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Mastering the NCLEX the First Time: Strategy and Tips

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Note: The NCLEX exam is expected to change in 2023. Learn more about what means for nursing students.

Nurses must pass the National Council Licensure Examination (NCLEX) to become licensed. Registered nurses take the NCLEX-RN, while licensed practical nurses (called licensed vocational nurses in some states) sit for the NCLEX-PN. Both exams test a candidate’s nursing knowledge and practice readiness in four focus areas: providing a safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiological integrity.

While multiple-choice questions comprise most of the exam, other formats may be included. The exam follows a variable question format in which the computer adapts to the test-taker’s performance with increasingly difficult questions, continuing until the computer reaches 95% certainty of a passing score.

This guide focuses on NCLEX test-taking strategies, with advice from nurses who have passed the NCLEX-RN exam . While the NCLEX-RN has 74-145 questions, Alaina Ross, an RN and expert contributor for Test Prep Insight, advises test-takers not to worry.

“Do not automatically assume you failed if the exam goes past 75 questions,” she says. “Stay focused, stay positive, and keep trucking.”

The exam will shut off when it reaches a 95% certainty of a passing score or if the test-taker misses too many questions to achieve a passing score.

How Learning Styles Help in Test Taking

Anne Dabrow Woods, chief nurse at Wolters Kluwer, Health Learning, Research and Practice, suggests that nurses preparing for the NCLEX acknowledge their learning style and stick with methods that have worked in the past. Styles include auditory, kinesthetic, visual, or a combination of styles and study habits.

“Some tried and true methods are using mnemonics, drawing out concepts or relationships, using the teach-back method where you teach someone else about concepts and applications, or using flashcards,” Dabrow Woods says.

“As adult learners,” Dabrow Woods adds, “we retain more information if we use a variety of study methods to learn information.”

NCLEX Test-Taking Strategies

When trying to improve your test-taking skills, it may help to identify the components of a multiple-choice question:

• The stem is the part that asks the question

In addition to the correct answer, there will also be:

• The case (patient’s situation or scenario)
• Distractors (choices that are actually wrong or not the best answer)

It is easier to analyze a question once you have identified each part. Read the stem at least twice to thoroughly understand the question.

Below are key strategies to use while taking the NCLEX.

Identify Keywords

One of the most effective NCLEX strategies involves focusing on keywords. “For instance, if the question asks for an intervention, look for the answer that is an intervention,” Dabrow Woods advises. Answers that emphasize signs and symptoms, or anything other than an intervention, can be eliminated right away, she says.

Identify Repeated Words

Examinees should pay close attention to repeated words and synonyms that appear in both questions and answers. For example, for a question that contains “signs,” the right answer may include “symptoms.”

“Test-takers have a tendency to read too much into answer choices and overanalyze,” says Ross. “Do not fall into this trap!”

Do Not Second Guess Yourself

Do not second guess what is being asked, cautions Dabrow Woods, and do not change your answers. “The first answer is usually the correct one if you have taken the time to reason through the question,” says Dabrow Woods.

Ross advises, “Read each answer choice and pick the best choice based on instinct.”

Look for Opposite Answers

If two of the answer choices have opposites, like increased heart rate or decreased heart rate, one of the two choices is usually the correct answer. Correctly answering NCLEX-style questions requires familiarity with all the types of questions you may see on the exam, says Ross.

Read the Entire Question Before Answering

“Read the entire question before focusing on the answer,” says Dabrow Woods. Examinees who do not thoroughly read the questions may miss a keyword or phrase or misinterpret the question’s focus.

“Whether you are taking a practice test or the real NCLEX exam, make sure you understand what the question is really asking,” advises Dabrow Woods.

Eliminate Distractors

Eliminate distractors first in the answer choices and then focus on any options that might be correct. Dabrow Woods advises examinees to read the question and answers, “then start eliminating the distractors that are not correct.”

For instance, Dabrow Woods suggests, “If the question asks for an intervention but some of the distractors are signs and symptoms, eliminate those distractors and focus on the one distractor that most closely resembles the right answer.”

Use Prioritization Techniques

Questions using words such as initial , first , and best are asking for your prioritizing skills. The choices are usually all correct but only one should be done first. When prioritizing, you should consider the following:

• ABC’s (Airway, Breathing, and Circulation): Patients with airway problems or interventions to provide airway management receive top priority.
• Maslow’s Hierarchy of Needs: Physiologic needs (pain, food, sleep) come first before safety and security and psychosocial problems. This is typically used in complex patients with multiple problems.
• Nursing Process: Assessment should always be done before planning anything or instituting interventions. Ask yourself if you would need to collect more assessment data on this patient before jumping into an intervention or calling the doctor.

NCLEX World

In the NCLEX world, you are one nurse with only one patient, and all the orders you need are written. The only time the nurse would need to call the doctor is after intervention has failed and there is nothing else the nurse can do. Never call a physician about something that is expected with the disease process. It is essential for nursing students to know the expected signs and symptoms of a disease versus signs and symptoms of potential complications.

Tips From Nurses Who Mastered the NCLEX

Take the day before the exam off; stop studying and relax .

Dabrow Woods says, “Practice relaxation breathing so when you start to become stressed, you can easily manage it down to an acceptable level.” She also advises eating “something with protein and carbs prior to going into the exam so you don’t experience hypoglycemia.”

Dabrow Woods and other nurses recommend taking a formal NCLEX prep course. “Choose one that follows the NCLEX blueprint, has many practice questions and tests, and has a proven track record,” says Dabrow Woods.

She also suggests filling up your gas tank the night before and taking a practice drive to the location.

“Practice tests will identify the areas where you should take time to prep,” says Dabrow Woods. “Schedule at least two hours per day to devote to studying.”

Ross agrees and says that practice helps you gauge your strengths and weaknesses. “This will then guide which areas you need to focus on to see improvement,” she says.

According to Ross, “Overanalysis and reading too much into answer choices kills NCLEX test-takers.”

“Many times, test-takers overthink questions by questioning what is being asked or thinking about a real-life experience they have encountered in practice,” Dabrow Woods states. “Don’t second guess what is being asked and don’t bring your personal experience into the question scenario.”

Schedule your exam as soon as possible after your nursing program ends. This is the time when the material will be freshest in your mind, and early testing means less study time relearning information.

“The NCLEX is most easily mastered through practice by doing rather than by content review,” says Ross.

“The exam is several hours in length,” Dabrow Woods reminds candidates.

