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Frequently Asked Questions About ______________NCLEX Alternate Item Formats_____________

1. When did NCSBN first introduce alternate item formats? NCSBN first presented information on alternate items to boards of nursing at the NCSBN Annual Meeting in 1999, and a demonstration of some of the potential item formats was conducted. The reports of the NCSBN Examination Committee at the 2000 and 2001 NCSBN Annual Meetings provided updates on a pilot study using alternate item formats. All NCSBN presentations about the NCLEX examination, including the NCLEX Invitational, have included updates on alternate items since 2000. In November of 2000, deans and directors of nursing education programs were sent a letter from NCSBN that mentioned these new item types. This letter was sent to more than 3,500 nursing education programs. In 2001, NCSBN members (boards of nursing) selected a new test vendor for the NCLEX examinations; implementation of alternate item formats was a significant part of the approved contractual scope of work. A letter and fact sheet addressing alternate items was distributed to boards of nursing in December 2002. 2. Why did NCSBN add new formats to items (questions) in the NCLEX? NCSBN's quality improvement program helps us continuously identify better, more effective ways to assess entry-level nursing competence. Technology has evolved since NCSBN introduced computerized testing in 1994, and we are now able to use technology to present questions in alternative formats. 3. What is an alternate item format? An alternate item format (previously known as an innovative item format) is an examination item, or question, that uses a format other than standard, four-option, multiple-choice items to assess candidate ability. Figures 1 through 7 (on pages 614) represent types of alternate items that are administered to candidates. Alternate item formats may include: Multiple-response items (Figure 1) that require a candidate to select one or more than one response; Fill-in-the-blank items (Figure 2a and 2b) that require a candidate to type in number(s) in a calculation item; Hot spot items (Figure 3) that ask a candidate to identify one or more area (s) on a picture or graphic; Chart/exhibit format (Figure 4a and 4b) where candidates will be presented with a problem and will need to read the information in the chart/exhibit to answer the problem;

Copyright © 2010 National Council of State Boards of Nursing, Inc. (NCSBN) All rights reserved. The NCSBN logo, NCLEX®, NCLEX-RN® and NCLEX-PN® are registered trademarks of NCSBN

Ordered Response items (Figure 5) that require a candidate to rank order or move options to provide the correct answer; Audio item format (Figure 6) where the candidate is presented an audio clip and uses headphones to listen and select the option that applies; and Graphic Options (Figure 7) that presents the candidate with graphics instead of text for the answer options and they will be required to select the appropriate graphic answer.

Any item formats, including standard multiple-choice items, may include multimedia, charts, tables or graphic images. 4. Have alternate items replaced the current NCLEX items? The alternate items have been added to the current NCLEX-RN® and NCLEX-PN® item pools; they did not replace the items that are in the current NCLEX examinations. 5. Are there a certain percentage of alternate items on the NCLEX examinations? There is no established percentage of items with alternate formats that will be administered to candidates. The NCLEX examination is computer adaptive and items are based on the candidate's ability. There are alternate item types in all areas of the test plan, across all difficulty levels. 6. How will alternate items improve the measurement of entry-level nursing ability? Alternate items will allow candidates to demonstrate their entry-level nursing competence in ways that are different from the standard multiple-choice items. In addition, some nursing content areas can be assessed more readily and authentically with alternate items. For example, the item in Figure 2 requires the candidate to perform a calculation without the benefit of selecting the answer from among four answer options. The ability to calculate is more readily assessed with this type of item than with a standard multiple-choice item. Similarly, the item in Figure 3 more accurately and directly assesses the skills needed for practice as compared to a multiple-choice item. 7. How are alternate items developed? The same rigorous process that is used to develop standard multiple-choice NCLEX items is being used to develop the alternate items. Item writers from NCSBN member boards who meet NCSBN criteria are selected to attend item writing sessions and write items based on item pool needs. As with standard multiple-choice items, each item must be validated in at least two approved nursing textbooks or references.

8. Are alternate items pretested? Yes. As with the standard items, alternate items are pretested before becoming part of the operational (scored) part of the examinations in order to gather statistical information about the items. As with multiple-choice items, alternate items have to meet NCSBN's stringent statistical criteria. 9. How is item scoring criteria developed and validated?


