NGN NCLEX 2026: Item Types, CJMM & How to Pass It
Next Generation NCLEX (NGN) launched April 1, 2023 for NCLEX-RN and PN. NGN items are built on the Clinical Judgment Measurement Model — a six-function framework for clinical reasoning. Item types include unfolding case studies, bow-tie, trend, highlight, matrix, and cloze, some with partial credit. All current candidates take NGN.
Editorial
Last reviewed · May 30, 2026
Meta title: NGN NCLEX 2026: Item Types, CJMM s How to Pass Them
Meta description: Next Generation NCLEX launched April 2023. Learn the 6 CJMM layers, all NGN item types (bow-tie, case study, trend), and how to prepare for each.
*TL;DR: Next Generation NCLEX (NGN) launched on April 1, 2023, for both NCLEX-RN and NCLEX-PN. NGN items are built on the Clinical Judgment Measurement Model (CJMM), a six-layer framework that assesses clinical reasoning. Item types include unfolding case studies, bow-tie items, trend items, highlight items, matrix/grid items, and cloze items. Some NGN questions allow partial-credit scoring. All current NCLEX candidates take the NGN version. *
Are you currently preparing for the NCLEX and keep seeing the term NGN NCLEX everywhere without a clear explanation of what actually changed? You are not alone.
In 2025, the first-time NCLEX-RN pass rate for U.S. test-takers dropped to 86.7%, the lowest it has been since 2022. That dip happened two full years into the NGN format. The candidates who struggled were not short on knowledge. Most had studied. What tripped them up was approaching a reasoning-based exam with a memorization-based strategy.
The NGN NCLEX, officially the Next Generation NCLEX, launched on April 1, 2023 for both the NCLEX-RN and NCLEX-PN. It did not replace the content of the exam. It changed how that content is tested. Instead of four options and one right answer, the NGN asks you to think through a patient scenario the way a real nurse would, layer by layer.
If you want to go deeper on practice, Testavia built its NGN prep course specifically around the clinical reasoning framework behind every item type.
That shift changes everything about how you prepare. Pair this with our guides on NCLEX practice questions, NCLEX pharmacology, and how to answer NCLEX questions. This guide breaks down exactly what the NGN is, how the item types work, how scoring actually functions, and what focused preparation looks like.
What Is Next Generation NCLEX (NGN)?
The NGN NCLEX is NCSBN's redesign of the world's premier nursing licensure exam. The core exam structure did not change. It is still a computerized adaptive test (CAT) and still covers the same four client needs categories. What changed is the way a portion of questions are asked, and that difference matters enormously for how you prepare.
Before April 2023, the NCLEX was heavily built around single-answer multiple-choice questions. A smart candidate could develop pattern recognition strategies that helped them pass without demonstrating true clinical reasoning. NCSBN's research identified this gap and built the next generation NCLEX specifically to close it. The exam now tests whether you can think through a patient scenario the way a practicing nurse would, not just whether you can identify the right answer from four options.
Every candidate who sat the NCLEX on or after April 1, 2023 took the NGN version. That applies to both NCLEX-RN and NCLEX-PN candidates. There is no opt-out and no legacy version still in use.
What Did NOT Change
The computerized adaptive testing (CAT) format
The four client needs categories
The passing standard framework
Traditional multiple-choice and select-all-that-apply (SATA) items still appear on the exam
What DID Change
A proportion of items are now NGN-specific item types
The scoring model for certain items uses partial credit rather than all-or-nothing
Questions are designed to assess clinical reasoning across a defined cognitive framework
Total item count now ranges from 85 to 150 including 15 pretest questions
The Clinical Judgment Measurement Model (CJMM): The Framework Behind NGN
Every NGN NCLEX item is built on a specific cognitive framework called the NCSBN Clinical Judgment Measurement Model, widely referenced as the CJMM. Understanding this framework is the single most important thing you can do before you start drilling practice questions. Without it, the item types feel arbitrary. With it, every question has a predictable cognitive demand.
The full NCJMM has five structural layers, from the broadest context of clinical practice down to the most specific measurable cognitive functions. What matters most for the exam is Layer 3, which contains the six cognitive functions that NGN items directly test.
The Six CJMM Cognitive Functions
1. Recognize Cues Identify which pieces of clinical information in a scenario are relevant and which are background noise. This is the starting point of every clinical decision.
2. Analyze Cues Determine what the relevant cues mean. A blood pressure reading of 88/52 is a cue. Understanding what it signals about the patient's condition is analysis.
