Preparing for the NCLEX
Open Resources for Nursing (Open RN)
The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is the exam that nursing graduates must pass successfully to obtain their nursing license and become a registered nurse. The purpose of the NCLEX is to evaluate if a nursing graduate (i.e., candidate) is competent to provide safe, competent, entry-level nursing care. The NCLEX-RN is developed by the National Council of State Board of Nursing (NCSBN), an independent, nonprofit organization composed of the 50 state boards of nursing and other regulatory agencies.[1]
The NCLEX-RN is a pass/fail examination administered on a computer using computer adaptive testing (CAT). CAT means that every time a candidate answers a test item, the computer reestimates their ability based on all their previous answers and the difficulty of those items. The computer then selects the next item based on an estimated 50% chance of the candidate answering it correctly. In this manner, the next item is not too easy nor too difficult, and a candidate’s true ability level is determined. Each item is perceived by the candidate as challenging because it is targeted to their ability. With each item answered, the computer’s estimate of the candidate’s ability becomes more precise.
The computer stops providing items when it is 95% certain that the candidate’s ability is clearly above or clearly below the passing standard, the candidate has received the maximum number of questions, or the candidate has run out of time without demonstrating a competence level to pass. Testing accommodations may be provided for eligible candidates with the authorization of the candidate’s State Board of Nursing (SBON).[2],[3]
See an image of a simulated graduate taking the NCLEX in Figure 11.1.[4]
Read more about the NCLEX at https://www.ncsbn.org/nclex.htm.
Watch a video about how the NCLEX uses computer assistive technology (CAT) at https://www.ncsbn.org/356.htm.
Registering to Take the NCLEX
Before you can register to take the NCLEX, you will need an Authorization to Test (ATT). To receive an ATT, complete the following steps[5]:
- Apply for a nurse license from your State Board of Nursing (SBON) or other nursing regulatory body
- Register with Pearson VUE and pay the exam fee
- Wait to receive your ATT from Pearson Vue
- Schedule your exam with Pearson VUE
Be sure to start this process well in advance of your target date for taking the NCLEX.
Read specific instructions regarding registering and taking the NCLEX-RN by downloading the most current NCLEX-Candidate Bulletin from the NCSBN. The content includes the following:
- Registering for the exam
- Scheduling the exam
- Understanding test site rules and regulations
- Preparing for the day of the exam
Download the most current NCLEX-Candidate Bulletin from https://www.ncsbn.org/nclex.htm.
Next Generation NCLEX
A new edition of NCLEX was released in 2023 with “Next Generation” questions.
The Next Generation NCLEX (Next Gen) uses evolving case studies and new types of test questions based on a new NCSBN Clinical Judgment Measurement Model (NCJMM) that assesses how well the candidate can think critically and use clinical judgment when providing nursing care. The NCJMM assess the candidate’s ability to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take actions, and evaluate outcomes.[6]
Five new Next Generation test item types are called extended multiple response, extended drag and drop, cloze (drop-down), extended hot spot (highlighting), and matrix-grid:
- Extended Multiple Response: Extended Multiple Response items allow candidates to select one or more answer options at a time. This item type is similar to the current NCLEX multiple response item but has more options and uses partial credit scoring.[7]
- Extended Drag and Drop: Extended Drag and Drop items allow candidates to move or place response options into answer spaces. This item type is like the current NCLEX ordered response items but not all of the response options may be required to answer the item. In some items, there may be more response options than answer spaces.[8]
- Cloze (Drop – Down): Cloze (Drop – Down) items allow candidates to select one option from a drop-down list. There can be more than one drop-down list in a cloze item. These drop-down lists can be used as words or phrases within a sentence or within tables and charts.[9]
- Enhanced Hot Spot (Highlighting): Enhanced Hot Spot items allow candidates to select their answer by highlighting predefined words or phrases. Candidates can select and deselect the highlighted parts by clicking on the words or phrases. These types of items allow an individual to read a portion of a client medical record (e.g., a nursing note, medical history, lab values, medication record, etc.), and then select the words or phrases that answer the item.[10]
- Matrix/Grid: Matrix/Grid items allow the candidate to select one or more answer options for each row and/or column. This item type can be useful in measuring multiple aspects of the clinical scenario with a single item. In the example below, each of the eight rows will need to have one of the three answer choices selected.[11]
View a NCSBN video on Next Generation test items.
Participate in an NCLEX tutorial at https://www.ncsbn.org/nclex-tutorial.htm.
