Anatomy of an NCLEX Question

Studying for your NCLEX means taking hundreds of practice tests. That’s okay! It’s a great way to prepare to sit for your exam for several reasons:

1. You become familiar—and comfortable—with the formats of the test items.
2. You can find any areas of nursing content that you especially need to focus on.
3. You become proficient at sitting for a few hours as you practice for NCLEX.
4. You learn to look for clues that tell you what the question is really

Once you understand the structure of NCLEX questions, and how to “dissect” them, you have an automatic edge on Test Day. Just taking a few seconds to consider each question can provide a lot of information and increase the odds of getting it right.

If you haven’t already done it, download the National Council of State Boards of Nursing (NCSBN) Test Plan for NCLEX-RN or NCLEX-PN. It covers everything you need to know about how to prepare for the examination. Nurse Plus uses it to design the practice tests.

Practice tests: “Ideal” questions for the “real” NCLEX

The first thing to remember about the NCLEX is that it’s an “Ivory Tower” examination. The questions are written for ideal situations, where a nurse has plenty of time and works in the perfect setting. For example, you may read a question about sitting with a dying patient for hours. Ask most nurses and they will tell you they would love to be able to provide that kind of one-to-one support, but it’s not likely to happen during a typical shift.

Study with perfection in mind. When Nurse Plus receives comments like, “I never saw a nurse actually do this,” or “This is an unrealistic situation,” we remind our subscribers to stick to the principles and concepts of nursing practice. Even when super busy, nurses are always striving for the ideal.

Second, stick to the exact scenario in the question. It’s easy to think of your own experiences, or something that you’ve read or seen. If you’ve already been working in a healthcare setting, you might have a different perspective of the scenario. For NCLEX, you can’t make any assumptions. All the information you’re going to get is there, so don’t start imagining “What if…”

Start with the stem of the question

Let’s take a typical multiple-choice question from NCLEX and look at its parts. Multiple-choice questions, with four possible choices, will make up 80-90% of your NCLEX. While some will be simple recall questions, such as asking about a normal laboratory value or vital sign parameters, most will require some level of application, analysis, or evaluation.

• Read the stem of the question carefully.

  Don’t skip a single word. The stem sets up a situation or tells you what the focus of the question is about. Look for key words or hints:

  • The word EXCEPT indicates a “negative event query.” It indicates you must choose the WRONG answer. Be careful, because your first impulse may be to go for one of the three correct responses instead of the incorrect one.

    Example: Scopolamine and atropine are two examples of anticholinergic medications. All of the following are frequent side effects EXCEPT:

  • The words most, first, immediate, essential, best, primary, initial, or next indicate that you must establish a priority.

    Example: The nurse works at a community hospital with a “float” policy that requires staff to work on other units, depending on census and/or acuity. When the nurse floats to an unfamiliar unit, what is the BEST action for the nurse?

  • Statements that include, “further teaching (education or instruction) is necessary” tell you that the answer will contain incorrect information.

    Example: The nurse in the ophthalmology clinic is instructing a client on the use of timolol maleate (Timoptic). Which of the following statements by the client indicates a need for further education?

  • Statements that include “understands the teaching (education or instruction)” tell you that the answer will contain correct information

    Example: The nurse is providing discharge instructions to a client who was admitted with a diagnosis of acute pancreatitis. The nurse will know that the client understands how to prevent another episode when the client makes which of the following statements?

  • Some questions will provide details about a specific event or situation that indicate what the correct answer will be about.

    Example: The nurse is caring for a 17-year-old athlete who sustained a basilar skull fracture during a football game. The nurse knows to assess for Battle’s sign in 24-48 hours post-injury. Where will the nurse observe this sign?

Three ways to select the correct response

1. 1

   After reading and analyzing the stem of the question, phrase it in your own words.

   This can help you remember what you’ve studied or a nursing concept.

   • Example: The parent of a child with a short leg fiberglass cast phones the clinic because their child complains of a constant itching inside the cast. Which intervention is appropriate for the nurse to suggest?
   • You might think, “I know it’s important to prevent any damage to the skin inside the cast. That means nothing should be put down the cast. What else can be done to decrease the itching and maintain skin integrity?” After that, you may have an idea before proceeding to the four options.

2. 2

   You can also think of the correct answer before looking at the choices.

   This is a good technique for recalling facts, such as drug names, client teaching, or signs and symptoms.

   • Example: Parents bring their 2-month-old to the clinic for a routine check-up. The baby is being bottle-fed and tolerating the formula well. The nurse instructs the parents not to prop the bottle during feedings. Besides the risk of choking, it also puts the infant at risk for:
   • Remember the anatomy: The Eustachian Tube is short and straight in infants. If formula pools at the back of the baby’s throat, it can enter the middle ear, allowing bacteria to also enter, and cause an ear infection.

3. 3

   If you’re not sure, read each of the possible options.

   Multiple-choice questions have three incorrect choices, called “distractors,” and one correct choice, called the “key.” NCLEX test items are written so that if you have no knowledge of the topic, you can’t randomly pick out the key; all the options seem reasonable.

