Discussion 4
Preparing Students for the NCLEX
A. NCLEX, NCLEX-RN, and NCLEX-PN Test Plan
One of the outcomes of prelicensure nursing programs is for graduates to pass an
examination that measures their knowledge and competencies to engage in safe and
effective nursing practice. At the entry level for professional nursing, graduates take the
NCLEX-RN® (National Council Licensure Examination for Registered Nurses) or, if
graduating from a practical or vocational nursing program, they take the NCLEX-PN®
(National Council Licensure Examination for Practical Nurses). Certification validates
knowledge and competencies for professional practice in a specialized area of nursing.
As part of this process, nurses may take certification examinations that assess their
knowledge and skills in a nursing specialty such as critical care or pediatric nursing.
Other certification examinations measure knowledge and competencies for advanced
practice, for teaching, and for administrative roles. As students progress through a
nursing program, they should have experience with tests that are similar to and prepare
them for taking licensure and certification examinations when they graduate. Because the
focus of the NCLEX and most certification examinations is on nursing practice, the other
advantage to incorporating items of these types in teacher-made tests is that it provides a
way of assessing whether students can apply their theoretical learning to clinical
situations. Teachers can develop items that present new and complex clinical situations
for students to critically analyze. Items can focus on collecting and analyzing data, setting
priorities, selecting interventions, and evaluating outcomes; providing patient-centered
care; communicating with patients, their families, and other healthcare providers;
documenting care; teaching; and other processes fundamental to nursing practice. This
type of testing is a means of assessing higher and more complex levels of learning and
provides essential practice before students encounter similar questions on licensure and
certification examinations.
The chapter includes examples of items written at different cognitive levels,
thereby avoiding tests that focus only on recall and memorization of facts, and sample
stems that can used for clinically oriented test items. The types of items presented in this
chapter are similar to those found on the NCLEX and many certification tests. By
incorporating items of these types on tests in nursing courses, teachers help students
acquire experience with this type of testing as they progress through the program,
preparing them for taking licensure and certification examinations as graduates. The
reader should keep in mind that Chapter 7, Assessment of Higher Level Learning,
presented other ways of assessing higher level learning. The chapter begins with an
explanation of the NCLEX test plans in use at the time this edition of the book was
prepared (2019). NCLEX and certification examinations are updated every few years to
keep current with practice. Based on the most recent practice analysis, which documented
the complex decisions nurses make when caring for patients, the National Council of
State Boards of Nursing (NCSBN) is exploring use of innovative types of test items to
evaluate clinical judgment—the Next Generation NCLEX project (NCSBN, 2019a).
Readers are advised to refer to the NCLEX and certification test plans in use when
developing examinations and quizzes for their own nursing students.
In the United States and its territories, graduates of nursing programs cannot
practice as RNs or as practical nurses (PNs) or vocational nurses (VNs) until they have
passed a licensure examination. These examinations are developed by the NCSBN based
on extensive analyses of the practice requirements of RNs and licensed practical nurses
(LPNs) or vocational nurses (LVNs). Items are piloted and tested extensively to ensure
they are valid, reliable, and legally defensible, including an analysis of potential biases
such as those related to ethnicity and gender (Woo & Dragan, 2012). The licensure
examination results then are used by the state boards of nursing as one of the
requirements for practice in that state or territory.
In developing the NCLEX-RN, the NCSBN conducts an analysis of the current
practice of newly licensed RNs across clinical areas and settings. This is a continuous
process allowing the licensure examination to stay current with the knowledge and
competencies needed by entry-level nurses. To ensure that the NCLEX-RN measures the
essential competencies for safe and effective practice by a newly licensed RN, the
NCSBN reviews the test plan or blueprint every 3 years (NCSBN, 2018). For the most
recent revision of the test plan, 2,275 newly licensed RNs prioritized how frequently they
performed 142 nursing activities and rated the overall importance of each activity.
Findings are used to develop the NCLEX-RN test plan and items on the test.
In the safe and effective care environment category, two subcategories of content
are tested on the NCLEX-RN: (a) management of care and (b) safety and infection
control. In the management of care subcategory, the test items focus on providing and
directing nursing care that enhances care delivery to protect clients and healthcare
providers. Examples of content tested in this category include advance directives;
advocacy; assignment, delegation, and supervision; case management; collaboration with
the interdisciplinary team; concepts of management; confidentiality/information security;
continuity of care; establishing priorities; ethical practice; informed consent; legal rights
and responsibilities; and performance improvement (quality improvement) among others
(NCSBN, 2019b). In the NCLEX-RN, 17% to 23% of the items assess management of
care. In the safety and infection control subcategory, test items focus on prevention of
accidents, emergency response planning, ergonomic principles, handling hazardous and
infectious materials, reporting incidents and irregular occurrences, safe use of equipment,
standard precautions, and use of restraints, among others (NCSBN, 2019b). Between 9%
and 15% of the items on the NCLEX-RN relate to safety and infection control.
The third category of client needs, psychosocial integrity, also has no
subcategories. This category focuses on nursing care that promotes the emotional, mental,
and social well-being of clients experiencing stressful events, and the care of patients
with acute and chronic mental illness. Examples of content tested include abuse,
behavioral interventions, coping, crisis intervention, cultural awareness and influences on
health, end-of-life care, grief and loss, mental health, sensory and perceptual alterations,
and therapeutic communication and environment (NCSBN, 2019b). Six percent to 12%
of the items on the NCLEX-RN ask questions about psychosocial integrity.
Five processes that are fundamental to nursing practice are integrated throughout
each of the categories of the test plan: (a) nursing process, (b) caring, (c) communication
and documentation, (d) teaching and learning, and (e) culture and spirituality (NCSBN,
2019b). Thus, there can be test items on teaching patients and the nurse’s ethical and
legal responsibilities in patient education as part of the management of care subcategory,
teaching nursing assistants about the use of restraints in the safety and infection control
subcategory, health education for different age groups in the health promotion and
maintenance category, and teaching about diagnostic tests in the reduction of risk
potential subcategory. The other processes are integrated similarly throughout the test
plan. Many of the items on the NCLEX examinations are developed based on clinical
scenarios. Those scenarios can involve any age group of patients in acute care hospitals,
long-term care, community health, or other types of settings.
The taxonomy for the cognitive domain is used for developing and coding items
on the NCLEX-RN (NCSBN, 2019b). This taxonomy was presented in Chapter 1,
Assessment and the Educational Process. The majority of items are at the application
(applying) and higher cognitive levels (NCSBN, 2019b). This has implications for testing
in prelicensure nursing education programs. Faculty members should avoid preparing
only items that require remembering and understanding facts and specific information on
their tests. Although some low-level questions are essential to assess students’
knowledge, test items also need to ask students to use their knowledge and analyze data
and clinical situations to decide on approaches to take. Test blueprints can be developed
to list not only the content and number of items in each content area but also the level of
cognitive complexity at which items should be written. An example of a blueprint of this
type was provided in Exhibit 3.3 in Chapter 3, Planning for Testing.
