What You Need To Know About Changes To The NCLEX Exam

Every new nurse passes the NCLEX to earn a state license. The exam decides whether a graduate has the knowledge and judgment to practice. The National Council of State Boards of Nursing (NCSBN) reviews the test about every three years and updates it to keep pace with healthcare.

That review process produced the biggest overhaul in years: the Next Generation NCLEX (NGN), which launched April 1, 2023, and is now the only version candidates take. This page covers what changed and how to prepare for it.

What the NGN changed

The NGN exists to measure clinical judgment, not just recall. The NCSBN found that new nurses routinely care for critically ill patients and make complex decisions, a pattern confirmed by its 2017 RN Nursing Knowledge Survey. The old format tested whether you knew the content. The NGN tests whether you can use it to make the right call at the bedside.

The NCSBN built the exam from research questions embedded in the 2017-2018 NCLEX administrations. Candidates answered an optional research section that did not count toward their score, which gave the council data on how the new item types performed. Test-takers averaged about a minute per question.

The exam does not quiz clinical knowledge directly. You need that knowledge to reach the correct answer, but the questions are built around judgment and decision-making.

The clinical judgment model

The NGN measures the NCSBN Clinical Judgment Measurement Model. It mirrors how a nurse actually thinks at the bedside: assess the client's needs, form a hypothesis, refine it, act, and evaluate the outcome. If the outcome falls short, you re-evaluate and adjust. The questions weigh environmental factors, like the setting, the medical record, and the complexity of the task, against individual factors, like your skill level, experience, and knowledge.

Each item walks you through the steps of clinical reasoning:

1. Recognize cues. The question gives you information, and you decide what is relevant and what is not.
2. Analyze cues. You prioritize the information against the clinical presentation.
3. Form hypotheses. You determine what else you need to establish a hypothesis.
4. Generate and prioritize solutions. You rank hypotheses by urgency and generate actions that lead to a good outcome.
5. Take action and evaluate. You choose the appropriate action, judge the outcome, and consider what might have worked better.

A 2016 NCSBN pilot study drove these changes. It found that clinical knowledge is essential but not sufficient on its own, and that clinical judgment, which the council defines as "the observable outcome of decision-making and critical thinking," develops progressively from a combination of factors rather than any single one. Weak clinical judgment also feeds preventable harm, which is why the exam now targets it directly.

New item types

To test judgment, the NGN adds question formats beyond the standard multiple-choice items. The exam stays computer adaptive and keeps some traditional questions, but case studies now drive much of it, with information on one side of a split screen and the question on the other. The new formats include:

Extended multiple response. A "select all that apply" with more options and partial credit. When a patient is deteriorating, you rarely pick just one action, and this format reflects that.

Extended drag-and-drop. You move options into answer spaces, but not every option is used, so you need a deeper grasp of the material to sort the relevant from the irrelevant.

Cloze (drop-down). You pick answers from one or more drop-down lists embedded in a table, chart, or sentence. A single case study can ask for up to six responses.

Matrix (grid). Given a scenario and data, you check the appropriate boxes in a grid, for example sorting clinical actions into essential, nonessential, and harmful.

Enhanced hot spot (highlight). You read part of a client chart and click the specific words or phrases that answer the question.

The exam still carries a research section that does not count toward your score. It collects data to refine scoring and timing and changes each quarter. There is nothing to prepare for it and no penalty for the items.

Scoring

The old NCLEX scored each item as all-correct or all-incorrect. The NGN uses partial credit on the new item types, so you can earn points on a question even if you miss part of it. Scoring is separate from the passing standard, which is the line between candidates who pass and those who do not. A panel of nursing subject-matter experts sets that standard.

Why the NCLEX changed

The NCLEX is how every state confirms that a graduate can practice safely. Because nurses own complex decisions and healthcare moves fast, the exam has to measure judgment, not just knowledge. Discussions about updating it started in 2009, after research showed the existing clinical decision-making models needed work. Over the next six years, the NCSBN ran two studies that confirmed how highly newly licensed RNs, supervisors, facilities, and educators rate clinical judgment. That evidence, plus the cost of preventable errors, pushed the council toward the NGN.

How the NGN affects nursing curriculum

Programs adjusted to prepare students for the NGN, but the NCSBN does not expect schools to overhaul their curriculum. The job is to teach clinical judgment effectively, which programs need to do for practice anyway. Schools meet accreditation standards with some flexibility in how they teach the concepts. The Clinical Judgment Measurement Model does not replace the nursing process; it is an evidence-based framework for testing graduates and a tool educators can use to build and assess judgment in the classroom.

How to prepare

Build clinical reasoning skills. The judgment the NGN tests rests on critical thinking and decision-making, so practice applying knowledge to scenarios, not just memorizing facts. Work through case studies and the new item types until the format feels routine. The model aims to produce nurses ready for more complex patients as the population ages and chronic disease rises, which is exactly the kind of thinking the exam now rewards.