As with the current process, nursing content experts from across the country review all the items. These content experts evaluate the items to determine the correct and acceptable answers based on their clinical expertise. In addition, these experts assess each item for currency, accuracy, scope of practice and entry-level practice. 10.When do alternate items that are being pretested become operational (scored) items? Alternate items have been available for use as operational items since October 1, 2003. It is impossible for candidates to determine whether an item is a pretest item or an operational item because items with alternate formats will be in pretest and operational item pools simultaneously. For that reason, NCSBN continues to recommend that candidates treat all examination items in the same manner and select the best answer for each item. 11.Does the implementation of alternate items affect candidate pass rates? These item formats do not affect candidate pass rates. These items have a calibrated difficulty level as do standard multiple-choice items, and, as such, are counted like standard items when computing a candidate's final ability estimate. 12.How is examinee performance scored on alternate items? As with standard multiple-choice items, alternate items are scored either right or wrong. 13.How much time will be needed to answer alternate items? Based on cognitive processing ability of the candidate, some of the items will take less time and some will take more time than standard multiple-choice items. Currently, it is estimated that candidates typically require between 60 and 70 seconds per multiple-choice item. Information about length of time it takes to respond to an item is collected and used by the NCSBN NCLEX Examination Committee and NCSBN staff to make decisions about each item. 14.Is it true that if a candidate misses any medication calculation questions they will automatically fail the NCLEX® examination? It is NOT true that if a candidate misses a calculation item they will automatically fail the NCLEX examination. As noted previously, all items "count" the same. 15.How are fill-in-the-blank items scored? How are typographical errors handled? All answers will be scored as right or wrong. The candidate will be presented with a question and asked to calculate and type in the answer. Should rounding be necessary, it is to be performed at the end of the calculation. A tutorial is provided as part of the examination. All possible response options that can be considered as correct will be counted as a correct answer. 16.In the "fill-in-the blank" type of questions, does the candidate have to enter a preceding "0" before the decimal point? The examination allows the candidate to enter in the "0". However, if candidates do not enter the preceding zero, the answer submitted will default to include a preceding "0". 17.Do calculator items have a decimal place?


Yes, unless the item requests that the candidate records their answer using a whole number. If asked to record to one (or two) decimal places, the candidate must enter the decimal point for the answer to be correct.

18.When should a candidate round a calculation item? As noted in Figure 2, calculation items should be rounded at the end of the calculation. 19.Are there Hot Spot questions that are currently active? Hot Spot items are available to candidates in the examination. 20.Do multiple response items have less than 3 correct responses? Multiple response items are described as having five or six options with a minimum of two correct (key) options. Items contain the statement "Select all that apply". 21.Are multiple response items up to existing NCLEX standards? All potential NCLEX examination items undergo the same rigorous quality control checks, including content, statistical and psychometric analyses. 22.What type of "prompt" appears in the stem about answering a chart exhibit alternate format? Can the candidate proceed without opening a tab? In other words, although a warning appears, can candidates answer a question and move to the next question even if they did not open all of the exhibit tabs? The prompt that appears regarding answering a chart exhibit item is: "Click on the exhibit button below for additional client information." A candidate can respond to an exhibit item without opening the individual exhibits, however it is not recommended since the exhibits provide additional information. 23.Does the addition of alternate items affect the timeline for delivering examination results to candidates and to boards of nursing? Use of alternate item types does not affect the operational processes for delivering results to boards of nursing and candidates. 24.Did the candidate fee increase with the addition of alternate items? The candidate fee was not increased with the use of alternate item formats. 25.What other high stakes testing programs use alternate item formats? Licensure examinations for architects, physicians and accountants all use methodologies other than multiple-choice questions to make determinations of candidate competence. Additionally, examinations in information technology certification and education use simulations and other formats to make high stakes decisions about candidates. In each of these cases, the assessment method has been found to be psychometrically sound. 26.How does NCSBN assist the nursing community to prepare for these types of items? NCSBN has a commitment to keep the nursing community informed and will continue to supply updated information about alternate item research on its Web site,


27.For some recent graduates, the NCLEX will be the first time they experience alternate item formats. How can nursing programs help familiarize students with these kinds of items prior to the examination? There is a tutorial available on the Pearson VUE Web site for candidates to access and view alternate item formats. Additionally, the NCLEX-RN and NCLEX-PN Detailed Test Plans contain information on items that use alternate formats. 28.Is there any other information that would be helpful for candidates to know about computer adaptive testing (CAT) and these alternate item formats? Yes, a thorough understanding of how CAT works would be helpful. For information about CAT or to download a copy of the current NCLEX® Examination Candidate Bulletin, visit For More Information Updated information on the NCLEX examination is posted on the NCSBN Web site ( and is presented in the current NCLEX® Examination Candidate Bulletin. If you have questions about the NCLEX examination item formats, contact NCSBN Examinations Department (toll-free) at: 866.293.9600 or by e-mail:[email protected]



Figure 1. Multiple-Response Item


Figure 2a. Fill-in-the-blank


Figure 2b. Fill-in-the-blank


Figure 3. Hot Spot


Figure 4a. Chart/Exhibit


Figure 4b. Chart/Exhibit


Figure 5. Ordered Response


Figure 6. Audio


Figure 7. Graphic



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