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Effective April 1, 2023, NGN or Next Generation NCLEX will take effect! The National Council Licensure Examination (NCLEX) has changed to meet the growing demands of the healthcare system—to ensure that it accurately measures a nurse’s ability to provide safe and effective patient care.  

You’re probably wondering what the changes are, and if the questions will be more difficult. Read on and find out what had changed in the NCLEX, why, and how they can prepare for the test in 2023.  

Why Was NGN Developed? 

In a 2019 study, the National Council of State Boards of Nursing (NCSBN) found that clinical judgment was linked to 46% of all tasks performed by entry-level nurses.¹ Nursing educators, employers, and healthcare providers have noticed that the current NCLEX exam, which relies heavily on multiple-choice questions, did not accurately measure a nurse’s clinical judgment or ability to think critically in complex patient situations. 

In response to these findings, the NGN will feature items that can accurately measure nurses’ clinical judgment and decision-making skills in real-world situations. 

What Changed in the NCLEX? 

The NGN will focus more on real-life case studies, requiring a lot of critical thinking and nursing knowledge, says Sarah, a nurse who’d already passed the NCLEX. You can expect in the April exam interactive patient scenarios that require you to make decisions about patient care. 

When compared to the current NCLEX exam, the NGN places a greater emphasis on patient safety. Questions on the NGN are designed to assess your ability to recognize and respond to potential patient risks, such as adverse reactions to medications or complications during procedures. 

Next Generation NCLEX Test Items 

You’ll likely receive a minimum of 85 and a maximum of 150 questions on the exam. However, since 15 of those questions aren’t usually scored, you can expect about 70-135 scored questions. The NGN will include question types including multiple-response, fill-in-the-blank, and ordered-response questions. Here are five new test item types to expect: 

1. Extended Multiple Response 

Also known as multiple response or “select-all-that-apply” questions, these present a scenario and a list of options from which you must select all that apply to the situation. This type of question requires you to analyze the scenario thoroughly and apply your knowledge, as you must identify all of the correct options to receive full credit. 

Here’s an example of an Extended Multiple Response question: 

Scenario: A nurse is caring for a patient who has just been diagnosed with diabetes. The patient has been prescribed insulin and is being discharged from the hospital. The nurse is providing discharge instructions to the patient and their family. 

Question: Which of the following statements should the nurse include in the discharge instructions? Select all that apply: 

A. “You should always carry a source of fast-acting carbohydrates with you, like candy or juice.” 

B. “You should avoid exercise for at least two hours after taking your insulin.” 

C. “You should check your blood sugar levels at least four times a day.” 

D. “You should always inject your insulin into the same site.” 

In question items like this, you’ll be required to select the correct answers regardless of whether there is more than one. 

2. Extended Drag and Drop 

This requires candidates to drag and drop answer choices into appropriate categories or sequences. This type of question is used to evaluate your ability to prioritize nursing interventions, organize nursing care, or manage patient care equipment and supplies. 

Here’s an example of an Extended Drag and Drop question: 

Scenario: A patient has been admitted to the hospital with chest pain and shortness of breath. The physician has ordered several diagnostic tests, including an electrocardiogram (ECG) and a chest X-ray. The nurse is responsible for preparing the patient for these tests. 

Question: Drag and drop the correct preparation steps for the ECG and chest X-ray into the appropriate categories below. 

[ECG Preparation] [Chest X-ray Preparation] 

  • Instruct the patient to remove all jewelry and metal objects—Instruct the patient to remove all clothing from the waist up 
  • Apply electrodes to the patient’s chest and limbs—Position the patient standing upright against the X-ray plate 
  • Have the patient lie still and avoid talking during the test—Ask the patient to hold their breath while the image is taken 

Here, you’ll be required to drag and drop each response option to the correct category to receive full credit. 

3. Cloze (Drop Down) 

This type presents a passage of text with certain words or phrases missing. Candidates must select the correct answer choice from a dropdown menu to fill in the blanks. This type of question evaluates your ability to apply nursing concepts to real-world scenarios or to identify key information in patient health histories. 

4. Enhanced Hot Spot or Highlighting 

This type requires you to select specific areas of an image or text by clicking or highlighting them. This type of question evaluates your ability to identify specific anatomical structures or to recognize clinical cues in patient data. 

This is an example of an Extended Hot Spot or Highlighting question: 

Scenario: A patient is experiencing pain in their right shoulder. The physician suspects a rotator cuff injury and has ordered a diagnostic test to confirm the diagnosis. 

Question: Click on the area of the diagram that corresponds to the rotator cuff. 

[Image of a human shoulder with various areas highlighted] 

For full credit, you must be able to identify and select the correct area that corresponds to the rotator cuff. 

5. Matrix or Grid 

This type presents a table or matrix with multiple answer choices in rows and columns. This question evaluates your ability to compare and contrast different nursing interventions, or to identify risk factors associated with specific patient health problems. 

More Precision with Partial Credit Scoring  

In addition to new items, the NCSBN introduced a new partial credit NGN scoring model including: 

  • 0/1 Scoring: This a binary scoring system that assigns a score of 0 or 1 to each item on an assessment. This is typically used for multiple-choice questions, where you can select a specified number of answers such as a drop-down cloze, a drop-down table, or bowtie questions. In this model, you’ll receive full credit for correct answers and no credit for incorrect answers 

  • +/- Scoring: This is used for extended or matrix multiple-response questions. Here, you’ll gain full credit for correct answers, but lose a point for incorrect responses. 

  • Rationale Scoring: You only receive credit for responses based on the quality of your reasoning. Here, the options must be correctly picked to earn a point.  

How Can You Prepare for the Upcoming NGN? 

Preparing for the NCLEX exam can be a long and tiring process. This is why we have compiled a comprehensive list of everything you need to know about the upcoming NCLEX, including the requirements, schedule, location, and practice questions. Learning fundamental NCLEX preparation tips can go a long way in assuring success, but due to the changes made, here’s what you can do to prepare better: 

  • Sharpen your critical thinking skills. The NGN is designed to assess a student’s ability to think critically and apply their knowledge in practical situations. Consider engaging in discussions with peers, and participating in case studies and simulations. 

  • Focus on application. The NGN will focus on the application of knowledge rather than just recalling facts. By developing the ability to apply your nursing knowledge to real-world scenarios, you’ll be on your way to passing the test. 

  • Refresh your knowledge of anatomy and physiology. Questions such as the extended hot spot or highlighting style will require you to identify and locate specific areas within an image or diagram. It’s helpful to sharpen your ability to analyze and interpret the question prompt and the provided image or diagram. There are many study aids available to help you prepare, including textbooks, study guides, and online resources.  

  • Solidify your clinical vocabulary. Cloze (Drop Down) questions may require you to carefully read and analyze a sentence or passage to determine the appropriate word or phrase that best fits the context. These questions are aimed at assessing your understanding of a specific topic.  

  • Reinforce your practical understanding of the diagnostic procedures. This includes the steps involved in patient preparation.  


Get a direct placement with employers of your choice at PRS Global. We’re here to help you find the perfect job to start your nursing career through our personalized support and guidance. 

From helping you prepare for interviews to negotiating job offers, we are here to help you every step of the way. Why wait? Contact us today to learn more about how we can help you find your dream nursing job! 


  1. NCSBN. “NGN Talks: A Look at the Strategic Practice Analysis & Special Research Section Video Transcript C2019 National Council of State Heards of Nursing, Inc.” Accessed March 6, 2023.