The test plan for the NCLEX-PN is developed and organized similarly to the RN
examination. In the most recent practice analysis for this test plan, LPN/LVNs who were
newly licensed were asked how frequently they performed 151 nursing activities and the
importance of those activities (NCSBN, 2019c). The activities were then used as the
framework for the development of the test plan for the PN examination. The test plan is
structured around client needs and integrated processes fundamental to the practice of
practical and vocational nursing. The same four client needs categories are used for the
NCLEX-PN with differences in some of the subcategories, related content, and
percentage of items in each category and subcategory. In the safe and effective care
environment category on the NCLEX-PN, 18% to 24% of the items are on coordinated
care, and 10% to 16% are on safety and infection control. Between 6% and 12% of the
items assess the second category of client needs: health promotion and maintenance. Nine
percent to 15% of the items on the NCLEX-PN address psychosocial integrity. The last
category of client needs, physiological integrity, has four subcategories similar to the RN
test plan: basic care and comfort (7%–13% of the items), pharmacological therapies
(10%–16% of the items), reduction of risk potential (9%–15% of the items), and
physiological adaptation (7%–13% of the items; NCSBN, 2016). Five processes are
integrated throughout the test: (a) the clinical problem-solving process (nursing process),
(b) caring, (c) communication and documentation, (d) teaching and learning, and (e)
culture and spirituality. Items are developed at all cognitive levels with the majority
written at the application or higher levels of cognitive abilities, similar to the NCLEX-RN
test plan.
B. Types of Items on the NCLEX Examinations
The NCLEX examinations contain multiple-choice items and alternate item
formats. Earlier chapters described how to construct each type of item used on the
NCLEX: multiple-choice (Chapter 5, Multiple-Choice and Multiple-Response); the
alternate formats of multiple-response (Chapter 5, Multiple-Choice and Multiple-
Response), fill-in-the-blank (for calculations), and ordered response (Chapter 6, Short-
Answer (Fill-in-the-Blank) and Essay); and hot-spot and chart or exhibit (Chapter 7,
Assessment of Higher Level Learning). Some items include audio and the candidate
listens to an audio clip and selects a response; other items have graphics. Any of the types
of items might include a table, a chart, an image, or sound as part of the item. These items
with multimedia have the capacity to assess higher levels of thinking and do so more
authentically than a text-based item.
The NCLEX-RN Detailed Test Plan, as outlined by the National Council of State
Boards of Nursing (NCSBN) in 2016 and updated in subsequent revisions such as 2019b,
serves as a comprehensive guide that offers invaluable insights into the practice activities
utilized during the development of examination items. This detailed plan meticulously
delineates the content areas and subcategories assessed within each category of the
NCLEX-RN, providing a structured framework that ensures the exam effectively
evaluates the essential knowledge and competencies required for safe and competent
nursing practice. The test plan begins by conducting a rigorous job analysis, which
involves gathering data from a wide array of healthcare professionals, educators, and
stakeholders across different clinical specialties and practice settings. This foundational
step aims to identify the critical tasks, responsibilities, and challenges encountered by
newly licensed Registered Nurses (RNs) in their everyday practice. By capturing this
information, the NCSBN ensures that the NCLEX-RN reflects the current realities of
nursing practice and remains relevant to the evolving healthcare landscape. Based on the
findings of the job analysis, the NCLEX-RN Detailed Test Plan delineates specific
content areas and subcategories that correspond to the identified domains of nursing
practice.
Each of these categories and subcategories is further detailed in the NCLEX-RN
Detailed Test Plan, specifying the percentage of exam questions allocated to each area.
This allocation is based on the relative importance of each category in ensuring the
competence of entry-level nurses. Moreover, the test plan provides guidance on the
development of examination items (questions) within each content area. Subject matter
experts (SMEs), who are experienced nurses and educators, collaborate to develop items
that align with the specified content outline. These items undergo rigorous review
processes to ensure accuracy, relevance, clarity, and adherence to psychometric
principles. Piloting and statistical analyses further validate the performance of items,
ensuring they effectively discriminate between candidates of varying ability levels.
By adhering to the NCLEX-RN Detailed Test Plan, the NCSBN ensures that the
licensure examination remains a valid and reliable measure of entry-level nursing
practice. The plan not only informs the creation of examination content but also serves as
a benchmark for nursing education programs, guiding curriculum development and
ensuring that graduates are adequately prepared to meet the demands of contemporary
nursing practice. In essence, the NCLEX-RN Detailed Test Plan exemplifies the
NCSBN's commitment to maintaining the highest standards of nursing regulation and
education, thereby safeguarding public health and promoting excellence in nursing care
nationwide.
As previously mentioned, the National Council of State Boards of Nursing
(NCSBN) conducts thorough analyses of the practices of newly licensed Registered
Nurses (RNs) and Practical Nurses (PNs) or Vocational Nurses (VNs) across various
clinical specialties and healthcare settings. This comprehensive examination aims to
identify the core knowledge, skills, and competencies essential for these nurses to
practice safely and effectively. The analysis process begins with a detailed job analysis,
which involves gathering data from a diverse range of healthcare professionals,
educators, and stakeholders within the nursing profession. By consulting with these
experts, the NCSBN obtains insights into the specific tasks, responsibilities, and
challenges faced by newly licensed RNs and PNs/VNs in their daily practice. This
information is crucial for understanding the scope of practice and the professional
expectations placed upon entry-level nurses in different clinical specialties, such as
medical-surgical nursing, pediatrics, maternal-child health, psychiatric-mental health, and
geriatrics, among others. Furthermore, the NCSBN evaluates the knowledge areas that
are foundational to safe and competent nursing practice across various healthcare
settings, including hospitals, long-term care facilities, outpatient clinics, community
health centers, and home health agencies. This analysis helps to identify the common
clinical scenarios and challenges encountered by newly licensed nurses and the critical
thinking skills required to address these challenges effectively.
In addition to clinical competencies, the NCSBN assesses non-clinical skills such
as communication, teamwork, ethical decision-making, and cultural competence. These
skills are essential for fostering effective patient-centered care, promoting positive health
outcomes, and ensuring patient safety in diverse healthcare environments. Moreover, the
NCSBN's analysis incorporates feedback from practicing nurses regarding emerging
trends, advancements in healthcare technology, changes in regulatory requirements, and
evolving standards of care. This ongoing dialogue with the nursing community ensures
that the licensure examinations, such as the NCLEX-RN for Registered Nurses and
NCLEX-PN for Practical/Vocational Nurses, remain current, relevant, and aligned with
the latest developments in nursing practice.
By synthesizing these insights and data, the NCSBN develops comprehensive
frameworks and competency standards that serve as the foundation for licensure
examinations and educational programs in nursing. These frameworks guide the creation
of examination content, ensuring that the NCLEX accurately assesses the knowledge,
skills, and abilities necessary for entry-level nurses to provide safe, competent, and
compassionate care to patients across the lifespan and in diverse healthcare settings. In
conclusion, the NCSBN's rigorous analysis of the practices and knowledge requirements
of newly licensed RNs and PNs/VNs plays a pivotal role in shaping the future of nursing
education, regulation, and practice. By continually refining and updating its examination
processes based on empirical data and expert input, the NCSBN upholds the highest
standards of quality and integrity in nursing licensure, thereby safeguarding public health
and promoting excellence in nursing care nationwide.