3. Prioritize Hypotheses Rank the possible explanations for the patient's presentation by urgency and probability. Which condition is most likely? Which one is most dangerous if missed?
4. Generate Solutions Identify nursing interventions that would address the prioritized problem. This layer moves from diagnosis to action planning.
5. Take Action Select the most appropriate intervention to implement from the options available. This is not just knowing what to do but choosing the right thing at the right time.
6. Evaluate Outcomes Assess whether the actions taken improved the patient's condition. Is the patient responding as expected? Does the plan need to change?
How CJMM Layers Map to NGN Item Types
CJMM Layer | NGN Item Type | What the Question Asks |
|---|---|---|
Recognize Cues | Highlight item | Identify relevant findings in a clinical note |
Analyze Cues | Trend item | Interpret what serial data means about the patient |
Prioritize Hypotheses | Bow-tie (left branch) and Matrix | Rank or select the most likely conditions |
Generate Solutions | Bow-tie (right branch) and Matrix | Select appropriate nursing interventions |
Take Action | Matrix and Drop-down | Choose which actions to take |
Evaluate Outcomes | Trend item and Unfolding case study items 5 and 6 | Determine if the patient is improving or deteriorating |
The NGN Item Types: What Each One Looks Like
The NGN item types introduced in April 2023 are the most visible change to the exam. There are six core formats. NCSBN expanded the item type library in Fall 2025 with the addition of Drag-and-Drop Cloze, Drop-Down Cloze, and Drop-Down Rationale items. Check the current full list on the NCSBN NGN page. Here is what each original item type looks like and what it demands.
NGN Item Type Reference Table
Item Type | Visual Format | CJMM Layer | Scoring |
|---|---|---|---|
Unfolding case study | 6 items around one evolving patient scenario | All 6 CJMM layers across the set | Each item scored independently |
Bow-tie item | Three-column visual: causes, action, parameters | Prioritize Hypotheses and Generate Solutions and Take Action | Partial credit possible |
Trend item | Serial data over time, select interpretation | Analyze Cues and Evaluate Outcomes | Typically all-or-nothing per selection |
Highlight item | Clinical note passage, click relevant findings | Recognize Cues | Partial credit possible |
Matrix/grid item | Rows and columns, check all that apply per row | Multiple CJMM layers depending on design | Partial credit possible |
Cloze/drop-down | Sentence with blank filled from drop-down list | Variable by scenario | Typically all-or-nothing |
Unfolding Case Study
This is the most complex NGN question type on the exam. Six items follow a single patient from one clinical moment to the next, covering admission through outcome or discharge. Each item within the set tests a different CJMM layer in sequence, starting with Recognize Cues and finishing with Evaluate Outcomes. Items within the case study may use any other NGN format. You cannot skip ahead and you cannot carry assumptions from one item to the next without the new information the scenario provides. Each exam includes three unfolding case studies.
Bow-Tie Item
The bow-tie is visually distinctive and one of the most misunderstood formats. Think of it as three columns.
Left column: Select the most likely cause(s) or conditions driving the patient's presentation
Center column: Identify the priority nursing action to take
Right column: Select what parameters to monitor after that action
A structural example: a patient presents with confusion and a blood pressure of 80/50. Left column asks you to identify the cause (hypovolemic shock). Center asks for the nursing action (initiate IV fluid resuscitation). Right asks what to monitor (urine output and blood pressure trends). All three columns together represent one clinical decision sequence. Some bow-tie items carry partial credit, so getting two of the three columns right still earns you points.
Trend Item
The trend item shows you lab values or vital signs recorded at multiple time points. Your job is to select the correct interpretation of what direction the patient is heading and what it means clinically. This is an Analyze Cues and Evaluate Outcomes item. It tests whether you can read change over time and draw a clinical conclusion from movement in the data.
Highlight Item
You receive a clinical note, a nursing note, a physician order, or a lab report. You click on the findings that are abnormal or require nursing attention. This sounds simple. It is not. The skill being tested is the ability to separate relevant clinical data from documentation that is normal or irrelevant. That is a core nursing function, and it is harder than it looks when the notes include 15 data points and only 3 matter.
Matrix/Grid Item
The matrix presents multiple rows, each representing a condition or scenario element, and multiple columns representing interventions or assessment actions. You check all that apply per row. Each row is treated as an independent clinical decision. The matrix can test multiple CJMM layers depending on how it is designed, and partial credit applies across rows.