But test-takers must wear masks when inside the testing center and may wear gloves. Testing centers will implement social distancing and sanitizing and also limit the number of test-takers permitted in the centers. The test content and format should not change.

Helpful Exam Prep Resources

Passing the NCLEX: Tips from Nurses

The NCLEX contains a significant amount of information, which can certainly feel overwhelming to anyone preparing. These expert tips and resources can guide you through the study process.

6 Things to Know About the NCLEX Examination

Stressed about how to prepare for the NCLEX? This NCLEX study guide goes over 6 need-to-know bits of information for aspiring nurses.

The Ultimate NCLEX Study Guide

Find out how this NCLEX study guide offers prospective nurses step-by-step instructions on how to pass the NCLEX, including details about test material and format, the scoring system, and what to do after you pass.

Meet Our Contributors

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN

A nurse for over 35 years and a board-certified nurse practitioner since 1998, Dr. Dabrow Woods practices as an acute care/critical care nurse practitioner for Penn Medicine, Chester County Hospital. She also serves as adjunct faculty in the graduate nursing program at Drexel University and precepts nurse practitioner and DNP students. Dr. Dabrow Woods is the chief nurse of Wolters Kluwer, Health, Learning, Research and Practice, a global company that produces and publishes information for healthcare professionals in education, practice, and research.

Alaina Ross, RN, BSN

Alaina Ross, RN, BSN, has 10 years of experience as a post-anesthesia care unit nurse. Ross is also an expert contributor for Test Prep Insight , a test prep company that helps students pass exams like the Test of Essential Academic Skills and NCLEX.

Reviewed By:

Elizabeth Clarke, FNP, MSN, RN, MSSW

Elizabeth Clarke, FNP, MSN, RN, MSSW, is a board-certified family nurse practitioner . A native of Boston, Massachusetts, Clarke tired of the cold and snowy winters and moved to Coral Gables, Florida to complete her undergraduate degree in nursing at the University of Miami. After working for several years in the UHealth and Jackson Memorial Medical systems in the cardiac and emergency room units, Clarke returned to the University of Miami to complete her master of science in nursing (MSN). Since completing her MSN degree , Clarke has worked providing primary and urgent care to pediatric populations.

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NCLEX Practice Questions Test Bank for Free

Welcome to our collection of free NCLEX practice questions to help you achieve success on your NCLEX-RN exam! This updated guide for 2024 includes 1,000+ practice questions, a primer on the NCLEX-RN exam, frequently asked questions about the NCLEX, question types, the NCLEX-RN test plan, and test-taking tips and strategies.

Table of Contents

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• What is Next Generation NCLEX (NGN)? 

Safe and Effective Care Environment

• Health Promotion and Maintenance 
• Psychosocial Integrity 

Physiological Integrity

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• Multiple Response Select N 

Multiple Response Grouping

• Highlight in Text 

Highlight in Table

Matrix multiple response, matrix multiple choice.

• Drag and Drop Cloze 

Drag and Drop Rationale

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Looking for the complete collection of practice questions? For more NCLEX practice questions, please visit our Nursing Test Bank here .

We have included more than 1,000+ NCLEX practice questions covering different nursing topics for this nursing test bank ! We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning .

We recommend you do all practice questions before you take the actual exam. Doing so will help reduce your test anxiety and help identify nursing topics you need to review. To make the most of the practice exams, try to minimize mistakes to less than 15 questions and take your time answering the questions, especially when reading the rationales.

Quiz Guidelines

Before you start, here are some examination guidelines and reminders you must read:

• Practice Exams : Engage with our Practice Exams to hone your skills in a supportive, low-pressure environment. These exams provide immediate feedback and explanations, helping you grasp core concepts, identify improvement areas, and build confidence in your knowledge and abilities.
• You’re given 2 minutes per item.
• For Challenge Exams, click on the “Start Quiz” button to start the quiz.
• Complete the quiz : Ensure that you answer the entire quiz. Only after you’ve answered every item will the score and rationales be shown.
• Learn from the rationales : After each quiz, click on the “View Questions” button to understand the explanation for each answer.
• Free access : Guess what? Our test banks are 100% FREE. Skip the hassle – no sign-ups or registrations here. A sincere promise from Nurseslabs: we have not and won’t ever request your credit card details or personal info for our practice questions. We’re dedicated to keeping this service accessible and cost-free, especially for our amazing students and nurses. So, take the leap and elevate your career hassle-free!
• Share your thoughts : We’d love your feedback, scores, and questions! Please share them in the comments below.

Included NCLEX-RN question sets for this nursing test bank are as follows. Please click on the links below and you’ll be redirected to the quiz page:

NEW UPDATE: Introducing Challenge Exams and Practice Exams

Engage with these new modes to enhance your learning journey, each tailored to meet different needs and propel you towards academic achievement.

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• Step up to Challenge Exam Mode to test your mastery. With rigorous questions, a leaderboard, and a timer, it’s designed to assess your readiness and foster a competitive spirit.

Test your mastery with these Challenge Exams :

Build your confidence and grasp core concepts with these Practice Exams :

The National Council Licensing Examination (NCLEX) is a comprehensive test administered by the National Council of State Boards of Nursing (NCSBN). It assesses whether candidates possess the necessary knowledge and skills to provide safe and effective nursing care at the entry level. The NCLEX is available in two versions: the NCLEX-RN for registered nurses and the NCLEX-PN for practical/vocational nurses.

The NCSBN, composed of nursing regulatory bodies from all 50 states in the US, the District of Columbia, and four US territories, is responsible for safeguarding the public by ensuring safe nursing care. It sets the standards and guidelines for nursing licensure and develops the NCLEX examinations.

Becoming a registered nurse (RN) requires meeting specific licensure requirements determined by the licensing authorities in each jurisdiction governed by the NCSBN. One of these requirements is passing the NCLEX-RN, which evaluates the competencies necessary for practicing safely and effectively as an entry-level RN. The NCLEX-RN is used by member boards of nursing and many Canadian nursing regulatory bodies to inform their licensure decisions.

What is Next Generation NCLEX (NGN)?

The Next Generation NCLEX (NGN) is currently in effect this April 2023 for RN and LPN /LVN candidates. The change in the NCLEX is driven by the need to adapt to the increasing complexity of client care, advancements in healthcare practice, and the demand for safe clinical decision-making. The NGN aims to address the declining ability of new nursing graduates to make safe clinical decisions by integrating clinical judgment as a key competency. The NGN test format will remain adaptive but with fewer test items. Candidates will encounter Unfolding Case Studies and Stand-Alone Items , scored using partial credit with three different scoring rules. These changes in the NGN aim to assess critical thinking and the ability to make safe clinical judgments during various phases of client care.

