data. Case studies unfold. Later items often add a new note or lab — answer from the latest data, not from what you remembered.
- Expected vs. unexpected. Flushing on magnesium, 90% SpO2 in some clients with COPD, mild anemia in chronic kidney disease: abnormal isn't always actionable.
- Contraindicated is its own category. In "indicated / contraindicated / non-essential" matrices, contraindicated means it could cause harm; non-essential means it's harmless but not needed now.
- Every trend row counts. The point of a trend item is usually the one value moving the wrong way while everything else improves.
- Don't overthink the bowtie. Pick the condition first; the right actions and parameters follow from it and should make sense together.
A 2-week NGN drill plan
- Days 1–2: Take the candidate tutorial and work the case studies in NCSBN's free Sample Pack untimed. Label each item with its clinical judgment step.
- Days 3–6: Two case studies a day across med-surg, maternity, pediatrics, and mental health. After each, write one sentence: "The key cue was ___."
- Days 7–9: Stand-alone drills — five bowtie and five trend items a day.
- Days 10–12: Mixed timed sets of 30–40 items with case studies included, at about 2 minutes per item.
- Days 13–14: Review your error log and redo every item you missed.
Ready to try it? Our free NCLEX-RN practice test includes two full case studies, a bowtie, and a trend item. For the big picture, see the NCLEX-RN guide.
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ReadFrequently asked questions
How many case studies are on the NCLEX?
Three, with six items each (18 items total), on both the NCLEX-RN and NCLEX-PN under the 2026 test plans.
Are bowtie and trend items part of a case study?
No. They're stand-alone clinical judgment items, each with its own client data. They make up about 10% of the exam, depending on how long your exam runs.
Can I get partial credit on select-all-that-apply items?
On items with more than one correct response, NCSBN awards partial credit using plus/minus, zero/one, or rationale scoring, depending on the format. With plus/minus scoring, wrong selections subtract points, so don't pad your answer with guesses.
Is the NGN harder than the old NCLEX?
It's different. NGN items ask you to work through a whole clinical situation instead of recalling one fact, which feels harder if you've only drilled traditional questions. The goal hasn't changed — safe, entry-level practice — and NCSBN's Board of Directors reviews the passing standard every three years. Candidates who practice the formats before test day avoid most of the surprises.
Do case studies count if they seem easy?
Assume every item counts. The exam includes 15 unscored pretest items, but they look exactly like scored items, so there's no way to tell which ones don't count.