Next Generation NCLEX (NGN): Question Types Guide [2026]

The Next Generation NCLEX (NGN) introduced six new question types in April 2023 that test clinical judgment — your ability to make safe patient care decisions using real-world reasoning, not just recall. This guide explains what each question type looks like, how they're scored, and how to prepare.

Key Takeaways

• NGN adds 6 new question types: Matrix, Highlight, Cloze (Drop-Down), Bow-Tie, Trend, and Extended Multiple Response.
• These appear in 3 unfolding case studies on your exam (6 questions per case = 18 NGN items total).
• NGN questions use partial credit scoring — you get points for partially correct answers.
• All NGN questions are based on the NCSBN Clinical Judgment Measurement Model (CJMM).

Why the NCLEX Changed

The NCSBN found that traditional multiple-choice questions (4 options, 1 correct answer) were not adequately measuring clinical judgment. A nurse could memorize pathophysiology and select correct answers without demonstrating the ability to recognize, analyze, plan, and evaluate — the cognitive steps needed for safe bedside care.

The NCSBN Clinical Judgment Measurement Model (CJMM) was developed to address this gap. It measures clinical judgment across six cognitive steps:

1. Recognize cues — identify relevant information from the patient scenario
2. Analyze cues — determine what the information means clinically
3. Prioritize hypotheses — rank possible explanations by urgency
4. Generate solutions — identify appropriate nursing actions
5. Take actions — select the interventions to implement
6. Evaluate outcomes — determine whether the actions achieved the desired result

Every NGN question tests one or more of these steps.

The 6 NGN Question Types

1. Matrix/Grid

You're presented with a table where you must check or select answers across multiple rows and columns. Each row represents a nursing action, assessment finding, or patient characteristic. Columns represent evaluation criteria (e.g., "Effective," "Ineffective," "Unrelated").

Example scenario: A patient's vital signs, lab values, and symptoms are listed in the left column. You must classify each finding as "Expected" or "Unexpected" based on the patient's diagnosis.

How to approach it: Work row by row. For each finding, ask yourself: "Given this patient's condition and treatment plan, is this finding expected or abnormal?"

2. Highlight

You're given a block of text — typically a nursing assessment, EHR note, or provider order — and must highlight (select) the specific words, phrases, or sentences that answer the question.

Example scenario: A nurse's shift note describes a patient's symptoms. You must highlight the findings that indicate a complication of the patient's surgery.

How to approach it: Read the entire text first without highlighting. Then reread the question, identify the specific clinical concern, and highlight only the directly relevant findings.

3. Cloze (Drop-Down)

A passage with blank spaces where you select answers from dropdown menus. The passage is typically a clinical narrative, and each dropdown represents a clinical decision point.

Example scenario: "The nurse should first assess the patient's dropdown: airway / blood pressure / pain level and then administer dropdown: morphine / naloxone / epinephrine based on the assessment findings."

How to approach it: Read the complete passage with the blanks before selecting any dropdown. Understand the clinical flow before filling in individual decisions.

4. Bow-Tie

The most complex NGN format. You connect a central patient condition to:

• Left side: Contributing factors (causes, risk factors, assessment findings)
• Right side: Nursing interventions and monitoring parameters

The visual layout resembles a bow tie, with the diagnosis in the center knot.

Example scenario: Central condition: acute heart failure. Left side: select 2 contributing factors from a list. Right side: select 2 priority interventions and 2 monitoring parameters.

How to approach it: Start at the center — clearly identify the condition. Then work left (what caused or contributed to this?) and right (what do I do about it and how do I know it's working?).

5. Trend

You're presented with serial data points (vital signs, lab values, or assessment findings) collected over time and must interpret the trend — is the patient improving, worsening, or stable?

Example scenario: A post-operative patient's vital signs at 0800, 1000, 1200, and 1400. You must identify which trend indicates a complication and select the appropriate nursing action.

How to approach it: Don't focus on any single data point. Look at the direction of change. A blood pressure that drops from 130/80 to 118/74 to 102/68 to 90/60 is a trend worth catching, even though each individual reading might look acceptable in isolation.