In summary, the following are the key changes between the previous NCLEX format and the Next Generation NCLEX (NGN): 

• Same adaptive test format but reduced number of items. The Next Generation NCLEX (NGN) will retain the adaptive test format, similar to the current NCLEX, but with fewer test items. Candidates will answer between 85 and 150 items, with 15 as pretest or unscored items. 
• Case studies. All candidates will encounter three (3) Unfolding Case Studies, each consisting of six test items (a total of 18 items). Clinical situation information will be presented to candidates in a medical record format resembling a table-like structure. These situations are designed to assess their ability to think critically and make safe clinical decisions across different phases of client care. In addition to the case studies, some candidates may have Stand-Alone Items for their NGN exam.
• New NGN item types. The NGN exam will feature new item types, which include questions in unfolding cases and stand-alone items, highlight, cloze, matrix, bow-tie, drag and drop, and extended multiple responses. 
• Scoring differences. NGN test items will be scored differently compared to the current NCLEX. They will utilize partial credit scoring with three different scoring rules: the 0/1 scoring rule, the +/- scoring rule, and the rationale scoring rule. These are explained further below. 

NCLEX-RN Test Plan

The NCLEX test plan is a content guideline to determine the distribution of test questions. NCSBN uses the “Client Needs” categories to ensure the NCLEX covers a full spectrum of nursing activities. It is a summary of the content and scope of the NCLEX to serve as a guide for candidates preparing for the exam and to direct item writers in the development of items.  Additionally, to assess the knowledge, skills, abilities, and clinical judgment necessary for entry-level nursing practice, the NCLEX-RN Test Plan utilizes Bloom’s taxonomy for the cognitive domain. This taxonomy provides a foundation for writing and coding examination items, focusing on application-level or higher-level cognitive abilities that require advanced thought processing.

The content of the NCLEX-RN is organized into four major Client Needs categories: Safe and Effective Care Environment, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. Some of these categories are divided further into subcategories. Below is the NCLEX-RN test plan effective as of April 2023 until March 2026: 

There are two subcategories under Safe and Effective Care Environment.

• Management of Care category includes content that tests the nurse’s knowledge and ability to direct nursing care that enhances the care delivery setting to protect clients, significant others, and healthcare personnel. 
• Safety and Infection Control category includes content that tests the nurse’s ability required to protect clients, families, and healthcare personnel from health and environmental hazards. 

Health Promotion and Maintenance

Health Promotion and Maintenance category includes content that tests the nurse’s ability to provide and direct nursing care to the client that incorporates knowledge of expected growth and development, preventing and early detection of health problems, and strategies to achieve optimal health. 

Psychosocial Integrity

The Psychosocial Integrity category is content related to the promotion and support for the emotional, mental, and social well-being of the client experiencing stressful events and clients with acute or chronic mental illness . 

In the Physiological Integrity category are items that test the nurse’s ability to promote physical health and wellness by providing care and comfort, reducing risk potential, and managing health alterations. There are four subcategories under Physiological Integrity. 

• Basic Care and Comfort are content to test the nurse’s ability to provide comfort and assistance to the client in performing activities of daily living . 
• Pharmacological and Parenteral Therapies category includes content to test the nurse’s ability to administer medications and parenteral therapies (IV therapy, blood administration, and blood products). 
• Reduction of Risk Potential category includes content to test the nurse’s ability to prevent complications or health problems related to the client’s condition or prescribed treatments or procedures. 
• Physiological Adaptation category includes questions that test the nurse’s ability to provide care to clients with acute, chronic, or life-threatening conditions. 

Clinical judgment is a central component of the NCLEX-RN Test Plan, reflecting the evolving demands and complexity of nursing practice. Nurses must engage in an iterative, multi-step process that utilizes nursing knowledge to observe and assess situations, identify client concerns, and generate evidence-based solutions to ensure safe client care. Clinical judgment questions are represented through Unfolding Case Studies or individual Stand-Alone Items , with case studies addressing each step of clinical judgment. The following are the six clinical judgment cognitive skills: 

• Recognize cues “What matters most?” Identifying relevant and important information from various sources, such as medical history, laboratory studies, and vital signs.
• Analyze cues “What could it mean?” Organizing and connecting recognized cues to the client’s clinical presentation.
• Prioritize hypotheses “Where do I start?”   Evaluating and prioritizing hypotheses based on urgency, likelihood, risk, difficulty, time constraints, and other factors.
• Generate solutions “What can I do?” Identifying expected outcomes and using hypotheses to define a set of interventions aligned with the expected outcomes.
• Take action “What will I do?” Implementing the highest-priority solution(s) identified.
• Evaluate outcomes “Did it help?” Comparing observed outcomes to expected outcomes to assess the effectiveness of interventions.

Additionally, In contrast to the nursing process or ADPIE , the NCSBN focuses on AAPIE ( assessment , analysis, planning, intervention, evaluation), wherein nursing diagnosis is not tested at the current NGN because it is not considered a universal language used in health care or the nursing profession. In nursing practice and for the NGN, students must use their pathophysiology knowledge to analyze client assessments and connect them with common conditions in healthcare settings. 

Integral to nursing practice, several processes are integrated throughout the Client Needs categories and subcategories:

• Caring. In an atmosphere of mutual respect and trust, nurses interact with clients, providing encouragement, hope, support, and compassion to help achieve desired outcomes.
• Clinical Judgment . An observed outcome of critical thinking and decision-making, clinical judgment (discussed above) is a dynamic and iterative process. It involves using nursing knowledge to observe and assess situations, prioritize client concerns, generate evidence-based solutions, and deliver safe client care.
• Communication and Documentation. Verbal and nonverbal interactions between nurses, clients, significant others, and the healthcare team. Accurate and comprehensive documentation ensures adherence to practice standards and accountability in care provision.
• Culture and Spirituality. Recognizing and considering the unique preferences, standards of care, and legal considerations of clients (individuals, families, groups, and populations) in the context of their culture and spirituality.
• Nursing Process. A systematic approach to client care encompassing assessment, analysis, planning, implementation, and evaluation.
• Teaching/Learning. Facilitating acquiring knowledge, skills, and abilities that promote behavioral change.

Who writes questions for the NCLEX? The NCSBN sets the criteria and selection process for item writers who are registered nurses. Many of them are nursing educators with an advanced degrees in nursing, so if you’ve completed an accredited nursing program, you have already taken several tests written by nurses with backgrounds similar to those who write for the NCLEX.

