Presented by: Ainslie Nibert, Associate Dean and Associate Professor, at Texas Women's University College of Nursing This webinar will help your create critically-thinking test items for this semester’s exams. Item types covered will include: Single-answer Multiple Choice; Select-all-that-Apply (Multiple Response); Fill-in-the-Blank; Hot Spot; Chart Type (Exhibit Item); Drag-and-Drop (Prioritized or Ordered Response); and items enhanced with Audio files and/or Graphic images. You’ll also obtain a quick refresher on how to use student response data from these new questions to guide future editing, so that you can receive a bonus benefit from your item writing efforts. By including the alternative item types in your teacher-made exams, you can be assured that your students will gain valuable experience (and less anxiety) with answering these types of items presented in all of the different formats that they will see on their licensure exams.

1. EAC 2018 | Fort Lauderdale | June 27-29
Thank you for joining.
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Creating Test Items Using NCLEX®
Alternative Item Types
Ainslie T. Nibert, PhD, RN, FAAN

2. CREATING TEST ITEMS USING
NCLEX® ALTERNATIVE ITEM
TYPES
Ainslie T. Nibert, PhD, RN,
FAAN
Assoc. Dean/Assoc.
Professor
College of Nursing
Texas Woman’s University
Houston, TX

3. OBJECTIVES
Create/Edit test items that assess at the
application/analysis level.
Write test items using the alternative formats on the
NCLEX-RN®.
Identify the item types-in-progress that the NCSBN is
preparing for use on the Next Generation NCLEX-RN®.

5. Five Guidelines to Developing Effective
Critical Thinking Exams
 Assemble the “basics.”
 Write critical thinking test items.
 Pay attention to housekeeping duties.
 Develop a test blueprint.
 Scientifically analyze all exams.

6.  Critical Thinking Test Items
 Item Analysis Software & Blueprinting
 Test Item Banking & Exam Delivery
Tools for creating effective tests:

7. Critical Thinking Test Items
 Contain Rationale
 Written at the Application Level or Above
 Require Multilogical Thinking to Answer
 Ask for High Level of Discrimination
Source: Morrison, Nibert, & Flick (2006)

8. CRITICALLY-THINKING
QUESTIONS
Which intervention is most important?
Which intervention, plan, assessment data
is/are most critical to developing a plan of
care?
Which intervention should be done first?
What action should the nurse take first?
Which intervention, plan, nursing action has
the highest priority?
What response is best?

9. 9

10. FAIR/COMMON UNIVERSAL
LANGUAGE
The client is running late for an appointment.
The client understands Buddhist practices are peaceful.
The client is on five different medications.
The client ate a submarine sandwich.
The alcoholic client with delirium tremens is agitated.
After the client sneezed, the nurse said “bless you.”
The nurse is giving a report on the client.
The nursing unit is working shorthanded.

11. LATEST NCLEX® TEST ITEM
FORMAT CONSIDERATIONS
Units of Measure
•International Systems of Units (SI)
•Metric
•Imperial Measurement
Generic vs. Trade Names for Medications
•Generic names only in most cases
•References to general classifications of
medications

12. NCLEX® ALTERNATIVE TEST
ITEMS
Multiple-response items (“Select all that apply”)
Graphic Options (graphics imbedded as answer options)
Fill-in-the-blank
Ordered Response items (Ranking or “Drag and Drop”)
Hot spot
Chart/exhibit format
Audio or Video (imbedded clips)
Any item formats, including standard multiple-choice
items, may include multimedia, charts, tables or graphic
images.

13. MULTIPLE RESPONSE: SELECT
ALL THAT APPLY

14. IMBEDDED GRAPHICS - STEM

15. FILL IN THE BLANK

16. ORDERED RESPONSE: DRAG
AND DROP
What are the steps that the nurse should take to obtain a urine
specimen for culture and sensitivity from an indwelling urinary
catheter?
A. Attach the catheter tubing to the bed linens.
B. Securely fasten the clamp on the drainage bag.
C. Transfer the specimen to a sterile container.
D. Attach the drainage bag to the bed frame.