6. Extended Multiple Response (EMR)

Similar to Select All That Apply (SATA) but with partial credit scoring. You select all correct options from a list, and you receive credit proportional to how many correct options you selected minus any incorrect selections.

Example scenario: "Select all nursing interventions appropriate for a patient with acute asthma exacerbation." Options include 6–8 interventions, of which 3–4 are correct.

How to approach it: Evaluate each option independently — treat each as a true/false question. Don't look for patterns in the number of correct answers.

How NGN Questions Are Scored

Traditional NCLEX questions are all-or-nothing: you get 1 point for the correct answer and 0 points for anything else. NGN questions use partial credit scoring:

This means even if you don't get every element right, you can still earn partial credit. On a 6-point bow-tie question, getting 4 connections correct earns 4 points — not zero.

Where NGN Questions Appear on the Exam

NGN questions are delivered inside 3 unfolding case studies. Each case study follows a single patient through a clinical scenario with 6 questions that progress through the CJMM steps:

1. Questions 1–2: Recognize and analyze cues
2. Questions 3–4: Prioritize hypotheses and generate solutions
3. Questions 5–6: Take actions and evaluate outcomes

You'll work through 3 cases × 6 questions = 18 NGN items on your exam. These are scored and count toward your pass/fail determination. They are integrated into the overall CAT algorithm alongside traditional MCQ, SATA, and ordered-response questions.

How to Prepare for NGN Questions

Practice the Formats

Familiarity reduces test-day anxiety. If you've never seen a bow-tie or matrix question before, encountering one for the first time under exam pressure wastes time and cognitive energy.

Resources for NGN-specific practice:

• NGN Practice Questions — our question set covering all 6 formats
• NCLEX Practice Test — includes integrated NGN case studies
• NCSBN's official NGN resources — sample questions from the test maker

Think in Clinical Judgment Steps

For every practice question, train yourself to identify which CJMM step you're performing:

• "Am I recognizing relevant information?" (Step 1)
• "Am I analyzing what this data means?" (Step 2)
• "Am I ranking possible problems?" (Step 3)
• "Am I choosing interventions?" (Steps 4–5)
• "Am I evaluating whether it worked?" (Step 6)

Read the Entire Case Before Answering

Unfolding case studies reveal new information with each question. Read all available information before answering — earlier questions may provide context that changes the interpretation of later data points.

Common NGN Mistakes

1. Rushing through matrix questions — each row is independent. Don't assume a pattern across rows.
2. Over-highlighting — in highlight questions, selecting too much text reduces your score. Be precise.
3. Ignoring trends — a single normal vital sign within a deteriorating trend is still a red flag. Look at direction, not snapshots.
4. Leaving bow-tie sections blank — partial credit means partial answers are worth something. Never leave a section empty.

Related Resources

• NGN Practice Questions — hands-on practice with all 6 formats
• NCLEX Study Guide — complete preparation roadmap
• NCLEX Practice Test — full-length simulation with NGN case studies
• NCLEX Pass Rate — how NGN affected pass rates
• NCLEX Study Plan — when to add NGN practice to your schedule

Frequently Asked Questions

How many NGN questions are on the NCLEX?

There are 18 NGN questions on the exam, delivered across 3 unfolding case studies (6 questions per case). These are scored items that count toward your pass/fail result.

Do NGN questions make the NCLEX harder?

They test different skills than traditional MCQ. If you only practiced standard 4-option questions, NGN items will feel harder. If you practiced all 6 formats, they're manageable. The passing standard itself has not changed since the NGN launch.

Can I pass the NCLEX without getting NGN questions right?

The NGN items contribute to your overall ability estimate through the CAT algorithm. Poor performance on NGN items doesn't automatically mean failure, but strong performance helps your estimate rise faster. The best strategy is to practice all formats.

Are NGN questions on the NCLEX-PN too?

Yes. Both the NCLEX-RN and NCLEX-PN include NGN question types with unfolding case studies. The clinical complexity of PN cases is adjusted to match the LPN scope of practice.