Focus on Students: Anatomy of NCLEX Questions

This article will bring insight to the anatomy of NCLEX questions and tips for success. Nursing Students NCLEX Article

Focus on Students:  Anatomy of NCLEX Questions

Do you remember the first time you heard the words "NCLEX style questions"? Your first formal introduction to NCLEX was most likely during nursing school orientation. Unfortunately, the nursing faculty did not realize students were overwhelmed with new information and were not concerned with a type of question. In teaching nursing school, I found students would often use the same strategies and study habits that have been successful in other college courses. However, students realize after the first exam just how different NCLEX style questions are from exams taken in the past. This article will demystify NCLEX questions and increase the confidence of nursing students, at any level, to tackle nursing exams- including the official NCLEX.

For students preparing to take the actual NCLEX- pay close attention to the article "tips". Nursing instructors do not always understand how to write an NCLEX question and you will need to stray from the nursing exams you are used to taking.

An NCLEX question has 3 parts- a stem, a key, and distractors. The stem asks a question or requires completion of a question pertaining to the client. The question stem will provide all the necessary information you need to answer the test item.

The Stem

  • Describes the client (individual or group needing intervention)
  • May pose a question. For example, "The nurse is assessing a client with exacerbation of congestive heart failure. Which of the following symptoms would the nurse expect to find?"
  • May require completion of a statement. For example, "The nurse is teaching a caregiver how to administer bolus enteral feedings. The nurse identifies a need for additional teaching with the caregiver states"

Stem Tips

  • The stem will always provide the information you need to correctly answer the question. A common pitfall is reading detail into the scenario that is not provided in the stem.
  • NCLEX world is ideal, nursing is fully staffed and an order exists for the treatments and interventions in the question stem. There is no need for the test taker to build in additional details that come with nursing in the "real world". There is no need to add "what if" to the stem scenario.
  • The NCLEX will use the term "primary healthcare provider" (PHCP) for any member of the healthcare team authorized to provide orders for the client. PHCPs may include physicians, nurse practitioners and specialty physicians (neurologist, cardiologist ect).

The key and distractors are the options available for answering the NCLEX item. The answer options are multiple choice and may be in a "select all that apply" format. The answer key is the item's correct answer. It is important to understand the concept behind distractors.

The Distractors

  • Keep in mind that there will be only one (1) correct answer unless the item is a "select all that apply".
  • Outside of NCLEX world, nursing tests may have distractors that are also correct- just not the answer the instructor was looking for. Remember, NCLEX world is ideal and there will always be a clear answer.
  • Distractors, or wrong choices/answers, are designed to take your focus away from the item's key. There will not be obviously outrageous wrong distractors on NCLEX. Distractors will seem plausible and if the test taker is unsure- distractors are successful in drawing attention away from the correct answer.

Let's go back to our sample stem and add a key and distractors.

Example 1

The nurse is assessing a client with exacerbation of congestive heart failure. Which of the following symptom would the nurse expect to find?

  • Low Hematocrit- distractor
  • Orthopnea- key
  • Weight loss- distractor
  • Diarrhea- distractor


Although low hematocrit sounds very plausible, it is not a common symptom of CHF exacerbation. Weight gain is common due to fluid retention and diarrhea is not a symptom typically associated with CHF.


I am going to travel back to my days in nursing school and predict the overthinking details many of you added to the question stem

  • "The patient may require rehydration after diuretics leading to low hematocrit"
  • "If the patient wasn't eating- it is possible the client lost weight
  • "Diarrhea is a very common side effect, therefore, this must be the right answer"


The question stem will provide all the necessary and pertinent information needed to identify the correct answer. It is a common pitfall to add additional information to the stem.

Example 2

The nurse is teaching a caregiver how to administer bolus enteral feedings. The nurse identified a need for additional teaching with the caregiver states

  • "I will measure residual gastric content prior to bolus feeding."- distractor
  • "I will raise the head of the client's bed to 35 degrees."- distractor
  • "I will use a new syringe with each feeding."- distractor
  • "I will discard residual gastric contents prior to feeding."- key


Gastric contents should not be discarded and need to be readministered after checking residual. Discarding gastric contents increases risk for electrolyte imbalances.


Many nursing school exams and practice NCLEX questions provide more detail that the official NCLEX. Exams questions in nursing school often provide detailed gender, age and other information in the stem. Again, when taking the official NCLEX, it is important to avoid reading details into the questions.

For Example

Nursing school stem- "A 48-year-old male presented to the emergency room after falling off a ramp while working and broke his right femur. Which of the following assessment is most important for the nurse?"

NCLEX stem- An adult client presents to the emergency room with a broken femur. Which of the following would be essential for the nurse to assess?

Final Tip

Did you know the National Council of State Boards of Nursing (NCSBN) publishes a detailed NCLEX test plan just for students? The detailed plan is published to prepare students to successfully take the NCLEX exam. The publication also includes example test items for practice. You can explore the student test plan at Test Plans | NCSBN.

What about NCLEX style questions still mystify you? What future article topics would help you prepare for NCLEX?


Nurse with over 20 years experience and diverse career path- community health, management, education and end of life care.

121 Articles   502 Posts

Share this post

Share on other sites