The NCLEX-RN is a crucial step for registered nurse (RN) candidates seeking licensure. Administered through computerized adaptive testing ( CAT ), this examination utilizes computer technology and measurement theory to create a personalized and accurate assessment of each candidate’s knowledge and skills. 

The CAT system employed in the NCLEX-RN ensures that each candidate receives a unique examination tailored to their abilities. As the test progresses, the computer selects items from a large item pool based on the candidate’s previous answers. These items are classified according to the test plan categories, difficulty levels, and clinical judgment steps. The CAT system continually recalculates the candidate’s ability estimate and selects subsequent items accordingly, creating an exam that aligns with the NCLEX-RN Test Plan requirements. This dynamic approach allows candidates to demonstrate their competence effectively.

Additionally, unlike traditional fixed-length exams, which assign the same items to all candidates, CAT selects items based on the candidate’s ability, resulting in a more accurate assessment. The CAT scoring algorithm estimates the candidate’s ability by considering all previous answers and the difficulty level of those items. By administering items that challenge the candidate appropriately, the exam gathers maximum information about their ability.

Pass or Fail Decisions: How to Pass the NCLEX?

Passing the NCLEX-RN requires you, the candidate, to meet a specific passing standard established by the NCSBN Board of Directors (BOD). The passing standard represents the minimum ability level necessary for safe and effective entry-level nursing practice. The BOD reevaluates this standard every three years, considering various factors such as a standard-setting exercise conducted by experts and psychometricians, historical data on candidate performance, and information on the educational readiness of aspiring nurses. Once the passing standard is set, it is uniformly applied to all candidates during the scoring process. The NCSBN indicates that these three rules govern pass-or-fail decisions: the 95% Confidence Interval Rule , Maximum-Length Exam Rule , and Run-Out-Of-Time Rule .

In this scenario, the computer stops administering test questions when it is 95% certain that your ability is clearly above the passing standard or clearly below the passing standard. 

When your ability is close to the passing standard, the CAT gives you items until the maximum number of items is reached. At this point, the computer disregards the 95% confidence rule and decides whether you pass or fail by your final ability estimate. If your final ability estimate is above the passing standard, you pass; if it is below, you fail. 

In the event that a candidate runs out of time before completing the maximum number of items and the computer has not reached a 95% certainty regarding the candidate’s pass or fail status, alternative criteria come into play.

• If the candidate has not answered the minimum required number of items, the candidate will automatically fail.
• If the candidate has answered at least the minimum required number of items, the final ability estimate will be determined based on all the responses given before the exam time expires. If the score meets or exceeds the passing standard, the candidate will pass. Otherwise, the candidate will fail.

New Scoring System in the Next Generation NCLEX

The Next Generation NCLEX (NGN) incorporates different item formats, and for items that have multiple correct answers, partial credit scoring is implemented . Unlike the previous exam format, where items are scored as either all correct or all incorrect, the NGN will use polytomous scoring models to evaluate partial understanding. For example, in the previous version of NCLEX (multiple response) SATA (select-all-that-apply) items, only endorsing all the correct options results in a correct score. However, the new approach will acknowledge partial understanding, allowing differentiation between candidates with different numbers of correct options. This change will provide a more accurate assessment of candidates’ knowledge, skills, and abilities.

Three methods are used to assign partial credit for these items: plus/minus scoring, zero/one scoring, and rationale scoring. Understanding the scoring models is crucial for NCLEX-RN takers to know how their answers are evaluated and how scores are determined.

The 0/1 scoring rule is used for multiple-choice items. Choosing the correct option earns one point while selecting an incorrect option gives a score of zero. This rule applies to single response items, including the example multiple-choice item.

The +/– scoring rule measures a candidate’s ability to identify relevant information. It assigns points for correct options and deducts points for incorrect options. It is used for multi-point items, and the total score is calculated by adding correct options and subtracting incorrect ones. The lowest possible score is zero. This rule is applied to NGN question types such as multiple-response and select all that apply.

The rationale scoring rule is used for questions that assess paired information. To earn a score of one point, both answer options must be correct. If either option is incorrect, the score is 0.

How Many Questions Are on the NCLEX?

All RN candidates must answer a minimum of 85 items , while a maximum of 150 items be administered during the five-hour time allotment. Each NCLEX-RN exam includes 15 pretest items (unscored), which are indistinguishable from operational (scored) items.

To ensure the effectiveness of computerized adaptive testing (CAT) in the NCLEX, the difficulty level of each item needs to be determined beforehand. This is achieved by administering these items as pretest items to a large group of NCLEX candidates. Since the difficulty of pretest items is initially unknown, they are not part of your score and are not considered when evaluating a candidate’s ability or determining pass-fail outcomes. Once a sufficient number of responses are collected, the pretest items undergo statistical analysis and calibration. If they meet the required NCLEX statistical standards, they can be used as operational items in future exams. Therefore, candidates must approach every item with their best effort, regardless of whether it is a pretest or an operational item.

The length of the NCLEX-RN examination varies for each candidate based on their responses, but there is a five-hour time limit for the exam, including all breaks. To ensure completion within the allotted time, candidates must maintain a reasonable pace, spending approximately one to two minutes per item . It’s important to note that the length of the examination does not determine pass or fail outcomes; candidates can succeed or fail regardless of the examination’s duration.

Case Studies in NGN

The Next Generation NCLEX (NGN) has introduced case studies that present practical clinical scenarios and include test items aligned with six cognitive abilities of the clinical judgment model. The scenario can occur in various settings, and the client’s outcome can vary, including improvement, stability, or decline with complications. Laboratory results, if included, are presented in a table, and abnormal values are highlighted with an “L” or “H”. There are two types of case studies: Unfolding Case Study with six test items assessing specific skills and Stand-Alone Items with a single test item independent of a case study.

An Unfolding Case Study presents a realistic client situation with evolving data resembling a medical record. It includes multiple phases over time, reflecting changes in the client’s condition. The case study evaluates all six cognitive skills of the clinical judgment model through six questions. Each test-taker receives three (3) unfolding case studies, totaling 18 items across those cases. 

Stand-Alone Items are case studies with a single question, with the item presented as a bow-tie or a trend question type. Candidates who take more than the minimum number of items on the NCLEX receive around six to seven stand-alone cases. 