Preparing for the Examination
Since the first day of nursing school, you have been working towards successfully passing the NCLEX-RN. After you graduate, it is important to implement strategies for success for taking the NCLEX, such as reviewing the NCLEX-RN Test Plan, setting up a dedicated review schedule based on your test date, and reviewing material you learned throughout nursing school.[12]
NCLEX Test Plan
The NCLEX-RN Test Plan provides a concise summary of the content and scope of the exam and serves as an excellent guide for preparation. NCLEX-RN test plans are updated every three years based on surveys of newly licensed registered nurses to ensure the NCLEX questions reflect fair, comprehensive, current, and entry-level nursing competency.[13]
The NCLEX Test Plan categorizes test questions based on categories and subcategories referred to as “Client Needs”[14]:
- Safe and Effective Care Environment
- Management of Care
- Safety and Infection Control
- Health Promotion and Maintenance
- Psychosocial Integrity
- Physiological Integrity
- Basic Care and Comfort
- Pharmacological and Parenteral Therapies
- Reduction of Risk Potential
- Physiological Adaptation
In addition, the following concepts are applied throughout the client needs categories[15]:
- Nursing Process
- Caring
- Communication and Documentation
- Teaching and Learning
- Culture and Spirituality
Download the current NCLEX-RN Test Plan from https://www.ncsbn.org/testplans.htm.
Review Schedule
Many students find it helpful to create and follow a study calendar with topics to review based on the NCLEX Test Plan.
Reviewing Material
Some graduates prefer to attend an NCLEX review course to prepare for the examination whereas others prefer to review their notes from nursing school on their own. Be sure to review the NCLEX Candidate Rules before the day of the examination.[16],[17]
Day of the Examination
On the day of the examination, it is normal to experience some anxiety. However, it is important to use techniques to manage anxiety, so it does not impact your ability to think through and answer the test questions. Use positive self-talk and remind yourself that you have been preparing for this examination since the first day of nursing school. Read additional tips for the day of the NCLEX and tips for testing in the following boxes.
| Tips for the Day of the NCLEX[18] |
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| Tips for Testing[19] |
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After the Examination
If your State Board of Nursing (SBON) or nursing regulatory body (NRB) participates in the “Quick Results Service,” you can receive your “unofficial” results two business days after the exam if you pay for this service. Official results are sent to you approximately six weeks after the exam.[20]
If you didn’t pass the exam, you’ll receive an NCLEX Candidate Performance Report (CPR). The CPR is an individualized document that shows how a candidate performed in each of the test plan content areas. Graduates who fail the exam can use the CPR as a guide to prepare them to retake the exam.[21]
If you need to retake the exam, you will need to wait a minimum of 45 days before you can retake the NCLEX per NCSBN policy. This length of time is determined by your SBON (or NRB) and will be reflected in your new ATT’s validity dates. Read the steps for retaking the NCLEX in the following box.
| Steps for Retaking the NCLEX |
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- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN Examinations. (2021). 2021 NCLEX examination candidate bulletin. https://www.ncsbn.org/candidatebulletin.htm ↵
- “Woman_with_computer.jpg” by Cumminsr at English Wikipedia is licensed under CC BY-SA 3.0 ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN Examinations. (2021). 2021 NCLEX examination candidate bulletin. https://www.ncsbn.org/candidatebulletin.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
- NCSBN. https://www.ncsbn.org/nclex.htm ↵
You have worked hard to obtain a nursing license and it will be your livelihood. See Figure 5.7[1] for an illustration of a nursing license. Protecting your nursing license is vital.
Actions to Protect Your License
There are several actions that nurses can take to protect their nursing license, avoid liability, and promote patient safety. See Table 5.5 for a summary of recommendations.
Table 5.5 Risk Management Recommendations to Protect Your Nursing License
| Legal Issues | Recommendations to Protect Your License |
|---|---|
| Practicing outside one’s scope of practice |
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| Failure to assess & monitor |
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| Documentation |
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| Medication errors |
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| Substance abuse and drug diversion |
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| Acts that may result in potential or actual client harm |
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| Safe-guarding client possessions & valuables |
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| Adherence to mandatory reporting responsibilities |
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Culture of Safety
It can be frightening to think about entering the nursing profession after becoming aware of potential legal actions and risks to your nursing license, especially when realizing even an unintentional error could result in disciplinary or legal action. When seeking employment, it is helpful for nurses to ask questions during the interview process regarding organizational commitment to a culture of safety to reduce errors and enhance patient safety.