Cloze and Drop-Down Items
These present a sentence or short passage with one or more blanks. You select the correct word or phrase from a drop-down list to complete a clinical statement accurately. The cognitive demand varies. A drop-down rationale item, added in Fall 2025, asks you not just to select the action but to select the reasoning behind it.
How Is NGN Scored? (Partial Credit Explained)
NGN scoring is one of the least understood aspects of the exam and one of the most important for strategy. Traditional NCLEX items are binary. Right or wrong. One point or zero. The NGN NCLEX introduced a mixed scoring model where certain item types earn partial credit rather than all-or-nothing.
NCSBN uses three scoring models for NGN items:
0/1 scoring: Correct answer earns 1 point. Incorrect answer earns 0. No subtraction.
+/- scoring: Correct answer earns +1 point. Incorrect answer subtracts 1 point. The minimum score for any item is 0, so you cannot go below zero on a single item.
Rationale scoring: All-or-nothing per unit within the item. Each component is fully correct or scores zero.
What This Means for Your Strategy
Partial credit only applies to specific item types, primarily bow-tie and highlight items. Not every NGN item uses partial credit. The practical implication is clear. Never leave an NGN item blank. If you select three of the five correct findings in a highlight item, you earn partial credit. If you leave it blank, you earn nothing.
This is a meaningful departure from old SATA strategy, where some candidates were taught to be conservative with selections. On NGN partial-credit items, selecting what you are reasonably confident about is always the right move. Clearing all your selections out of uncertainty costs you points you could have earned.
One more thing worth understanding. Partial credit does not mean the exam is easier. The clinical scenarios are more complex than traditional MCQ items. The scoring model simply reflects the reality that complex clinical decisions rarely have exactly one correct element.
How to Prepare for NGN Items
Preparing for NGN NCLEX items is different from traditional NCLEX prep. The content knowledge base is the same. The preparation approach is not. Most candidates who struggle with how to pass NGN NCLEX are using study strategies built for a different version of the exam.
Four principles separate effective NGN preparation from everything else.
1. Learn the CJMM Layers Before You Drill Questions
This is not optional. If you open a question bank and start drilling NGN practice questions without understanding the six CJMM functions, you are practicing recognition of formats rather than clinical reasoning. Learn what each layer asks you to do first. Then every question you practice has a clear cognitive purpose.
2. Practice Each Item Type Separately Before Mixing
Bow-tie items have a specific three-part logic. Unfolding case studies require sustained reading and continuity of reasoning across six items without losing the thread. Highlight items demand a different kind of attention than trend items. Mixing all formats from day one before you are comfortable with each one adds confusion and slows skill development. Spend focused time on each format in isolation before combining them.
3. Read Clinical Scenarios as a Nurse, Not as a Test-Taker
This is the single most consistent advice from candidates who perform well on NGN. Before you look at the question stem, read the scenario and form a clinical picture. What is happening with this patient? What is the most urgent concern? What would you do next? The exam rewards candidates who engage with the scenario clinically. It penalizes pattern-matching.
4. Use Rationale Explanations for Every Wrong Answer
Because NGN items test a cognitive process, the rationale for a wrong answer tells you which CJMM layer you misapplied and why. That meta-level feedback is where the real learning happens. Reading "the answer is B" teaches you a fact. Reading "this item tested Prioritize Hypotheses and your selection reflected Generate Solutions, which comes next in the sequence" teaches you clinical reasoning. The two are not the same thing.
If you want a structured path through all of this, Testavia built its NGN prep course specifically around the CJMM framework. Every item in their QBank is tagged by CJMM layer so you know exactly what you are practicing and why. With 2,500 or more NCLEX questions covering all six NGN item types and a 99 percent pass rate across their student base, Testavia is the platform built for how the exam actually works now. Start with a free diagnostic and find out which CJMM layers need your attention before exam day.
Written by · Verified educator
Testavia editorial
Nathan Cole
RN
Medical-Surgical nurse & health writer
Meet Nathan, a registered nurse with over five years of experience in Medical-Surgical care, based in New York City. Having worked with a wide range of patients through some of their most vulnerable moments, Nathan brings a grounded, real-world perspective to his writing on healthcare. His goal is simple: to bridge the gap between medical knowledge and everyday understanding, making health topics feel less intimidating and more empowering for everyone. When he's not caring for patients, Nathan channels his passion for medicine into writing that educates, comforts and inspires.
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