Question Types in the NCLEX-RN

The different question types for the NCLEX-RN include the following: 

Extended Multiple Response

In Extended Multiple Response item types, test-takers can choose one or more options in Multiple Response Select All That Apply, select a specific number of items in Multiple Response Select N, or choose options from different groupings presented in a table in Multiple Response Grouping, with scoring rules based on the selected type. Extended multiple response may include the following formats:

The Multiple Response Select All That Apply item type allows test-takers to choose one or more answer options. It uses the +/- Scoring Rule, where selecting correct information earns points (+1), and selecting incorrect information results in points deducted (-1). The maximum points achievable are equal to the number of correct options, and the minimum score is 0, with no negative scores. The item must have a minimum of five options and can have up to ten options, with the possibility of all ten options being correct.

Multiple Response Select N

The Multiple Response Select N item type informs the test-taker about the specific number of items (N) that can be selected. The question provides a range of options, with a minimum of five and a maximum of ten options. It uses the 0/1 Scoring Rule, where each correct response earns 1 point, while any incorrect response results in 0 points.

The Multiple Response Grouping utilizes a table to present options, with a minimum of two and a maximum of five groupings. Each grouping consists of a minimum of two and a maximum of four options, ensuring an equal number of options within each grouping. Test-takers are required to select at least one option from each grouping. The item follows the +/- Scoring Rule, meaning there is no negative score per grouping. The total score for the item is determined by summing the points earned within each grouping. The maximum score achievable equals the number of keys (N).

For this NGN item type, the test-taker is presented with information and must highlight specific parts of the information provided.  Highlight question type include the following formats:

Highlight in Text

It involves a paragraph of information where the test-taker must select (highlight) specific parts of the text based on the question’s requirements. The item can include a maximum of ten options for selection and uses the +/- Scoring Rule. 

The Highlight in Table item type involves a table of information. The candidate is tasked with selecting (highlighting) specific parts of the text within the table based on the question’s prompt. The item can include a maximum of ten options for selection. The table has two columns, including a header, and can have up to five rows. This item type uses the +/- Scoring Rule. 

Matrix/Grid

In the Matrix NGN item type, test-takers are presented with a grid-like structure to which they must respond. There are two variations: Matrix Multiple Response, where each column can have multiple correct responses, and Matrix Multiple Choice, where test-takers select one answer option per row. Extended multiple response may include the following formats:

The Matrix Multiple Response item type consists of response columns, where each column can have multiple correct responses. The item can have between two and ten columns and four to seven rows. In each column, at least one response option must be selected, but it is possible to select one or more responses per column. The item follows the +/- Scoring Rule, with no negative score per column. The total score for the item is determined by summing the points earned within each column. The maximum score achievable is equal to the number of keys (N).

The item includes a minimum of four rows and a maximum of ten rows. It can have either two or three options/columns. Test-takers are allowed to select one answer option per row. The item follows the 0/1 scoring rule, where the test-taker earns 1 point for each correct response and 0 points for incorrect responses. The total score for the item is obtained by summing the scores over the rows. The maximum score achievable is equal to the number of rows.

Drag and Drop

In the Drag and Drop NGN question type, test-takers are presented with options to drag and drop into specific targets. There are two variations: Drag and Drop Cloze, where options are placed in response targets to complete sentences and Drag and Drop Rationale, where options are matched to causes and effects. Drag and drop may include the following formats:

Drag and Drop Cloze

The Drag and Drop Cloze item type includes a range of four to ten options. It can have one or more response targets where the options are dragged to. The item must have a minimum of one sentence with one target per sentence and up to five sentences, each with one target per sentence. The item follows the 0/1 Scoring Rule, where a correct response earns 1 point and incorrect responses earn 0 points. The total score is obtained by summing the scores across all targets, with the maximum score achievable being the number of targets.

The Drag and Drop Rationale type involves one sentence with one cause and one effect or one sentence with one cause and two effects. The sentence can be a single dyad (one sentence with two targets) or a single triad (one sentence with three targets). Each drag & drop target can have three to five options. The item follows the Rationale Scoring Rule where both answer options must be correct to earn a point. 

The Drop Down question type in NGN includes three variations: Drop Down Cloze, Drop Down Rationale, and Drop Down in Table. Drop down may include the following formats:

The Drop Down Cloze item type presents one or two sentences of information that require completion using drop-down options. Each drop-down can contain three to five options. The item must have a minimum of one sentence with one drop-down per sentence and can include up to five sentences, each with one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Drop Down Rationale item type presents either one sentence with one cause and one effect or one sentence with one cause and two effects. Each drop-down can contain three to five options. The scoring follows the Rationale Scoring Rule, where X and Y must be correct to earn one point. The maximum points that can be earned are 1 point for a dyad (one sentence with two targets) and 2 points for a triad (one sentence with three targets).

The Drop Down in Table item type presents a table of information with drop-down options located in various parts of the table. The item must have a minimum of three columns and three rows and a maximum of five columns and four rows. One column serves as the header column. Each row contains one drop-down. The item follows the 0/1 Scoring Rule, where the score is calculated by summing the correct responses across all drop-downs. The maximum score achievable is equal to the number of drop-downs.

The Bow-tie item type is visually designed to resemble a bow-tie shape. It consists of five options on the left side, five options on the right side, and four options in the middle well of the bow-tie. The item addresses all of the cognitive skills within a single item. The Bow-tie item follows the 0/1 scoring rule. The left and right wells have two answer options each, while the middle well has one answer option, resulting in a maximum possible score of 5 points. Each correct response earns 1 point, while incorrect responses earn 0 points.

The Trend item type presents information in a medical record or flow sheet format that spans over time, requiring the test-taker to analyze information across different points in time. The item addresses multiple cognitive skills within a single item. It can utilize any NGN item type except for the bow-tie. The scoring rule for the Trend item depends on the specific item type used.

Multiple-Choice Questions

Many questions on the NCLEX are in multiple-choice format. This traditional text-based question will provide you data about the client’s situation, and you can only select one correct answer from the given four options. Multiple-choice questions may vary and include: audio clips, graphics, exhibits, or charts.

A chart or exhibit is presented along with a problem. You’ll be provided with three tabs or buttons that you need to click to obtain the information needed to answer the question. Select the correct choice among four multiple-choice answer options. 

In this format, four multiple-choice answer options are pictures rather than text. Each option is preceded by a circle that you need to click to represent your answer.

In an audio question format, you’ll be required to listen to a sound to answer the question. You’ll need to use the headset provided and click on the sound icon for it to play. You’ll be able to listen to the sound as many times as necessary. Choose the correct choice from among four multiple-choice answer options. 

For the video question format, you must view an animation or a video clip to answer the following question. Select the correct choice among four multiple-choice answer options. 