Many health care agencies have adopted a culture of safety that embraces error reporting by employees with the goal of identifying root causes of problems so they may be addressed to improve patient safety. One component of a culture of safety is "Just Culture." Just Culture is culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless behaviors. [8]
The American Nurses Association (ANA) officially endorses the Just Culture model. In 2019 the ANA published a position statement on Just Culture. They stated that while our traditional health care culture held individuals accountable for all errors and accidents that happened to patients under their care, the Just Culture model recognizes that individual practitioners should not be held accountable for system failings over which they have no control. The Just Culture model also recognizes that many errors represent predictable interactions between human operators and the systems in which they work. However, the Just Culture model does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated).[9]
The Just Culture model categorizes human behavior into three categories of errors: simple human error, at-risk behavior, or reckless behavior. Consequences of errors are based on these categories.[10] When seeking employment, it is helpful for nurses to determine how an agency implements a culture of safety because of its potential impact on one’s professional liability and licensure.
Read more about the Just Culture model in the "Basic Concepts" section of the "Leadership and Management" chapter.
In addition to being aware of the legal and regulatory frameworks in which one practices nursing, it is also important for nurses to understand the legal concepts of informed consent and advance directives.
Informed Consent
Informed consent is the fundamental right of a client to accept or reject health care. Nurses have a legal responsibility to provide verbal and/or written information and obtain verbal or written consent for performing nursing care such as bathing, medication administration, and urinary or intravenous catheter insertion. While physicians have the responsibility to provide information and obtain informed consent related to medical procedures, nurses are typically required to verify the presence of a valid, signed informed consent before the procedure is performed. Additionally, if nurses do not believe the patient has adequate understanding of a procedure, its risks, benefits, or alternatives to treatment, they should request the provider return to clarify unclear information with the client. Nurses must remain within their scope of practice related to informed consent beyond nursing acts.
Two legal concepts related to informed consent are competence and capacity. Competence is a legal term defined as the ability of an individual to participate in legal proceedings. A judge decides if an individual is “competent” or “incompetent.” In contrast, capacity is “a functional determination that an individual is or is not capable of making a medical decision within a given situation.”[11] It is outside the scope of practice for nurses to formally assess capacity, but nurses may initiate the evaluation of client capacity and contribute assessment information. States typically require two health care providers to identify an individual as “incapacitated” and unable to make their own health care decisions. Capacity may be a temporary or permanent state.
The following box outlines situations where the nurse may question a client's decision-making capacity.
| Triggers for Questioning Capacity and Decision-Making[12] |
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If an individual has an advance directive in place, their designated power of attorney for health care may step in and make medical decisions when the client is deemed incapacitated. In the absence of advance directives, the legal system may take over and appoint a guardian to make medical decisions for an individual. The guardian is often a family member or friend but may be completely unrelated to the incapacitated individual. Nurses are instrumental in encouraging a client to complete an advance directive while they have capacity to do so.
Advance Directives
The Patient Self-Determination Act (PSDA) is a federal law passed by Congress in 1990 following highly publicized cases involving the withdrawal of life-supporting care for incompetent individuals. (Read more about the Karen Quinlan, Nancy Cruzan, and Terri Shaivo cases in the boxes at the end of this section.) The PSDA requires health care institutions, such as hospitals and long-term care facilities, to offer adults written information that advises them "to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives.”[13] Advanced directives are defined as written instructions, such as a living will or durable power of attorney for health care, recognized under state law, relating to the provision of health care when the individual is incapacitated. The PSDA allows clients to record their preferences about do-not-resuscitate (DNR) orders and withdrawing life-sustaining treatment. In the absence of a client’s advance directives, the court may assert an “unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual.”[14] For this reason, nurses must educate and support the communities they serve regarding the creation of advanced directives.
Advanced directives vary by state. For example, some states allow lay witness signatures whereas some require a notary signature. Some states place restrictions on family members, doctors, or nurses serving as witnesses. It is important for individuals creating advance directives to follow instructions for state-specific documents to ensure they are legally binding and honored.
Advance directives do not require an attorney to complete. In many organizations, social workers or chaplains assist individuals to complete advance directives following referral from physicians or nurses. Clients should review and update their documents every 10-15 years, as well as with changes in relationship status or if new medical conditions are diagnosed.
Although advanced directive documents vary by state, they generally fall into two categories, referred to as a living will or durable power of attorney for healthcare.
Living Will
A living will is a type of advance directive in which an individual identifies what treatments they would like to receive or refuse if they become incapacitated and unable to make decisions. In most states, a living will only goes into effect if an individual meets specific medical criteria.[15] The living will often includes instructions regarding life-sustaining measures, such as cardiopulmonary resuscitation (CPR), mechanical ventilation, and tube feeding.