17. HOT SPOT

18. IMBEDDED VIDEO CLIP

19. CHART-TYPE
Medical diagnosis: Acute Respiratory
Failure
Vital Signs: B/P = 120/72 mm Hg, heart
rate of 120/min, temperature 100.8 °F,
respiratory rate 34/min, and oxygen
saturation 78% on room air and 93% on
40% venti-mask.
Physical Exam: Breath sounds diminished
on the right side in the upper zone. SOB
on exertion. PERLA. Mild clubbing evident.
Oriented only to person.
Labs: White blood cell count was
11,000/mm3 with 29% neutrophils, 8%
lymphocytes, 16% monocytes and 33%
bands; Hematocrit 35%. Three sputum
samples were negative for acid-fast bacilli
(AFB). Arterial blood gas (ABG) analysis on
room air: pH 7.47, PaCO2 28 mm Hg,
PaO2 51 mm Hg.
A 58-year-old male
with 40-pack year
smoking history is
admitted to the ER.
Review the client’s
medical record. Which
laboratory finding
prompts the nurse to
take an immediate
action?
A.Hematocrit 35%
B. 29% Neutrophils
C.Respiratory rate
34/min

23. Use Examsoft item analysis data to track
students’ performance on all item types

25. RESOURCES FOR DEVELOPING CRITICAL
THINKING TEST ITEMS AND ALTERNATE
FORMAT ITEMS:
NATIONAL COUNCIL WEBSITE
www.nscbn.org
 NCLEX Test Plans
 2016 RN
 Candidate FAQ
 Alternate item formats
FAQ
 Exam Development FAQ
Source: https://www.ncsbn.org/9010.htm

26. WHAT IS THE NEXT-GEN
NCLEX®?

27. CLINICAL JUDGMENT MODEL
Dickison, P., Luo, X., Kim, D., Woo, A., Muntean, W., & Bergstrom, B. (2016). Assessing higher-order
cognitive constructs by using an information-processing framework. Journal of Applied Testing
Technology, 17(1), 1-19. Retrieved from
www.jattjournal.com/index.php/atp/article/view/89187/67797.

28. ITEM TYPES: THE NEXT-GEN
NCLEX®?
Item Types that measure Clinical Judgment
Enhanced Multiple Response (MS+)
Extended Drag and Drop (DD+)
Cloze items (CL)
Enhanced Hot Spots (HS+)
Dynamic Exhibits (DE)
Constructed Response (CR)
Source: NCSBN (2018) NGN FAQs for Educators. Chicago:
NCSBN. https://www.ncsbn.org/11447.htm

29. ITEM TYPE: EXTENDED MULTIPLE RESPONSE (EMR)
Case Study: 58-year-old male with 40-pack year smoking history admitted to the ER
Medical diagnosis: Acute Respiratory Failure
Vital Signs: B/P = 120/72 mm Hg, heart rate of 120/min, temperature 100.8 °F,
respiratory rate 34/min, and oxygen saturation 78% on room air and 93% on 40%
venti-mask.
Physical Exam: Breath sounds diminished on the right side in the upper zone. SOB on
exertion. PERLA. Mild clubbing evident. Oriented only to person.
Labs: White blood cell count was 11,000/mm3 with 29% neutrophils, 8%
lymphocytes, 16% monocytes and 33% bands; Hematocrit 35%. Three sputum
samples were negative for acid-fast bacilli (AFB). Arterial blood gas (ABG) analysis on
room air: pH 7.47, PaCO2 28 mm Hg, PaO2 51 mm Hg.

30. ITEM TYPE: CLOZE
Characteristics of item
Definition: of, relating to, or being a test of reading comprehension that involves
having the person being tested supply words which have been systematically deleted
from a text. [Origin] by shortening & alteration from closure [as in Gestalt theory.] –
Merriam Webster Dictionary (2018) https://www.merriam-
webster.com/dictionary/cloze
Most commonly used to assess language usage, particularly with those learning a
second language.
Typical format: Words may be deleted from the text in question either systematically
(ie every third word) or selectively, depending on the test creator’s objective in asking
the question.
Characteristics of item: patient’s medical history presented similarly to the chart-type
item. Typical of questioning faculty use with students in clinical experiences when
obtaining students’ rationale for taking some type of nursing action (ie why is the
nursing taking a particular action)
Incorporates drop-down boxes that include statements that will complete the
sentence.