This analysis identifies nursing activities that are frequently utilized by entry-level
nurses and are critical for ensuring patient safety. Understanding the core activities that
entry-level nurses commonly engage in is essential for shaping nursing education
curricula, designing effective training programs, and establishing proficiency standards.
Through comprehensive job analyses and consultations with healthcare professionals and
educators, key nursing tasks and responsibilities are identified. These activities
encompass a wide range of clinical and non-clinical duties that are foundational to safe
and competent nursing practice.
Among the most prevalent nursing activities identified are fundamental clinical
skills such as patient assessment, medication administration, wound care management,
and patient monitoring. These activities are crucial as they form the basis of direct patient
care and are integral to promoting patient well-being and recovery. Additionally, tasks
related to communication with patients, families, and healthcare team members, as well
as documentation of patient care activities, are highlighted as essential components of
nursing practice. Furthermore, the analysis underscores the importance of critical
thinking and decision-making skills in nursing practice. Entry-level nurses are often
required to prioritize patient needs, recognize changes in patient conditions, and
implement appropriate interventions in a timely manner. These cognitive abilities are
vital for effective clinical reasoning and ensuring optimal patient outcomes. In addition to
clinical tasks, non-clinical activities such as patient education, health promotion, and
advocacy are identified as significant aspects of nursing practice. Entry-level nurses play
a key role in empowering patients to participate in their care, promoting healthy
lifestyles, and advocating for patient rights and safety within healthcare settings.
Moreover, the analysis recognizes the importance of interdisciplinary
collaboration and teamwork in nursing practice. Entry-level nurses frequently collaborate
with physicians, pharmacists, therapists, and other healthcare professionals to deliver
comprehensive and coordinated care. Effective communication, mutual respect, and
shared decision-making are essential for achieving positive patient outcomes and
enhancing the quality of care provided. Overall, by identifying and emphasizing these
critical nursing activities, the analysis informs the development of educational programs,
licensure examinations (such as the NCLEX), and professional standards that ensure
entry-level nurses possess the necessary knowledge, skills, and competencies to deliver
safe and effective care across diverse healthcare settings. This systematic approach not
only supports the ongoing professional development of nurses but also contributes to the
promotion of patient safety and quality healthcare delivery.
The development of the NCLEX (National Council Licensure Examination)
involves a rigorous process designed to ensure its validity as a reliable measure of entry-
level nursing practice. This validity is crucial to uphold the integrity and effectiveness of
the exam in assessing the knowledge and skills necessary for safe and competent nursing
care. One of the foundational activities in developing the NCLEX is conducting a
comprehensive job analysis. This process involves identifying and analyzing the tasks
and responsibilities that entry-level nurses are expected to perform in their roles. Through
extensive consultation with practicing nurses, educators, and stakeholders in the nursing
profession, the National Council of State Boards of Nursing (NCSBN) gathers detailed
information about the scope of practice and the essential competencies required for safe
patient care.
Based on the findings from the job analysis, the content of the NCLEX (National
Council Licensure Examination) is meticulously determined to ensure it accurately
reflects the essential knowledge and skills required for entry-level nursing practice. The
job analysis conducted by the National Council of State Boards of Nursing (NCSBN)
involves gathering comprehensive data from a wide range of sources. This includes
surveys, interviews, and consultations with nurses, educators, employers, and
stakeholders across various healthcare settings. The goal is to identify the critical tasks,
responsibilities, and competencies that newly licensed nurses must possess to practice
safely and effectively. The findings from the job analysis inform the development of the
NCLEX Detailed Test Plan. This plan serves as a blueprint that outlines the distribution
of content areas and specifies the percentage of questions dedicated to each domain on
the exam. It ensures that the exam comprehensively evaluates candidates' understanding
and application of nursing knowledge across all essential areas of practice.
Subject matter experts (SMEs), who are experienced nurses and educators with
diverse clinical backgrounds, collaborate to develop exam items (questions) based on the
identified content areas. These SMEs ensure that each item is aligned with current
evidence-based practice guidelines, clinical standards, and regulatory requirements. They
review items for accuracy, relevance, and clarity, and ensure that they reflect the
complexities and realities of nursing practice. Newly developed items undergo rigorous
pilot testing with a sample of candidates to evaluate their performance. Statistical
analyses, such as item difficulty and discrimination indices, are conducted to assess how
well items differentiate between candidates of varying ability levels. Items that perform
well in discriminating between candidates are selected for inclusion in the operational
exam, while those that do not meet psychometric standards are refined or discarded.
The NCLEX content is continually reviewed and updated to ensure it remains
current and aligned with evolving healthcare practices and educational standards.
Changes in healthcare delivery, advancements in technology, and shifts in patient care
needs are considered in the ongoing revision of exam content to maintain its relevance
and validity. In summary, the careful determination of NCLEX content based on findings
from job analysis ensures that the exam effectively evaluates the knowledge and skills
essential for safe and competent nursing practice. This systematic approach supports the
preparation of newly licensed nurses to meet the demands of contemporary healthcare
environments and uphold high standards of patient care.
Subject matter experts (SMEs) are integral to the development of licensure exams
like the NCLEX, bringing their extensive experience as nurses and educators with diverse
clinical backgrounds to ensure a comprehensive and rigorous assessment of nursing
practice. SMEs involved in exam development represent various clinical specialties and
practice settings, including medical-surgical nursing, pediatrics, obstetrics, psychiatric-
mental health, geriatrics, and more. Their diverse backgrounds enable them to contribute
insights into the unique challenges, responsibilities, and best practices within each
specialty. This diversity ensures that the exam content covers a wide spectrum of nursing
care scenarios and skills required across different healthcare environments. SMEs
collaborate to establish a robust framework that outlines the content domains, categories,
and subcategories to be assessed in the exam. This framework is informed by
comprehensive job analyses and practice analyses, which identify the core competencies
and tasks performed by entry-level nurses. By synthesizing their collective expertise,
SMEs ensure that the exam blueprint reflects the current scope of nursing practice and
aligns with professional standards and regulatory requirements.
SMEs actively participate in the development and review of exam items
(questions) that align with the established framework. They contribute their clinical
knowledge to ensure that each item accurately assesses essential nursing knowledge,
critical thinking skills, and clinical judgment. SMEs evaluate items for relevance to
current practice guidelines, accuracy of content, clarity of language, and appropriateness
of distractors (incorrect answer choices) to ensure the validity and reliability of the exam.
Throughout the item development process, SMEs uphold high standards of quality
assurance. They conduct peer reviews and discussions to resolve discrepancies and refine
items based on feedback from their peers and psychometricians. This collaborative
review process ensures that exam content is free from bias, culturally sensitive, and
representative of the diverse patient populations and healthcare contexts encountered in
practice.
SMEs engage in ongoing professional development to stay abreast of
advancements in nursing research, clinical practice guidelines, and educational
methodologies. This continuous learning enables them to contribute to updates and
revisions of exam content in response to changes in healthcare delivery, emerging
technologies, and evolving patient care needs. In summary, SMEs with diverse clinical
backgrounds play a vital role in developing a robust framework for licensure exams like
the NCLEX. Their expertise ensures that the exam accurately reflects the breadth and
depth of nursing practice, preparing candidates to deliver safe, competent, and patient-
centered care in a rapidly evolving healthcare landscape. Through collaboration and
dedication to excellence, SMEs uphold the integrity and validity of the licensure exam,
ultimately contributing to the enhancement of nursing education, regulation, and quality
patient care.