Durable Power of Attorney for Healthcare
It is impossible for an individual to document their preferences in a living will for every conceivable medical scenario that may occur. For this reason, it is essential for individuals to complete a durable power of attorney for healthcare. A durable power of attorney for healthcare (DPOAHC) is a person chosen to speak on one’s behalf if one becomes incapacitated. Typically, a primary health care power of attorney (POA) is identified with an alternative individual designated if the primary POA is unable or unwilling to do so. The health care POA is expected to make health care decisions for an individual they believe the person would make for themselves, based on wishes expressed in a living will or during previous conversations.[16]
It is essential for nurses to encourage clients to complete advance directives and have conversations with their designated POA about health care preferences, especially related to possible traumatic or end-of-life events that could require medical treatment decisions. Nurses can also dispel common misconceptions, such as these documents give the health care POA power to manage an individual’s finances. (A financial POA performs different functions than a health care POA and should be discussed with an attorney.)
After the advance directives are completed and included in the client’s medical record, the nurse has the responsibility to ensure they are appropriately incorporated into their care if they should become incapacitated.
View state-specific advance directives at the American Association of Retired Persons website.
Karen Ann Quinlan is an important figure in the United States’ history of defining life and death, a client’s privacy, and the state’s interest in preserving life and preventing murder. In April 1975, Karen Quinlan was 21 years old and became unresponsive after ingesting a combination of valium and alcohol while celebrating a friend’s birthday. She experienced respiratory failure, and although resuscitation efforts were successful, she suffered irreversible brain damage. She remained in a persistent vegetative state and became ventilator dependent. Her parents requested her physicians discontinue the ventilator because they believed it constituted extraordinary means to prolong her life. Her physicians denied their request out of concern of possible homicide charges based on New Jersey’s law. The Quinlans filed the first “right to die” lawsuit in September of 1975 but were denied by the New Jersey Superior Court in November. In March of 1976, the New Jersey Supreme Court determined the parent’s right to determine Karen’s medical treatment exceeded that of the state. Karen was discontinued from the ventilator six weeks later. When taken off the ventilator, Karen shocked many by continuing to breathe on her own. She lived in a coma for nine more years and succumbed to pneumonia on June 11, 1985.
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- Sample Case: Nancy Beth Cruzan[18]
Nancy Cruzan is another important figure in the history of US “right to die” legal cases. At the age of 25, Nancy Cruzan was in a car accident on January 11, 1983. She never regained consciousness. After three years in a rehabilitation hospital, her parents began an eight-year battle in the courts to remove Nancy’s feeding tube. Nancy’s case was the first “right to die" case heard by the United States Supreme Court. Beyond allowing for the discontinuation of Nancy’s feeding tube, the U.S. Supreme Court ruled that all adults have the right to the following:1) Choose or refuse any medical or surgical intervention, including artificial nutrition and hydration.
2) Make advance directives and name a surrogate to make decisions on their behalf.
3) Surrogates can decide on treatment options even when all concerned are aware that such measures will hasten death, as long as causing death is not their intent.Nancy died nine days after removal of her feeding tube in December 1990. As a result of the Cruzan decision, the Patient Self-Determination Act (PSDA) was passed and took effect December 1, 1991. The act requires facilities to inform clients about their right to refuse treatment and to ask if they would like to prepare an advance directive.
- Sample Case: Nancy Beth Cruzan[18]
Sample Case: Terri Schaivo[19]
The Terri Schaivo case is a key case in history of advance directives in the United States because of its focus on the importance of having written advance directives to prevent family animosity, pain, and suffering. In 1990 Terri Schaivo was 26 years old. In her Florida home, she experienced a cardiac arrest thought to be a function of a low potassium level resulting from an eating disorder. She experienced severe anoxic brain injury and entered a persistent vegetative state. A PEG tube was inserted to provide medications, nutrition, and hydration. After three years, her husband refused further life-sustaining measures on her behalf, based on a statement Terri had once made, stating, “I don't want to be kept alive on a machine.” He expressed interest in obtaining a DNR order, withholding antibiotics for a urinary tract infection, and ultimately requested removal of the PEG tube. However, Terri’s parents never accepted the diagnosis of persistent vegetative state and vigorously opposed their son-in-law's decision and requests. Seven years of litigation generated 30 legal opinions, all supporting Michael Schiavo's right to make a decision on his wife's behalf. Terri died on March 31, 2005, following removal of her feeding tube.
