New Changes to an Old Exam
Patricia Walters-Fischer, RN, BS

Each year, thousands of nurses walk across a stage grinning from ear to ear and accept their graduation certificate or diploma. Although clinicals, care plans, and classroom work are behind them, they have one more huge step to take before obtaining state licensure: the National Council Licensure Examination (NCLEX-RN^®).

Unlike the knowledge-based tests given in nursing school, the NCLEX is application based. Students are tested on how they use critical thinking skills to make nursing judgments. This is similar to the skills required once a nurse starts working in the clinical areas.

Since 1977, the NCLEX has been the final gateway for new nursing graduates to earn state licensure. It’s also the cause of many late night study groups and anxiety attacks. More than 113,000 nursing graduates take the NCLEX each year.

But in the last 20 years, test construction has undergone major changes. With the increased diagnoses of attention deficit disorder, dyslexia, and other learning disorders, instructors and schools have researched different ways to format test-taking and present the information so that a broad range of students can understand and retain it better.

Although most nursing programs are divided into separate areas — medical, surgical, obstetrics, pediatrics, and psychiatric — the NCLEX is a compilation of every clinical area, each specialty, and pharmacology.

The NCLEX is divided into four categories: Safe and Effective Care Environment, Health and Promotions Maintenance, Psychosocial Integrity, and Physiological Integrity. The test is composed of four-option multiple-choice questions. The candidate is offered a minimum of 75 questions and a maximum of 265 questions. To pass the NCLEX, candidates must correctly answer about one-half of the more difficult questions.

Along with the four-option multiple choice questions, the National Council of State Boards of Nursing has developed alternate item format questions. These examination items, or questions, use a format other than standard, four-option, multiple-choice items to assess the candidate’s ability. Alternate item formats may include fill-in-the-blank items, multiple-choice items that require a candidate to select more than one response, or “Hot Spot” items asking a candidate to identify an area on a picture or graphic.

Fill in the Blank: Other than essay or short answer questions, fill in the blank tends to cause the most anxiety among test formats. But before throwing in the towel, it is essential to understand what exactly these fill in the blank questions require. This portion of the exam consists mostly of pharmacology calculations, specifically flow rates and calculation of medication doses.

Multiple Choice: Alternate item format multiple choice questions require the candidate to select more than one correct response. For example —

The signs of bacterial meningitis can be —

1. Ear pain
2. Red rash to body
3. Fever
4. Headache
5. Leg cramps
6. Neck stiffness

The correct answers are C, D, and F. If a nurse doesn’t choose the correct number of responses or picks an incorrect response, the entire question is counted wrong. The entire answer must be correct, and no partial credit is given.

Hot Spot: The Hot Spot section is more visual. Many times, answers to clinical questions are difficult to follow, for example, At what point are heart sounds loudest? With the present format, this question is followed by four descriptions and directions. But with the new format, an actual diagram or drawing of a chest is presented on the screen and the test taker simply points with the computer mouse to the loudest area. (In a normal heart, the part is between the fifth and sixth intercostals spaces, just under the nipple.)

The initial alternate item types are currently being pretested and may be available as operational items after October 1, 2003.

Once the new questions are in place, a passing grade will still be determined by answering more than 70% correct and by answering a minimum of 75 to a maximum of 265 questions. The cost of the test will stay at approximately $200.

As with any change, some will be pleased and others not. But overall, the new formats should give more nurses a broader range of ways to apply their knowledge base.

Patricia Walters-Fischer, RN, BS, has been a nurse for nearly 10 years and is now a full-time writer.