Subject matter experts (SMEs) play a critical role in ensuring that licensure exams
like the NCLEX reflect current evidence-based practice guidelines, clinical standards,
and regulatory requirements in nursing. Their expertise and experience contribute to the
development and validation of exam content that is relevant, accurate, and aligned with
the evolving landscape of healthcare. SMEs are knowledgeable about the latest research
and evidence-based practices in nursing. They review current literature, clinical
guidelines, and research findings to ensure that exam content incorporates best practices
and reflects the most current knowledge in healthcare. This ensures that candidates are
tested on concepts and skills that are supported by scientific evidence and have been
shown to improve patient outcomes. SMEs are typically practicing nurses or nurse
educators who have firsthand experience in clinical settings. They are familiar with
professional standards of practice set forth by organizations such as the American Nurses
Association (ANA), specialty nursing associations, and regulatory bodies. SMEs ensure
that exam questions adhere to these standards, covering essential clinical competencies
and ethical considerations required of entry-level nurses.
Licensure exams must align with regulatory requirements established by state
boards of nursing and national regulatory bodies such as the NCSBN. SMEs ensure that
exam content reflects these requirements, including legal and ethical responsibilities,
scope of practice, and licensure regulations specific to nursing practice. During item
development, SMEs review and validate exam questions to ensure they accurately assess
the knowledge and skills relevant to current practice. They scrutinize each item for
clarity, accuracy, relevance, and appropriateness within the context of evidence-based
practice and clinical standards. This rigorous review process helps to eliminate bias,
cultural insensitivity, or outdated information from exam content. SMEs participate in
ongoing review processes to monitor exam content and ensure its currency and relevance.
They contribute to periodic updates of exam blueprints and test plans based on changes in
healthcare practices, emerging trends, and advancements in technology. This ensures that
the licensure exam remains a valid and reliable assessment tool that prepares newly
licensed nurses to meet the demands of contemporary healthcare environments. In
conclusion, SMEs bring invaluable expertise and a commitment to excellence in ensuring
that licensure exams like the NCLEX reflect current evidence-based practice guidelines,
clinical standards, and regulatory requirements in nursing. Their contributions help to
maintain the quality, validity, and relevance of the exam, ultimately safeguarding public
health by ensuring that newly licensed nurses possess the necessary knowledge and skills
to deliver safe, effective, and compassionate care to patients.
The process of item development is another critical phase in establishing the
validity of the NCLEX. Skilled item writers craft questions that align with the identified
content areas and assess various cognitive levels of learning, from basic recall to higher-
order critical thinking. These items undergo rigorous review and validation by SMEs to
ensure accuracy, relevance, and clarity. Additionally, items are scrutinized to ensure they
are free from bias and cultural insensitivity, promoting fairness and equity in the
assessment process. Pilot testing plays a pivotal role in the validation process of the
NCLEX. During this phase, newly developed items are administered to a sample of
candidates who represent the diverse population of nursing graduates.
Statistical analyses of candidate performance play a crucial role in evaluating the
validity and reliability of items in licensure examinations like the NCLEX. These
analyses provide empirical data that help ensure the fairness, accuracy, and effectiveness
of the exam in assessing the knowledge and skills necessary for entry-level nursing
practice. Items that are too easy (answered correctly by most candidates) or too difficult
(answered correctly by very few candidates) may be flagged for review to ensure they
appropriately challenge candidates across the ability spectrum. It is calculated by
comparing the performance of candidates who score well overall on the exam with those
who score poorly. Items with high discrimination indices effectively distinguish between
candidates with varying levels of competence, indicating their ability to assess the
targeted knowledge and skills.
Reliability measures the consistency and stability of exam scores over repeated
administrations. Statistical methods such as Cronbach's alpha coefficient are used to
evaluate the internal consistency of exam items. A high reliability coefficient indicates
that the items collectively measure the intended construct (e.g., nursing knowledge)
reliably across different test forms and administrations. Statistical analyses also
contribute to gathering validity evidence for the exam. Validity refers to the extent to
which the exam measures what it intends to measure. Through criterion-related validity
studies, correlations can be examined between exam scores and external criteria (e.g.,
clinical performance evaluations) to establish the predictive validity of the exam.
Additionally, content validity is ensured through expert judgment and alignment with the
exam blueprint derived from job analyses and practice analyses. Statistical equating
methods are used to ensure that scores from different exam forms are comparable in
difficulty. This process involves linking the difficulty levels of items across different test
administrations to maintain the fairness and consistency of score interpretations over
time. Overall, statistical analyses of candidate performance provide a robust framework
for evaluating the psychometric properties of licensure exam items. By leveraging these
analyses, exam administrators can make informed decisions about item selection,
refinement, and maintenance, thereby enhancing the validity, reliability, and fairness of
the exam as a measure of entry-level nursing practice. This rigorous approach ensures
that the licensure exam accurately identifies competent candidates who are well-prepared
to provide safe and effective care in diverse healthcare settings.
In the development of licensure examinations such as the NCLEX, the selection
of items that effectively discriminate between candidates of varying ability levels is
crucial for maintaining the exam's validity and reliability. This process ensures that the
exam accurately assesses the knowledge, skills, and competencies required for entry-level
nursing practice. During the item development phase, subject matter experts (SMEs)
carefully craft multiple-choice questions (items) that cover a range of content areas and
cognitive levels specified in the exam blueprint. These items undergo rigorous review
processes to ensure they are accurate, relevant, and aligned with current nursing practice
standards. Once developed, these items are pilot-tested with a diverse sample of
candidates who represent the intended population of exam takers. Pilot testing allows
psychometricians and test developers to gather valuable data on how well each item
performs in distinguishing between candidates who demonstrate varying levels of
competence. Statistical analyses, such as item difficulty and item discrimination indices,
are used to evaluate the performance of each item.
Items that consistently perform well in discriminating between high-performing
and low-performing candidates are considered for inclusion in the operational exam.
High-performing items typically exhibit moderate difficulty, meaning they are
challenging enough to differentiate between candidates who possess different levels of
knowledge and skills. Additionally, these items demonstrate a strong correlation with
overall exam performance, indicating their reliability in predicting candidates' abilities.
On the other hand, items that do not meet psychometric standards may be flagged for
revision or removal from the item pool. Common issues that may lead to an item being
discarded include ambiguous wording, unintended cultural bias, poor distractor
effectiveness (incorrect answer choices), or inadequate alignment with the exam
blueprint. These items undergo thorough review and revision processes, involving input
from SMEs and psychometricians, to enhance their quality and effectiveness.
The continuous refinement of item banks through this rigorous selection and
validation process contributes to the overall validity and reliability of the licensure exam.
By ensuring that only high-quality items are included in the operational exam, the exam
administrators uphold the integrity of the assessment and provide a fair and equitable
evaluation of candidates' readiness to enter the nursing profession. In summary, the
selection of items based on their ability to discriminate between candidates of varying
ability levels is a critical aspect of licensure exam development. This process supports the
exam's validity by accurately measuring the competencies required for safe and effective
nursing practice, thereby maintaining public trust in the nursing profession and promoting
quality healthcare delivery.