Multiple-response or select all that apply (SATA) alternate format question requires you to choose all correct answer options that relate to the information asked by the question. There are usually more than four possible answer options. No partial credit is given in scoring these items (i.e., selecting only 3 out of the 5 correct choices), so you must select all correct answers for the item to be counted as correct. 

Tips when answering Select All That Apply Questions

• You’ll know it’s a multiple-response or SATA question because you’ll explicitly be instructed to “Select all that apply.”
• Treat each answer choice as a True or False by rewording the question and proceed to answer each option by responding with a “yes” or “no”. Go down the list of answer options one by one and ask yourself if it’s a correct answer.
• Consider each choice as a possible answer separate to other choices. Never group or assume they are linked together.

The fill-in-the-blank question format is usually used for medication calculation, IV flow rate calculation, or determining the intake-output of a client. You’ll be asked to perform a calculation in this question format and type in your answer in the blank space provided. 

Tips when answering Fill-in-the-Blank

• Always follow the specific directions as noted on the screen. 
• There will be an on-screen calculator on the computer for you to use. 
• Do not put any words, units of measurements, commas, or spaces with your answer, type only the number. Only the number goes into the box.
• Rounding an answer should be done at the end of the calculation or as what the question specified, and if necessary, type in the decimal point. 

In an ordered-response question format, you’ll be asked to use the computer mouse to drag and drop your nursing actions in order or priority. Based on the information presented, determine what you’ll do first, second, third, and so forth. Directions are provided with the question. 

Tips when answering Ordered-Response questions

• Questions are usually about nursing procedures. Imagine yourself performing the procedure to help you answer these questions.
• You’ll have to place the options in correct order by clicking an option and dragging it on the box on the right. You can rearrange them before you hit submit for your final answer.

A picture or graphic will be presented along with a question. This could contain a chart, a table, or an illustration where you’ll be asked to point or click on a specific area. Figures may also appear along with a multiple-choice question. Be as precise as possible when marking the location. 

Tips when answering Hotspot questions

• Mostly used to evaluate your knowledge of anatomy, physiology, and pathophysiology.
• Locate anatomical landmarks to help you select the location needed by the item.

So you’ve finally decided to take the NCLEX, the next step is registration or application for the exam. The following are the steps on how to register for the NCLEX, including some tips:

• Application to the Nursing Regulatory Board (NRB). The initial step in the registration process is to submit your application to the state board of nursing in the state in which you intend to obtain licensure. Inquire with your board of nursing regarding the specific registration process as requirements may vary from state to state.
• Registration with Pearson VUE. Once you have received the confirmation from the board of nursing that you have met all of their state requirements, proceed, register, and pay the fee to take the NCLEX with Pearson VUE . Follow the registration instructions and complete the forms precisely and accurately.
• Authorization to Test. If you were made eligible by the licensure board, you will receive an Authorization to Test (ATT) form from Pearson VUE. You must test within the validity dates (an average of 90 days) on the ATT. There are no extensions or you’ll have to register and pay the fee again. Your ATT contains critical information like your test authorization number, validity date, and candidate identification number.
• Schedule your Exam Appointment. The next step is to schedule a testing date, time, and location at Pearson VUE. The NCLEX will take place at a testing center , you can make an exam appointment online or by telephone. You will receive a confirmation via email of your appointment with the date and time you choose including the directions to the testing center. * Changing Your Exam Appointment. You can change your appointment to test via Pearson VUE or by calling the candidate services. Rules for scheduling, rescheduling, and unscheduling are explained further here . Failing to arrive for the examination or failure to cancel your appointment to test without providing notice will forfeit your examination fee and you’ll have to register and pay again. 
• On Exam Day. Arrive at the testing center on your exam appointment date at least 30 minutes before the schedule. You must have your ATT and acceptable identification (driver’s license, passport, etc) that is valid, not expired, and contains your photo and signature.
• Processing Results. You will receive your official results from the board of nursing after six weeks.

Important list and resources you need to know if you’re taking the NCLEX: 

• 2023 NCLEX Candidate Bulletin. This resource is a comprehensive guide for the NCLEX, providing essential information and contact details for candidates. It covers registration procedures, test fees, scheduling, testing accommodations, exam rules, and what to bring to the test site. The guide also includes details on the check-in process, breaks, technical issues, and the testing environment. It explains the results reporting process and retake-policy and provides information on the content, development, and test plans of the NCLEX. Additionally, it discusses the passing standard, item formats, and decision rules for passing or failing the exam.
• Sample Questions and Exam Preview. Get a headstart on your exam preparation with these sample test packs by the NCSBN. 
• Candidate Tutorial. With the new item types, we highly recommend testing how the Next Generation NCLEX (NGN) works. This tutorial guides you on interacting with different question types in your NCLEX exam. It provides a representative sample of items you may encounter during the test, allowing you to practice their functionality.

Please visit our Nursing Test Bank page if you’re looking to answer more practice questions from different topics and different question formats.

Recommended books and resources for your NCLEX success:

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy .

Saunders Comprehensive Review for the NCLEX-RN Saunders Comprehensive Review for the NCLEX-RN Examination is often referred to as the best nursing exam review book ever. More than 5,700 practice questions are available in the text. Detailed test-taking strategies are provided for each question, with hints for analyzing and uncovering the correct answer option.

Strategies for Student Success on the Next Generation NCLEX® (NGN) Test Items Next Generation NCLEX®-style practice questions of all types are illustrated through stand-alone case studies and unfolding case studies. NCSBN Clinical Judgment Measurement Model (NCJMM) is included throughout with case scenarios that integrate the six clinical judgment cognitive skills.

Saunders Q & A Review for the NCLEX-RN® Examination This edition contains over 6,000 practice questions with each question containing a test-taking strategy and justifications for correct and incorrect answers to enhance review. Questions are organized according to the most recent NCLEX-RN test blueprint Client Needs and Integrated Processes. Questions are written at higher cognitive levels (applying, analyzing, synthesizing, evaluating, and creating) than those on the test itself.

NCLEX-RN Prep Plus by Kaplan The NCLEX-RN Prep Plus from Kaplan employs expert critical thinking techniques and targeted sample questions. This edition identifies seven types of NGN questions and explains in detail how to approach and answer each type. In addition, it provides 10 critical thinking pathways for analyzing exam questions.

Illustrated Study Guide for the NCLEX-RN® Exam The 10th edition of the Illustrated Study Guide for the NCLEX-RN Exam, 10th Edition. This study guide gives you a robust, visual, less-intimidating way to remember key facts. 2,500 review questions are now included on the Evolve companion website. 25 additional illustrations and mnemonics make the book more appealing than ever.

