NCLEX-RN · Learn · 2 November 2026 · 5 min read
NCLEX Next Generation item types and how NCSBN scores them
Next Generation NCLEX item types explained: matrix, cloze, highlight, bow-tie and case studies, with NCSBN's plus/minus, zero/one and rationale scoring.
The Next Generation NCLEX, launched on April 1, 2023, mixes traditional multiple-choice items with newer formats such as matrix (grid), drop-down (cloze), highlight and bow-tie items, many of them inside case studies that unfold over six items. What matters most for your score is not the format's name but how it is scored. NCSBN uses three partial-credit methods for items with more than one correct answer: plus/minus, zero/one and rationale scoring. Knowing which applies tells you when guessing extra options costs points and when it does not.
This guide explains the common item formats, the case study structure and the three scoring rules, with tips for each.
A note on names
NCSBN's test plan, FAQs and candidate bulletin do not describe each item format by name; they point candidates to the official NCLEX Candidate Tutorial for that. The names used here (matrix, cloze, highlight, bow-tie and so on) are the standard vocabulary used for Next Generation items and the names our practice engine uses. The scoring rules below are official, from NCSBN.
Case studies: six items, six steps
Every NCLEX-RN exam includes three clinical judgment case studies, each made up of six items about the same client. The client information unfolds as you go, and the six items follow the six steps of NCSBN's Clinical Judgment Measurement Model, in order:
- Recognize cues: spot the relevant information.
- Analyze cues: connect the cues to the client's condition.
- Prioritize hypotheses: rank what is most likely and most urgent.
- Generate solutions: identify expected outcomes and interventions.
- Take action: carry out the interventions with the highest priority.
- Evaluate outcomes: compare what happened with what was expected.
Case study information comes in tabs, such as nurses' notes, vital signs, laboratory results and orders. NCSBN says you are not forced to open every tab, but you should review each one fully before you answer. Beyond the case studies, about 10% of the exam is stand-alone clinical judgment items.
The common item formats
| Format | What you do |
|---|---|
| Multiple choice | Choose one answer |
| Select all that apply | Choose every correct option |
| Matrix (grid) | Mark one or more cells in each row of a table |
| Drop-down (cloze) | Choose a word or phrase from a list for each gap in a sentence or chart |
| Highlight | Select the parts of a text, such as a nurse's note, that answer the question |
| Bow-tie | In the usual layout, choose a condition for the center, actions for one side and parameters to monitor for the other |
| Ordered response | Put steps in the correct order |
| Calculation | Type a numeric answer |
The NCSBN pages we read do not tie each format to one scoring rule. They tie the rule to the instruction: whether you may choose any number of options, are told how many to choose, or are asked to judge paired information.
Select all that apply
NCSBN says the qualifier "select all that apply" appears in bold, and that one or more options are correct. Do not assume there are at least two.
Calculation items
The item tells you whether to answer with a whole number or with one to two decimal places. Where decimals are asked for, you must type the decimal point. Round only at the end of the calculation. An on-screen calculator is provided; handheld calculators are not allowed.
The three scoring rules
1. Plus/minus
Used when you may select an unspecified number of options, as in "select all that apply" style items.
- +1 for each correct option you select.
- -1 for each incorrect option you select.
- The maximum is the number of correct options; the minimum is zero.
Our example: an item has four correct options among eight. You select three correct and two incorrect: 3 - 2 = 1 point out of 4. Had you selected only the three you were sure of, you would have scored 3.
Lesson: under plus/minus, every wrong option you add cancels a right one. Select only what you can justify.
2. Zero/one
Used when you are told to choose a specific number of responses.
- +1 for each correct response.
- 0 for an incorrect one, with no deduction.
- On a multipoint item, the total is the sum of correct responses.
Lesson: you must make the number of choices asked for, and a wrong choice costs nothing beyond the missed point, so always fill every required choice with your best answer.
3. Rationale scoring
Used when you evaluate closely paired information, such as a cause and its effect.
- Both parts of the pair must be correct to earn the point.
Lesson: read both halves together. A right cause paired with the wrong effect earns nothing.
No going back
Items appear one at a time. You can change an answer before you confirm it, but once you press NEXT you cannot return. Every item must be answered before you can move on. So take your time on each item rather than planning to review later.
How to practice
- Learn the rule for each instruction. As you read each item, ask: am I told how many to choose? If not, plus/minus is likely, and restraint pays.
- Do case studies in order. Our NCLEX-RN practice tests 1, 2 and 3 are case studies with a tabbed chart and six items in the clinical judgment order.
- Mix formats. Practice test 4 and practice test 5 are 60-item sets mixing every format above, scored by the NCSBN partial-credit rules.
- Review by category. Each result shows a breakdown by client-needs category; our guide to the eight client-needs categories explains them.
Our practice is fixed length, so it gives a percentage, not a pass or fail. The real exam is adaptive: see how the NCLEX CAT pass rules work. Everything is on the NCLEX-RN hub.
Key points
- NGN launched April 1, 2023; three six-item case studies on every exam.
- Plus/minus: wrong selections subtract, minimum zero.
- Zero/one: specific number to choose, no deduction.
- Rationale: both parts of the pair must be right.
Official sources: NCSBN 2026 NCLEX-RN Test Plan (effective April 1, 2026 to March 31, 2029), NCLEX FAQs, 2026 NCLEX Candidate Bulletin and the Next Generation NCLEX page on nclex.com, read on 1 November 2026. Portions copyrighted by the National Council of State Boards of Nursing, Inc. All rights reserved.