Standard setting is another crucial aspect of ensuring the validity of the NCLEX.
Through a systematic process involving expert judgment and statistical methodologies,
passing standards are established to define the minimum level of competence required for
entry into the nursing profession. These standards are based on empirical data derived
from the performance of a representative sample of candidates, ensuring that the passing
score accurately reflects the proficiency needed to practice safely as a nurse. In
conclusion, the meticulous development process of the NCLEX, guided by evidence-
based practices and rigorous psychometric principles, provides compelling evidence of its
validity as a measure of entry-level nursing practice.
By aligning with the current standards of nursing education and practice, the
NCLEX (National Council Licensure Examination) plays a pivotal role as a reliable
assessment tool that upholds public safety and ensures newly licensed nurses are
equipped with the essential knowledge and skills to deliver exemplary care across diverse
healthcare settings. The NCLEX is designed to assess the competencies required for safe
and effective nursing practice, reflecting the latest advancements in healthcare and
evidence-based practices. This alignment is achieved through meticulous processes such
as job analysis, content validation, and ongoing review by subject matter experts. These
processes ensure that the exam content remains relevant and responsive to the evolving
landscape of nursing education, healthcare delivery, and patient needs.
C. Administration of NCLEX Examinations
The NCLEX is administered to candidates by computerized adaptive testing
(CAT). The CAT model is such that each candidate’s test is assembled interactively as
the person is answering the questions. Each item on the NCLEX has a predetermined
difficulty level. As each item is answered, the computer reestimates the candidate’s
ability based on whether the answer is correct or incorrect (NCSBN, 2019b). The
computer then searches the item bank for an item with a 50% chance of being answered
correctly by the candidate. This is an efficient means of testing, avoiding questions that
do not contribute to determining a candidate’s level of nursing competence. The standard
for passing the NCLEX is criterion referenced. The standard is set by the NCSBN based
on an established protocol and is used as the basis for determining whether the candidate
has passed or failed the examination. The NCLEX-RN can range from 75 to 265 items,
with 15 of those being pretest items that are not scored. After candidates answer the
minimum number of items, the testing stops when the candidate’s ability is above or
below the standard for passing, with 95% certainty (NCSBN, 2019b).
Moreover, the NCLEX promotes consistency and fairness in licensure standards
nationwide. By establishing a uniform benchmark for entry into the nursing profession,
the exam ensures that all candidates, regardless of educational background or geographic
location, meet a standardized level of competence. This standardization enhances public
trust in the nursing profession by certifying that licensed nurses possess the necessary
qualifications to deliver safe and competent care to patients across various healthcare
settings. In conclusion, by aligning with current standards of nursing education and
practice, the NCLEX fulfills its mandate as a robust assessment tool that safeguards the
public interest. Through rigorous content development processes, adherence to best
practices in nursing education, and continuous review and enhancement, the NCLEX
ensures that newly licensed nurses are well-prepared to meet the challenges of modern
healthcare delivery. This commitment to excellence in nursing regulation contributes to
improved patient outcomes, enhanced professional credibility, and the promotion of
quality healthcare services for individuals and communities alike.
The NCLEX-RN Detailed Test Plan includes a list of the activity statements and
related content for each category and subcategory. This information is of value in
developing items for tests in a nursing program. For example, in the safety and infection
control subcategory, the activity statements describe the practices that RNs use to protect
clients and healthcare personnel from health and environmental hazards. An example of
one of these activity statements is, “Apply principles of infection control (e.g., hand
hygiene, aseptic technique, isolation, sterile technique, universal/ standard precautions)”.
A sample test item is also provided with each category and subcategory.
Because the NCLEX is an adaptive test, candidates complete different numbers of
items, and therefore the test takes varying amounts of time. If a candidate’s ability has
not been determined by the time the maximum number of items has been presented or
when the time limit has been reached, the examination then stops. All RN candidates
must answer a minimum number of 75 items. The maximum number they can answer is
265 within a time limit of 6 hours (NCSBN, 2019b). On the NCLEX-PN, PN and VN
candidates must answer a minimum of 85 items. The maximum number of items they can
answer is 205, during the 5-hour testing period allowed.
One key aspect of the NCLEX's alignment with current standards is its adherence
to the NCLEX Detailed Test Plan, which outlines the content areas and specific
competencies assessed in the exam. This plan is regularly updated to reflect changes in
nursing practice, emerging healthcare priorities, and advancements in medical
technology. By focusing on core domains such as safe and effective care environment,
health promotion and maintenance, psychosocial integrity, and physiological integrity,
the NCLEX ensures that candidates are evaluated comprehensively across essential
aspects of nursing practice. Furthermore, the NCLEX's role extends beyond assessing
theoretical knowledge to evaluating critical thinking skills and clinical judgment. The
exam includes scenario-based questions that require candidates to apply their knowledge
in realistic clinical situations, demonstrating their ability to make informed decisions and
prioritize patient care effectively. This approach not only tests cognitive abilities but also
prepares nurses to navigate complex healthcare environments and respond adeptly to
patient needs.
D. Preparation of Items at Varied Cognitive Levels
When courses have higher level outcomes, tests in those courses need to measure
learning at the applying and analyzing levels rather than at remembering and
understanding. This principle was discussed in earlier chapters. Items at higher levels of
cognitive complexity are more difficult and time-consuming to develop, but they provide
a way of evaluating ability to apply knowledge to new situations and to engage in
analytical thinking. The majority of items on the NCLEX are written at higher levels of
cognitive ability, requiring application of knowledge and analytical thinking. Students are
at a disadvantage if they encounter only test items that ask them to recall facts as they
progress through a nursing program. Low-level items assess how well students memorize
specific information, not whether they can use that knowledge to analyze clinical
situations and arrive at the best decisions possible for those situations. Students need
experience answering questions at the application and analysis levels before they take the
NCLEX. More important, if course outcomes are at higher levels of cognitive
complexity, then tests and other methods need to assess learning at those levels.
In graduate nursing programs, the development of test items at higher cognitive
levels is essential to effectively assess students' abilities to problem solve and think
critically through complex situations. These assessments are crucial in preparing students
for certification examinations they may encounter upon graduation. Test items at higher
cognitive levels challenge students to apply critical thinking skills and clinical reasoning
to complex patient care scenarios. These scenarios often reflect real-world challenges that
nurses face in clinical practice, requiring students to analyze multiple factors, prioritize
interventions, and anticipate outcomes based on evidence-based practice and theoretical
knowledge. Higher-level test items assess students' ability to identify problems, gather
relevant data, and generate effective solutions within the context of patient care. Students
must demonstrate their capacity to assess the situation comprehensively, consider
alternative approaches, and make informed decisions that promote patient safety, improve
outcomes, and optimize healthcare delivery.
Graduate-level test items integrate advanced nursing concepts and theories that
students have acquired through their academic coursework and clinical experiences.
