Better Questions, Better Nurses: A Guide to NCLEX® Item Writing

Let me tell you about the very first NCLEX-style question I ever wrote. I was fresh off years of clinical practice, full of enthusiasm, convinced I had crafted a brilliant question that would challenge even the sharpest students. But when I tested it with colleagues, one chose option A, another picked B, someone argued for C–and one brave soul finally asked, “Is this even testing anything?” That moment was humbling. But it also taught me something important. Writing a strong NCLEX-style item isn’t just about what you know. It’s about shaping how future nurses think and ensuring they’re ready to make safe and effective decisions in real clinical situations.

Why NCLEX Item Writing Matters

At its core, the NCLEX isn’t just a licensure exam–it’s a public safety measure. The exam ensures that every nurse entering the workforce can practice safely, competently, and independently from day one. In today’s complex healthcare environment, with higher acuity patients, faster-paced settings, and interprofessional teams, we need to measure more than recall. We need to measure how future nurses recognize, prioritize, and act under pressure.

This is where good item writing comes in. Done well, it can deepen learning, sharpen critical thinking, and reinforce the skills students will need most in their first year of practice. Done poorly, it can confuse learners, create frustration, and fail to capture the complexity of nursing judgment.

What Makes a Great NCLEX Item?

So, what separates a weak test question from a great one? Strong NCLEX-style items share a few essentials. They are aligned with measurable objectives, ensuring each question has a clear purpose. They are authentic, reflecting real nursing practice rather than trivia. They require higher-order thinking, pushing learners to analyze, prioritize, or evaluate beyond memorization. And they are fair, written clearly, free from bias, with plausible distractors that test reasoning instead of tricking students. Most importantly, they connect to the steps of the Clinical Judgment Measurement Model (CJMM) (NCSBN, 2025), helping students practice the same decision-making process they’ll need at the bedside. Together, these qualities turn a question into a tool for building true practice readiness.

Anatomy of a Strong NCLEX-Style Question

Every well-written NCLEX item has three essential parts that work together to challenge reasoning and mirror real-world decision-making.

• The Scenario
  This is the clinical backdrop. It should include the essential information, like a client’s age, diagnosis, or changes in condition, enough to set the stage without overwhelming the learner.
• The Stem
  This is the actual question being asked. A strong stem is concise, direct, and action focused. Avoid vague or negative phrasing, and instead frame stems that drive judgment, such as: “Which action should the nurse take first?” or “Which client requires immediate intervention?”
• The Options
  Answer choices include a best answer supported by evidence, along with plausible distractors that reflect common errors in reasoning. Good distractors challenge learners to think critically without being misleading. Keep options parallel in length, grammar, and format to avoid giving unintentional clues.

NCLEX Item Types

Today’s NCLEX isn’t limited to standard multiple-choice questions. A variety of item types are designed to test clinical judgment in different ways. As educators, using these formats in class or practice exams helps reduce test anxiety and reinforces higher-order thinking.

Here’s a quick overview of NCLEX item types:

• Multiple Response: Includes Select All That Apply (SATA), Select N, Grouping, and Matrix formats. Tests a student’s ability to evaluate each option independently.
• Drop-Down Items: Fill-in-the-blank style with menus; can be Cloze or table-based. Great for precision in applying knowledge.
• Drag-and-Drop: Requires ordering or matching interventions. Mirrors prioritization and sequencing in real practice.
• Highlight: Select relevant portions of a passage or table. Build skill in recognizing cues.
• Bowtie: Unique format linking risks, actions, and outcomes in one item. Assesses multiple CJMM steps at once.
• Trend: Requires interpreting data over time, like vital signs or lab values, to capture evolving clinical decisions.

One of the biggest shifts in the NCLEX has been the introduction of case studies, which better reflect the complexity of nursing practice. Instead of a single, isolated question, case studies unfold over time, requiring the learner to walk through multiple layers of the CJMM (NLN, n.d.). A case might begin with recognizing abnormal vital signs, progress to analyzing possible causes, then move on to prioritizing which risks are most urgent and finally ask the learner to evaluate whether an intervention was effective. This type of layered assessment challenges students to think dynamically, just as they must in clinical practice, where conditions can change from minute to minute.

Each type provides a different lens on judgment, and together they create a more complete picture of readiness for practice.

Peer Review: The Final Step

No matter how experienced you are, NCLEX item writing should never be a solo act. Peer review strengthens quality by catching unclear language, outdated clinical content, or unintentional bias. Reviewers can also verify alignment with learning objectives and ensure distractors are plausible. Think of peer review as your quality control system. It not only improves fairness but also protects students, and by extension, patients.

Final Thoughts

Writing NCLEX-style items is a skill that blends clinical knowledge with educational strategy. It requires intentionality, structure, and a focus on how nurses think in practice. By grounding items in measurable objectives, aligning them with the CJMM, and ensuring fairness and accuracy, educators can create questions that do far more than prepare students for an exam; they prepare them for safe, effective practice. At the end of the day, a strong item is more than just a question. It’s a bridge between classroom learning and bedside care, between theory and judgment, and ultimately, between preparation and practice.

Learn more about best practices for creating NCLEX item types and case studies from Kaplan Nursing experts in our recent webinar.

References

• National Council of State Boards of Nursing, Inc. (2025). Clinical judgment measurement model. https://www.nclex.com/clinical-judgment-measurement-model.page
• NCSBN. (2025). Prepare for success. https://www.nclex.com/prepare.page
• National League for Nursing. (n.d.). Unfolding cases. Retrieved fromhttp://www.nln.org/professional-development-programs/teaching-resources/ace-d/unfolding-cases