31. ITEM TYPE: CLOZE
Case Study: 57-year-old male with 40-pack year smoking history.
Ready for discharge from hospital.
Medical diagnosis: Chronic Obstructive Pulmonary Disease
Vital Signs: B/P = 120/70 mm Hg, heart rate of 82/min, temperature
97.8 °F, respiratory rate 34/min, and oxygen saturation 96% on room
air.
Physical Exam: Bilateral breath sounds. No SOB on exertion. PERLA.
Mild clubbing evident. Oriented to person, place time.
Labs: Hemoglobin 13.9 g/dL; platelets 399,000 mcL; White blood cell
count 10,200/mm3

32. ITEM TYPE: CLOZE
Question: The nurse is organizing the patient teaching plan for the patient to follow after
discharge. The patient is currently receiving these prescriptions:
Prednisone 40mg PO daily x 10 days
Ipratroprium bromide /albuterol per nebulizer q 4 hours
Albuterol 2.5mg q 2 hr prn dypsnea
Azithromycin 250mg PO daily x 4 days
Nicotine patch 21mg change daily
Enoxaparin 30mg SQ x 5 days
Which 2 medications require further clarification by the health care provider before initiating
teaching?
The nurse should not teach the patient about_____because
_________________________________.
The nurse should not teach the patient about_____because
_________________________________.

33. ITEM TYPE: EXTENDED DRAG & DROP
Characteristics of item
Typical format: A combination of drag & drop with matching.
Characteristics of item: test taker is asked to prioritize a set of items,
similar to the current alternative drag & drop item type, and in addition,
match the items to another list of criteria.
Incorporates drag & drop movement with the computer mouse.
Example
Management of patient care topic: 3 patients need to be moved to the floor
from the ICU. Prioritize (based on acuity) which patient comes up for
admission to the medical/surgical floor first/second/third. Now choose
assigned beds for each patient based on risks identified initially.

34. ITEM TYPE: HOT SPOT
Characteristics of item
Typical format: Expands the use of hot spot (choice of an item on the
computer screen by placing the mouse in a specific area of the screen)
beyond use of a graphic item (drawing or photo.)
Characteristics of item: test taker is asked to highlight text on the
screen (such as a textbook) for a specific purpose
Example
Safety: Highlight a section of text that indicates the potential hazard
for a patient (who is receiving IV therapy; who is scheduled for a
diagnostic test, etc) that led to your decision to (withhold the IV
therapy; reschedule the test.)

35. ITEM TYPE: DYNAMIC EXHIBITS
Characteristics of item
Typical format: Test taker reviews an unfolding case study. Patient
assessment findings, nursing actions, and response to treatment
elapsed over time (over several hours or several days.)
Nursing actions may or may not reflect standard of care; or may be
incomplete or flawed (ie negative patient response occurs to actions.)
Characteristics of item: Test taker is asked several constructed
response questions following the unfolding case study.

37. When instilling a client’s eye drops,
which technique(s) should the nurse
include?
1. Apply gentle pressure over the inner
canthus.
2. Apply firm pressure over the outer
canthus.
3. Hold the dropper six inches above the
eye.
4. Dab the cornea with a sterile cotton
swab to absorb excess moisture.
5. Ask the client to look up while placing
the drop.
6. Carefully drop the medication on the
cornea.
A. 1, 2, 3, and 6.
B. 4, and 5
C. 3 and 6 only.
D. 1 and 5 only.
E. All of the above.
When instilling a client’s eye drops, which
technique(s) should the nurse include?
(Select all that apply.)
A. Apply gentle pressure over the inner
canthus.
B. Apply firm pressure over the outer canthus.
C. Hold the dropper six inches above the eye.
D. Dab the cornea with a sterile cotton swab
to absorb excess moisture.
E. Ask the client to look up while placing the
drop.
F. Carefully drop the medication on the
cornea.

38. Item Writing Tools for
Success …
Knowledge
Test Blueprint
Testing Software

39. REFERENCES
Morrison, S., Nibert, A., & Flick, J. (2006). Critical thinking
and test item writing (2nd ed.). Houston, TX: Health
Education Systems, Inc.
National Council of State Boards of Nursing. (2016) 2016
NCLEX-RN test plan. Chicago, IL: National Council of
State Boards of Nursing.
https://www.ncsbn.org/RN_Test_Plan_2016_Final.pdf
National Council of State Boards of Nursing (2018) Next
Generation NCLEX Project. Chicago, IL: National Council
of State Boards of Nursing.
https://www.ncsbn.org/next-generation-nclex.htm
Nibert, A. (2010) Benchmarking for student progression
throughout a nursing program: Implications for

40. QUESTIONS?
Ainslie T. Nibert, PhD, RN, FAAN
anibert@twu.edu
Thanks for your time & attention!