These items require students to synthesize knowledge from various disciplines such as
pharmacology, pathophysiology, ethics, and healthcare policy to formulate holistic and
evidence-based care plans. Graduate nursing programs aim to prepare students for
certification examinations such as the Advanced Practice Registered Nurse (APRN)
certification exams (e.g., Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist,
Nurse Midwife). Test items at higher cognitive levels mirror the complexity and depth of
these certification exams, ensuring that students are adequately prepared to demonstrate
their readiness for advanced practice roles. By engaging with higher-level test items,
students develop the competencies required for advanced practice nursing roles. These
roles demand advanced clinical skills, leadership abilities, and the capacity to make
autonomous decisions in diverse healthcare settings. Test items assess students' readiness
to assume these responsibilities and contribute effectively to interprofessional healthcare
teams.
Developing test items at higher cognitive levels aligns with educational goals to
foster lifelong learning and professional development among graduate nursing students. It
promotes a deep understanding of nursing practice, encourages ongoing reflection on
clinical experiences, and prepares students to adapt to evolving healthcare challenges and
innovations. In conclusion, the development of test items at higher cognitive levels in
graduate nursing programs plays a pivotal role in preparing students for certification
examinations and advanced practice roles. These items assess students' critical thinking,
problem-solving abilities, and integration of advanced nursing concepts, ensuring they
are well-equipped to provide high-quality, evidence-based care as competent and
compassionate nurse leaders in healthcare.
When developing a new test, a blueprint is important in planning the number of
items at each cognitive level for the content areas to be assessed. By using a blueprint,
teachers can avoid writing too many items that require only recall of information. For
existing tests that were not developed using a blueprint, teachers can code items using
Bloom’s taxonomy or the updated taxonomy of the cognitive domain and then decide
whether more higher level items should be added. In developing items at varying
cognitive levels, it is important to remember the learning outcome intended at each of
these levels. Questions at the remembering or knowledge level deal with facts, principles,
and other specific information that is memorized and then recalled to answer the item. At
this level, items assess understanding of concepts and ability to explain them. These
questions are written at a higher level than remembering facts, but they do not assess use
of information in a new context.
At the applying level, students apply concepts and other types of knowledge as a
basis for responding to the item. At this level, test questions measure use of knowledge in
new or unique situations. One method for developing items at this level is to prepare
stems that have information that students did not encounter in their learning about the
content. The stem might present patient data, problems, or interventions different from
the ones discussed in class or in the readings. If examples related to nursing care of
adults, items might test the ability to use those concepts when the patient is an adolescent
or has multiple coexisting conditions. Questions at the analyzing level are the most
difficult to construct. They require analysis of a clinical or other situation to identify
critical elements and relationships among them. Items should provide a new situation for
students to analyze, not one encountered previously for which the student might recall the
analysis. Many of these items require learners to solve a problem and make a decision
about priorities or the best approach to take among the options. Or items might ask
students to identify the most immediate course of action to meet patient needs or manage
the clinical situation.
In assessments like the NCLEX, distinguishing between applying and analyzing
items can be nuanced but crucial for understanding the depth of cognitive skills being
evaluated. Items categorized at the analyzing level require candidates to go beyond
simple application of knowledge and instead focus on deeper critical thinking and
analysis of complex scenarios. Analyzing-level items begin by presenting candidates with
a detailed clinical scenario or problem. Candidates are required to identify and extract
pertinent data from the scenario, including key signs, symptoms, patient history, and
relevant laboratory or diagnostic findings. This step involves recognizing critical
elements that are central to understanding the patient's condition and determining
appropriate nursing interventions. Candidates must then identify critical elements within
the scenario that have significant implications for patient care. These critical elements
may include deteriorating vital signs, sudden changes in patient condition, adverse
reactions to medications, or the presence of complications. Recognizing these critical
elements requires a thorough understanding of pathophysiology, pharmacology, and
nursing assessment skills.
Analyzing-level items challenge candidates to evaluate the interrelationships
among the identified data points and critical elements. This involves synthesizing
information to understand how various factors contribute to the patient's overall clinical
picture and influence nursing decision-making. Candidates must demonstrate their ability
to connect cause-and-effect relationships, assess potential risks and benefits of different
interventions, and anticipate outcomes based on their analysis. Items at the analyzing
level demand a higher level of cognitive processing compared to applying-level items.
Candidates are expected to engage in critical reasoning, problem-solving, and clinical
judgment to formulate a comprehensive approach to patient care. They must consider
multiple factors simultaneously, prioritize nursing actions based on patient needs and
safety concerns, and justify their decisions with sound clinical reasoning.
Successful candidates integrate their knowledge of nursing principles, evidence-
based practice guidelines, ethical standards, and legal considerations into their analysis.
They apply theoretical knowledge to real-world scenarios, demonstrating a holistic
understanding of nursing practice and its application in complex healthcare
environments. In summary, items at the analyzing level on exams like the NCLEX
challenge candidates to move beyond basic application of knowledge to a deeper analysis
of clinical scenarios. By requiring candidates to identify relevant data, critical elements,
and their interrelationships, these items assess candidates' ability to think critically,
reason logically, and make informed decisions in dynamic healthcare settings. Mastering
these skills prepares candidates to provide safe, competent, and patient-centered care as
newly licensed nurses.
In analysis-level items on assessments like the NCLEX, students are challenged to
demonstrate their ability to discern between significant and nonsignificant information
within clinical scenarios. These items require candidates to apply critical thinking skills
and clinical judgment to determine the best approach or priority among several
alternatives provided. Analysis-level items typically present candidates with a detailed
clinical scenario that mimics real-world nursing situations. The scenario may describe a
patient's condition, symptoms, vital signs, and relevant medical history. It may also
include contextual information such as the healthcare setting, time constraints, and the
presence of other healthcare team members. Candidates must first identify relevant
information from the scenario. This includes recognizing key signs and symptoms,
assessing patient data, understanding the patient's medical history, and interpreting
diagnostic results or laboratory findings. They must differentiate between significant
(critical or relevant to patient care) and nonsignificant (less relevant or distractor)
information presented in the scenario.
Next, candidates must apply critical thinking skills to prioritize nursing actions or
interventions based on the identified information. They must consider factors such as the
urgency of patient needs, safety concerns, ethical considerations, and adherence to
clinical protocols or standards of care. The goal is to select the most appropriate course of
action that aligns with evidence-based practice guidelines and promotes optimal patient
outcomes. Analysis-level items typically provide multiple response options or nursing
actions. Candidates are tasked with evaluating each alternative and determining which
action is most likely to achieve the desired outcome or address the patient's immediate
needs effectively. This requires weighing the benefits and risks of each option and
considering potential consequences of the chosen action. Successful candidates
demonstrate their ability to apply clinical judgment to make informed decisions under
pressure. They integrate their knowledge of nursing principles, therapeutic interventions,
and patient assessment findings to select the best approach that reflects safe and
competent nursing practice.
Equally important is the ability to disregard or appropriately handle nonsignificant
information that may distract from the prioritization process. This ensures that candidates
remain focused on key patient care priorities and do not become overwhelmed by
irrelevant details. In conclusion, analysis-level items on exams like the NCLEX challenge
candidates to synthesize clinical information, prioritize nursing actions, and apply critical
thinking skills to complex patient scenarios. By mastering these skills, candidates
demonstrate their readiness to provide safe and effective care as newly licensed nurses in
diverse healthcare settings.
E. Framework of Clinical Practice
One of the processes integrated into the NCLEX test plans is the nursing process.