   If you’re not sure, look at each option. There is usually a distractor that is completely wrong and easy to eliminate. Then there’s a distractor that relates to the stem, but doesn’t answer the question. You can remove that one, two. Now you have two possibilities. Even if they seem similar, one is the BEST answer.

   • Example: A client with Stage IV pancreatic cancer is being discharged from the hospital to her home. She tells the nurse that she doesn’t want hospice care, because her family will take care of her. What is the nurse’s best response?
     1. This is a huge mistake. I hope you will reconsider.” (This is obviously incorrect. The nurse should never judge a client or make a condescending remark.)
     2. “I think your doctor already ordered hospice for you.” (Incorrect. Clients (or their proxy) decide whether they wish to have hospice care. The nurse is also avoiding a discussion with the client about her decision.)
     3. “Your care is going to be too much for your family.” (Incorrect. Again, a remark that is disrespectful and judgmental.)
     4. “I’m wondering how much you know about hospice.”(Correct. This response by the nurse is both supportive and uses assessment, the first step in the nursing process. It allows an opportunity for the nurse to share information that may can help the client make an informed decision.)

Quick tips to eliminate distractors

As you take practice tests, and when you sit for your NCLEX, there are a few ways to tell when a distractor is incorrect. Eliminating these can increase your chance of getting the question right.

• Eliminate distractors that are similar.

  When two choices are alike or comparable, they are probably not correct. Go to the other two and consider if one of them is the key.

  • Example: When teaching a client to change their colostomy appliance, what should be used to clean the skin around the stoma?
  • Two of the distractors are Alcohol wipes and Baby wipes. Both of them contain ingredients that could irritate the skin. Also, either one could be unavailable to a client, due to cost or lack of supply. Take these away, and you’re more likely to select Plain tap water, which is the best choice.

• Client safety comes first.

  Never choose an option that makes you leave a client or put them in any danger. This includes delegating a task to another team member whose scope of practice doesn’t allow them to perform the task. When solving a problem or analyzing a situation, the client is always the priority.

  • Example: In the event of a fire in a client’s home, your first action is to _______.
  • Of course, no matter where it takes place, you will follow the R.A.C.E. procedure and Remove the client from the fire.

• Don’t delay treatment or actions.

  There will be stems that describe a potentially serious situation, such as hypertension or an allergic reaction. You’ll be asked to choose the most appropriate intervention. Among the four options you may find, “Tell the client to call tomorrow,” or “Check the blood pressure again in four hours.” Usually deferring action, assessment, or treatment is the wrong choice.

  • Example: As a preceptor, the RN helps a graduate nurse learn to organize and prioritize tasks. Which action by the graduate nurse requires intervention by the preceptor?
  • Here’s the key response to this question: The graduate nurse waits to document until the end of the shift. You know that this type of delay isn’t appropriate, so it’s easy to select the correct answer.

• Don’t shirk your responsibility.

  Whether it’s passing the buck to another nurse, blaming a physician, or refusing to admit you made a mistake, don’t choose these options. As a licensed nurse, there is usually something you can do or an ethical standard to uphold. The NCLEX wants to make sure you understand how to function as an entry-level nurse.

  • Example: The nurse enters Mr. Olson’s room to administer morning medication and finds him on the floor next to his bed. When the nurse completes the incident report, which one of the following statements should be included?
  • Here are two distractors that can immediately be eliminated: “The client has been confused at times, so this was expected.” and “The UAP didn’t put the side rails back up and is responsible.” Both statements blame someone, instead of providing objective details about the event that should be included in the incident report.

• Restraints are the very last option.

  When the stem of the question hints at the possibility of using restraints, consider all other interventions first. Sometimes the stem will list all the measures already taken, so you will know that restraints are now indicated. If not, read the choices to select the best action to provide proper care.

  • Example: A preceptor is instructing a new nurse on the reasons for applying wrist and/or ankle restraints to a client. The preceptor realizes the need for further education when the new nurse states:
  • This question is also an example of a negative event query; it means you will choose the WRONG statement by the new nurse: “A restraint keeps the client in bed all night.” Study the types of restraints and know the least restrictive indications for applying them.

Nurse Plus wants to help you pass your NCLEX!

Nurse Plus is committed to helping you study for your NCLEX. Nurse Plus Premium offers practice tests in each of the Client Needs categories and subcategories. Sort by what you want to focus on, or take one of our marathon practice tests. We love to hear from you, too. That’s one of the ways we add to the question database—we listen to what’s important to you and what you need to feel confident and prepared.

Here are more articles to help you prepare for Test Day…and your exciting nursing career!

• NCLEX-RN and NCLEX-PN: What to Know Before You Study
• NCLEX Study Guide
• Types of NCLEX Questions and How They Are Written
• 27 Tips for New Nurses From Experienced Nurses

About the Author

Winona Suzanne Ball

Nursing Adviser, RN | MHS, Governors State University, IL
Full member of the American Nurses Association. Learn more