NCLEX RN Examination Prep Flashcards (2023 Edition) NCLEX RN Exam Review FlashCards Study Guide with Practice Test Questions [Full-Color Cards] from Test Prep Books. These flashcards are ready for use, allowing you to begin studying immediately. Each flash card is color-coded for easy subject identification.

173 thoughts on “NCLEX Practice Questions Test Bank for Free”

How much are you charging for it?

Thanks for being generous

Thank you for your kindness & generosity. This is a big help for us, especially those with financial constraints.

Thanks Matt Vera for your utmost effort in helping nurses to pass the exam

You’re most welcome! Good luck on your exams!

Hello Matt do you still have the Test Bank questions for 2021. If you do can I have them please and thank you.

Hi Winnie, Please visit our

Thanks heaps! Matt..

The site is very useful.

Thank you mam/sir

This is very helpful site. god bless🤗

Great website wish l knew about it before taking my nclex

Thank you so much for this free site. I found it just as helpful as Kaplan and Sanders which I paid for. I recommended this nurseslabs to some of my nurse friends preparing for the NCLEX. I used it to study and passed my NCLEX October 28. I will continue to use this as a reference. Once again Thank-You. A.Haynes RN

Hey Matt, I am impressed by your generosity. I couldn’t believe these were all free. In all fairness, there should be a tab for donations for the constant upkeep of the web. A very minimal way to show our gratitude.

Although I just started nursing school the i formation is mind blowing and very useful for me already. Thank you for your generosity. I will be using all the practice quizzes and test to prepare myself. Thank you again.

Thank you for this free nclex practice tests! May you have more blessings and success! I will take my exam next month.

Very informative and helpful

Thank you!You’re a big blessing to those who will take the exam.

I can’t thank you enough for this gift you have given us to use . God bless you.

Thank you so much Matt! This is helping me work toward my NCLEX with less pressure.

Thanks a lot can I get reading materials on PDF please

Thanks Matt Vera for ingenious effort.

You are heaven sent, Thank you Matt for helping us.

you guys all thank you so much for this massively hard work and huge success for all the nurses around the world .

Your efforts are immeasurable, you are not only helping nurses to pass their NCLEX exams but also increasing the number of qualified/competent nurses providing healthcare around the globe. We are grateful. I used this site to prepare for internal exams whilst I was in school and it really helped me. I’ll be writing NCLEX soon..

Planning to start this process, I think this will be so helpful to me. Thankyou very much

Thank you so much Nurse matt vera for this qbank,most beneficial, God bless you., if I may ask for some videos or pictures associated with the questions, will also help e.g lung sounds,abdominal sound etc thank you

I loved your blog and thanks for publishing this about NCLEX practice questions!! I am really happy to come across this exceptionally well written content. Thanks for sharing and look for more in future!! Keep doing this inspirational work and share with us.

My name is Daniel m Johnson from Tanzania I’m holding diploma in nursing and midwifery I’m looking for different nurse from different country so as we can share ideas and experience since I’m student I need to no much thing about nursing ….any one who is touched to please help me I wish to be came a good nurse and help different people from different society

What a wonderful thing to do for people! Thank you very much.

This very helpful to me, thank you.

You did a great job Matt…

This is so lovely

Very useful site. Thank you so much.

This is an amazing job Matt!! REALLY INCREDIBLE!!!

With all this I will certainly pass my NCLEX exams.

THANK YOU so so much Matt, this is great beyond measure.. I have been hook to this website. God will bless you and yours abundantly

You’re most welcome! :)

i just want to confirm for #39 it state pt need additional teaching so E should also be included to the answer cause it was contraindicated to MS right? . thank you :)

Yes, this has been corrected. Thank you! :)

Very informative and helpful. Thank you so much Sir/ madam

Thank you for providing regarding NCLEX preparation

Very informative. Thank you for update.

This is for sure the best nurse’s website ever. It really helped me a lot during my training.

Number 58 of NCLEX test 5 does not have the answers listed.

Hi Rebekah, this is now fixed. Thank you for letting us know!

This is very helpful

It’s very informative. Thanks

Thank you Matt Vera for providing information free of charge

Any advice of how well you can do on these question to build up your confidence?

Thanks a lot for great job. May the Lord Almighty shower His blessing upon you.

Thank you, this site is amazing. God bless you

Thanks alot.I,ve got a question What score ranges would be considered a Pass? I scored 69.33% overall. is that a Pass???

75% and above, from the analysis I got from a test after getting below 75

Thank you Nurse Matt. You deserve all the blessings! 🙏🏻😊

This is very helpful. Thank you Nurse Matt

Question 16 on practice test 9 asked about assessment during L sided CHF, yet the correct answer pertained to right sided HF. Just wanted to let you know…. Thanks for the practice questions! Appreciate all the work put into this.

Question 41 of NCLEX-RN Test 2 has two C choices. Thanks.

Hi, I like your questions, they’re very nice and challenging. Learning a lot from them.

I love this site.. Now all friends are learning serious from here

Thanks you guys are very generous

From Kenya, this site is so helpful,am learning a lot here.Thank you especially for the care plans.

Thank you so much

You Matt and your staff are such a blessing to us who will be taking the NCLEX RN exam. This site is very useful and helpful because it is very comprehensive and easy to understand. God bless and may tribe increase. Thank you so much

The site is very informative. I have learned a lot. Test questions are really amazing which I cannot find with other website. However, I got a low score, thus I need to further study especially on the areas wherein I got a below passing grade. I hope you will allow me. Thank you

thank you so much for creating this site for people like us. This excellent job. May God bless you in Jesus name —Amen

The Practice tests are awesome! The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of charge.

Thank you so much. It was really helpful. I passed the exam. God bless real good.

Thank you Matt for the awesome and great website! its beyond compare. I want more practice test questions to hone my knowledge in Nursing practice, however, when I am trying to open one of the practice tests, I cant go through it. Could you please allow me? God bless

Thank you Matt for this practice test. Now I know my strength and weaknesses and will concentrate of the system that needs for further study. Can I practice more in practice test no 2? Please allow me to go trough with it. Kudos to you and your staff.

Hi this is what i got, im so nervous due to my nclex exam its gonna be this coming oct. Its doesnt say pass or not.

Your score 48% Categories Basic Care and Comfort 100% Health Promotion and Maintenance 53.85% Pharmacological and Parenteral Therapies 26.67% Physiological Adaptation 54.55% Psychosocial Integrity 100% Reduction of Risk Potential 36.36% Safety and Infection Control 100%

Thanks so much for this useful information. God bless you.