This is also a framework taught in many nursing programs. If not presented as the nursing
process, most clinical courses address, in some form, assessment, data analysis, problems
or diagnoses, interventions, and evaluation. These areas provide another useful
framework for developing test questions. Items can examine assessment of patients with
varied needs and health problems, analysis of data, identification of problems, selection
of evidence-based interventions and treatments, and evaluation of the outcomes of care.
Current practices suggest that many test items focus on scientific rationale, principles
underlying patient care, and selection of interventions. Fewer items are developed on
collecting and analyzing data, determining patient problems, setting priorities and
realistic goals of care, and evaluating the effectiveness of interventions and outcomes.
Developing test items based on clinical scenarios in the stems of assessments
offers a robust opportunity to assess and evaluate specific learning outcomes in nursing
education. This approach not only enhances the relevance of assessments but also
simulates real-world clinical decision-making and problem-solving skills that are critical
for nursing practice. Clinical scenario-based items require students to apply their
theoretical knowledge and clinical skills to simulated patient care situations. This
application-oriented approach assesses students' ability to integrate information, analyze
data, and make informed decisions in a contextually relevant manner. By embedding
clinical scenarios into test items, educators can evaluate students' proficiency across the
nursing process (assessment, diagnosis, planning, implementation, evaluation). Each
phase of the nursing process can be assessed sequentially or concurrently within the
scenario, ensuring a comprehensive evaluation of students' clinical reasoning abilities.
Clinical scenarios prompt students to engage in critical thinking and clinical
judgment. They must prioritize nursing actions, anticipate potential complications, and
adapt care plans based on changing patient conditions. This encourages higher-order
thinking skills and prepares students to respond effectively to the dynamic challenges of
healthcare settings. Test items based on clinical scenarios allow educators to target
specific learning outcomes defined in the nursing curriculum. Whether assessing
competence in medication administration, therapeutic communication, patient safety
protocols, or ethical decision-making, scenarios provide a focused platform to evaluate
desired competencies. By replicating authentic patient care scenarios, these items mirror
the complexity and diversity of situations encountered in clinical practice. This
simulation-based assessment helps bridge the gap between theory and practice, preparing
students for the realities of nursing care delivery.
Incorporating clinical scenarios into assessments ensures a comprehensive
evaluation strategy that goes beyond rote memorization. It measures students' ability to
translate knowledge into action, demonstrating readiness for professional practice and
certification examinations. Analysis of student responses to scenario-based items
provides valuable feedback on strengths and areas for improvement. Educators can
identify learning gaps, tailor remediation efforts, and guide students toward achieving
proficiency in essential nursing competencies. Scenario-based items align closely with
the format and content of licensure examinations such as the NCLEX. They familiarize
students with the types of questions and decision-making processes they will encounter,
enhancing their readiness for successful examination outcomes. In conclusion,
developing test items based on clinical scenarios in the stems of assessments is a
powerful strategy for examining specific learning outcomes in nursing education. It
promotes active learning, critical thinking, and application of knowledge within the
context of patient care, ultimately preparing students to deliver safe and effective nursing
practice upon graduation.
Indeed, both standalone items and series of items related to specific clinical
scenarios facilitate testing at higher cognitive levels by requiring students to apply their
knowledge and skills to realistic patient care situations. Even in standalone items,
questions can be framed to present a clinical scenario or context that requires students to
apply their theoretical knowledge. For example, a question might ask students to select
the most appropriate nursing intervention based on a given patient scenario. Standalone
items can assess higher-order thinking skills such as critical analysis and clinical
judgment. Students may need to evaluate multiple options, consider implications of each
choice, and justify their decision based on evidence-based practice guidelines. Series of
items provide a comprehensive assessment by presenting a cohesive clinical scenario
followed by interconnected questions. This format challenges students to integrate
knowledge across the nursing process (assessment, diagnosis, planning, implementation,
evaluation) within a realistic context.
Students must sequentially or concurrently address different aspects of patient
care, from initial assessment to ongoing evaluation of interventions. This promotes
deeper engagement and understanding of the complexities involved in clinical decision-
making. Beginning with an assessment question about a patient's symptoms and
progressing to questions about prioritizing nursing diagnoses, selecting appropriate
interventions, and evaluating outcomes. Both formats encourage students to think
critically, solve problems, and make decisions that reflect the complexities of nursing
practice. They assess students' ability to analyze data, prioritize interventions, and adapt
care plans based on changing patient conditions. By presenting scenarios that mirror
clinical practice, these items prepare students for certification exams and professional
roles that require advanced clinical reasoning and evidence-based decision-making.
Incorporating both standalone items and series of items related to clinical
scenarios ensures a comprehensive assessment strategy in nursing education. It reinforces
the integration of theory into practice, enhances students' ability to think critically in
diverse clinical contexts, and prepares them to deliver safe, competent, and patient-
centered care. In conclusion, both standalone items and series of items related to clinical
scenarios effectively facilitate testing at higher cognitive levels in nursing education.
They challenge students to apply their knowledge, skills, and clinical judgment to
realistic patient care situations, thereby preparing them for success in clinical practice and
professional certification examinations.
In educational assessments, particularly in nursing education, items can be
developed in two main formats: standalone items or as a series of items related to one
clinical scenario. Both formats serve distinct purposes and offer unique benefits for
evaluating students' knowledge, clinical reasoning, and application of nursing concepts.
Standalone items are independent questions that each assess a specific aspect of
knowledge or skill. They can cover a broad range of topics and cognitive levels, from
basic recall of facts to higher-order thinking and clinical decision-making. These items
can be used to evaluate isolated concepts, skills, or principles without being constrained
by a broader clinical context. They allow instructors to assess a diverse range of learning
objectives efficiently. A standalone item could ask students to identify the correct nursing
intervention for a specific physiological condition, define a key concept related to patient
safety, or interpret a laboratory value in a hypothetical scenario.
Effective for assessing discrete knowledge and skills. They help identify gaps in
understanding and reinforce key concepts. Enhance critical thinking, problem-solving,
and clinical judgment. They promote integration of theory into practice and prepare
students for complex decision-making in healthcare settings. In summary, the choice
between standalone items and a series of items related to one clinical scenario depends on
the educational goals, desired depth of assessment, and the specific learning outcomes
being evaluated. Both formats play important roles in nursing education, contributing to
comprehensive assessment strategies that prepare students for successful clinical practice
and professional licensure.
F. Preparation of Students for the NCLEX Examinations
A number of studies have been done over the years to identify predictors of
success on the NCLEX-RN. Some factors related to performance on the NCLEX-RN are
Scholastic Aptitude Test (SAT), American College Testing (ACT), and other
preadmission test scores (Grossbach & Kuncel, 2011; Robert, 2018; Wambuguh,
Eckfield, & Van Hofwegen, 2016); scores on NCLEX readiness tests (Brodersen &
Mills, 2014; Brussow & Dunham, 2018; Penprase & Harris, 2013; Schooley & Kuhn,
2013; Sosa & Sethares, 2015); standardized assessment scores for specific content areas,
for example, fundamentals, pharmacology, and medical–surgical nursing (Chen &
Bennett, 2016; Emory, 2013, 2019; McCarthy, Harris, & Tracz, 2014; Twidwell &
Records, 2017; Yeom, 2013); grades in nursing courses and graduation grade point
average (Grossbach & Kuncel, 2011; Kaddoura, Flint, Van Dyke, Yang, & Chiang, 2017;
Romeo, 2013); being a transfer student (Simon, McGinniss, & Krauss, 2013); grades in
science courses (Elder, Jacobs, & Fast, 2015; Wambuguh et al., 2016); and student
characteristics, such as students who speak English as a second or an additional language
(Kaddoura et al., 2017), and emotional intelligence (Rode & Brown, 2019). Academic
achievement, in terms of nursing course grades and overall grade point average, has been
found across studies as predictive of student performance on the NCLEX-RN. In a meta-
analysis of 31 independent samples with 7,159 participants, admissions test scores (SAT
and ACT) and grades earned in nursing programs, especially grades in the second year,
were the best predictors of performance on the NCLEX.
A second area of the literature on the NCLEX-RN focuses on methods of
preparing students to pass the examination. Many schools use standardized examinations
designed to predict student performance on the NCLEX-RN and determine students’
readiness for taking the examination. By analyzing the results of standardized tests for
NCLEX readiness, faculty members and students can work together to design individual
plans for remediation so that students will be more likely to experience first-time success
on the licensure examination. Some of these approaches include curriculum review to
identify areas needing improvement, using readiness tests combined with remedial
learning activities to better prepare students for the NCLEX, student self-assessment of
content areas needing improvement, instruction for content mastery, test-taking tips,
managing test anxiety, cooperative study groups, courses that guide formal NCLEX-RN
preparation, and careful planning for the day of testing. Comprehensive mentoring and
coaching programs provide the support students and graduates need as they prepare for
taking the NCLEX.
Absolutely, preparing students for licensure examinations such as the NCLEX
involves more than just exposure to item formats; it also includes providing ample
practice with test-taking strategies and simulated exams. NCLEX features multiple-
choice questions that assess students' knowledge and application of nursing content
across various client needs categories (e.g., Safe and Effective Care Environment, Health
Promotion and Maintenance, Psychosocial Integrity, Physiological Integrity). These
include prioritization, delegation, and SATA (Select All That Apply) questions, which
require candidates to demonstrate critical thinking, clinical judgment, and decision-
making skills. Exposing students to a wide range of NCLEX-style items helps them
become comfortable with the structure and expectations of the exam, improving their
ability to navigate and respond effectively.
NCLEX-style test items, particularly those based on clinical scenarios, require
students to apply their nursing knowledge and skills to simulated patient care situations.
This application-oriented approach mirrors the practical challenges nurses face in real-
world settings, preparing students to make informed decisions under pressure during the
licensure exam. NCLEX-style questions are designed to assess students' critical thinking
abilities, clinical reasoning, and clinical judgment. ractice with these questions
encourages students to analyze data, prioritize nursing actions, and anticipate outcomes
based on the presented scenarios, crucial skills for success on the licensure exam.
Offering students practice tests simulates the exam environment and provides an
opportunity to assess their readiness. Practice tests help identify areas of strength and
weakness, allowing educators to tailor remediation efforts and provide targeted support
before the actual exam. Regular exposure to NCLEX-style questions and practice tests
helps alleviate test anxiety by familiarizing students with the exam format and
expectations. Confidence grows as students become more comfortable with navigating
different question types and managing time effectively during the exam.
Analyzing performance on practice tests provides valuable feedback to students
and educators alike. It allows students to identify areas requiring additional study and
practice, guiding focused review and reinforcement of key nursing concepts and skills.
Incorporating NCLEX-style practice into the nursing curriculum ensures alignment with
educational goals and prepares students comprehensively for licensure. It reinforces the
integration of theory and practice, promoting the application of nursing knowledge in
clinical scenarios similar to those encountered on the licensure exam. In conclusion,
providing students with experience in NCLEX-style test items and practice tests is
essential for preparing them for success on their licensing examination. This
comprehensive approach not only enhances students' proficiency in nursing knowledge
and skills but also builds confidence in their ability to excel under the rigors of the
NCLEX.
One of the principles emphasized was the need to prepare items at different
cognitive levels as indicated by the outcomes of the course. Items at the remembering or
knowledge level assess how well students memorized facts and specific information; they
do not, however, provide an indication of whether students can use that information in
practice or can engage in higher level thinking. To assess those higher level outcomes,
items must be written at the applying or analyzing levels or evaluated by methods other
than tests. It is worthwhile for faculty members to develop a test blueprint that specifies
the number of items to be developed at each cognitive level for content areas in the
course. By using a blueprint, teachers can avoid writing too many lower level items on an
examination. As students progress through a nursing program, they develop knowledge
and skills to assess patients, analyze data, identify patient needs and problems, set
priorities for care, select appropriate and evidence-based interventions, and evaluate the
outcomes of care. Testing within the framework of clinical practice or the nursing process
provides an opportunity to assess those learning outcomes. Items may be written about
data to collect in the particular clinical scenario, possible problems, approaches to use,
priorities of care, decisions to be made, varying judgments possible in a scenario, and
other questions that examine students’ thinking and clinical judgment as related to the
situation described in the stem of the item.
The format of testing that includes items based on clinical scenarios not only
assesses students' thinking and clinical judgment but also provides valuable experience
that closely aligns with the types of questions encountered on licensure and certification
examinations in nursing. Test items based on clinical scenarios replicate the format and
complexity of questions found on licensure and certification examinations, such as the
NCLEX-RN or specialty certification exams. By exposing students to these types of
questions during their education, educators help familiarize them with the structure,
wording, and expectations of professional licensure exams.
Clinical scenario-based items require students to apply their theoretical
knowledge and clinical skills to solve problems and make decisions in simulated patient
care situations. This application-oriented approach mirrors the practical challenges nurses
face in real-world settings, thereby enhancing students' readiness for the practical
demands of licensure and certification exams. These items challenge students to engage
in critical thinking, clinical reasoning, and evidence-based decision-making. They must
analyze data, prioritize interventions, and anticipate outcomes based on the presented
scenarios. Such cognitive processes are essential for success on licensure and certification
exams, which often require candidates to demonstrate proficiency in clinical judgment
across diverse patient care scenarios.
By practicing with scenario-based items, students become accustomed to
managing time effectively and selecting the best answers under pressure. This familiarity
helps reduce test anxiety and builds confidence in their ability to navigate the exam
format, including multiple-choice questions, prioritization tasks, and case studies.
Analyzing students' performance on scenario-based items provides valuable feedback to
educators about areas where students excel and areas needing improvement. Educators
can tailor remediation strategies to address specific weaknesses and further prepare
students for the rigor and expectations of licensure and certification exams.
Scenario-based items assess students' proficiency in applying the nursing process
(assessment, diagnosis, planning, implementation, evaluation) to clinical situations.
Mastery of these processes is crucial for passing licensure exams, as they reflect the
systematic approach required for safe and effective nursing practice. In conclusion,
incorporating scenario-based items into nursing education not only enhances students'
clinical reasoning and judgment but also better prepares them for the challenges of
licensure and certification examinations. This format ensures that students are well-
equipped to demonstrate their readiness to practice as competent and compassionate
nurses in diverse healthcare settings.