Thank you so much for all you do

The Practice tests are excellent. The rationales are all well-explained which I love because it gives me more knowledge and insight. Thank you for creating this website free of us. Remain blessed.

Like I am obsess with nurselab. A handy powerful tool, to keep you updated, thick and richly packed. You guys made reading so interesting and magnetic and very easy. Please do not stop. I recommend this to all nurses.

Love this. Thank you for sharing your generosity. I’ve been using this since I was still in college and I continue to use it until now.

Thank you so very much for this

I remain speechless but mostly grateful for your unconditional helpful assistance for this awesome richly throughout profound tool and opportunity given to me to increase my confidence, strengthen my knowledge, and be ready for my upcoming exam. Your questions and rationales are beyond my expectations. You are a God’ sent angel. Thank You. God Bless you. I will be forever grateful to you for making my dream come true! 🙌

This website can help me to review for NCLEX and it is for free! Thank you so much!

Amazing and really awesome job to you Matt and your entire team, may God replenish your source for giving us this for free. I have recommended to all my friends and family. Remain blessed and stay safe.

That’s very kind of you. Thank you so much! Bless you!

Your test questions have greatly helped me pass my NCLEX. I passed my NCLEX today and thank you to Nurseslabs. I came across this website by accident and I do not know how but it was divine intervention. I will definitely recommend Nurseslabs to my friends. The quality of the questions and rationales were very good and you would not think this is all for free the kind of work that came with it.

Kudos Nurseslabs and wishing all the future test takers all the best!

Wow Sam, congrats! What materials did you use other than nurseslabs? I’ve been answering nurseslabs also. My exam is on June. I hope I could also make it.

Thank you for this NCLEX sample test,as tool to determine areas i need to review/focus on for the proper exams.

This website can help me to review for NCLEX Thank you so much!

I just wanna ask why is that there are no more rationale posted after answering the question unlike before. Thanks by the way for the free and great Q & A bank. ❤

Sorry, we’re currently having some performance issues with that setup. Until we can resolve it, we have set each quiz to show results and rationales only after you have finished all the questions. Thank you for your understanding.

Hello, how do I get my score after taking the test to know if I am doing well or not

Hi, after you’re done answering all questions, the final item will direct you to the “Quiz Summary,” from there, click on the “Finish Quiz” button to get your final score.

Very great tool to study for the NCLEX. I passed my exam just by focusing on the questions and rationales provided here.

That’s great! Congratulations!

Thank you so much. It’s very helpful. God bless you…

Thank you for being generous. This is a big help.

I got 55/75.

Thank you so much for making this site.

Very helpful. Thank you and God bless…

Thank you so much, Nurse Matt for your generosity. Helping your fellow nurses and aspiring nurses to work abroad is such a selfless and noble act. God bless you and your team!

Thank you for your kind words, JB! Will pass on this message to the team. :) God bless!

The rationale after the question will really help us a lot specially when you are just using the question via online.

Hi Romel, we have temporarily changed this setting so that results and rationales will show only after you’ve finished the quiz. This is because we’re having some performance issues when using the previous setting. We’ll revert the changes once we’re sure the problem is resolved. Thanks for understanding!

I didn’t get my results after answering the 75 questions. Please why?

Hi Esther, did you click on the “Finish Quiz” button?

Thanks for all these questions where/how can i check my answers to these questions?

After answering the last item of the quiz, you’ll be redirected to the quiz summary. From there, click on the “Finish Quiz” button to view your score and results. You can also click on the “View Questions” button to review your answers and read the rationales.

Hi, thanks for providing so much useful information and all the test banks!

In RN practice Quiz 1:75 questions, for question 70, wonder if the correct phrase would be “would you NOT expect”?

Hi Cecilia, thanks for letting us know. We have corrected the question. Thank you! 🥰

Thank you for allowing me to practice the nurseslabs questions. The rationales are well explained. Thank you!

Thank you Ruth. Hope you’ve learned a lot from our practice questions. 🥰

God bless you

My name is Samuel. I just started with the RN practice questions. Thank you for the opportunity.

Hi, thank you so much for your generosity. Using this to prepare for my NCLEX and find it very informative. I will keep you posted on how it goes on the D-day

Frequently throughout the quiz, ARDS is given as “Adult Respiratory Distress Syndrome” instead of “Acute Respiratory Distress Syndrome”. This needs to be corrected.

Hi Bella, thanks for bringing this up.

Technically both terms are correct since “adult respiratory distress syndrome” is an earlier name referred to “acute respiratory distress syndrome” to differentiate it from respiratory distress syndrome in neonates and children. For the sake of uniformity, we have edited them to “acute respiratory distress syndrome”. You can read more about it here: https://doi.org/10.1164/ajrccm.149.3.7509706

This is so kind a gesture, remain blessed .The information is very understandable and helpful

I just wanted to thank you for taking the time to generate this website, this is really helpful and is free. God bless you

Thank you for your support and guide toward my nclex preparation.

Thanks for your generosity. I hope to pass my NCCLEX just on the first attempt Grateful for all your help

thanks for the help

Hi Sir, kindly explain why this question – The client with hyperemesis gravidarum is at risk for developing: Metabolic Acidosis is the answer. Thank you.

Quite familiar with the content. Thanks for this selfless initiative.

It has been a nice experience.

I love these practical questions. So helpful.

Thanks very much this is a good help for all students

Thank you for mett this free test which i have passed yesterday afternoon so ,it is greatest pleasure which will help me

Thank you so much for this great initiative.

Thanks for being kind God bless you

thank you for your help and kindness. It’s difficult to go back to school after 22 years of practice as a RN to take the test where you must cover a vast knowledge, which you do not use in everyday working (depends on the special field you are working. so I really appreciate your effort and dedication.

Matt Vera and all those helping us through this free medium, May God richly bless you abundantly. And may all your good desires come through

Hello Vera, I would start by thanking you for the great job you’ve done by helping us in our preparation for the exams. secondly would wish to know wther you have audio clips for lung, heart and abdominal sounds. thank you in advance and if any kindly let mh know pls.

What should we be scoring on these practice questions to let us know that we’re ready for the NCLEX

Do you have LPN test also?

Hi, please visit NCLEX-PN Practice Questions & Test Bank (200 Questions)

Thank you so much Nurse Matt you just don’t know how nurseslabs helped me in my nursing career and i even recommended nurseslabs to some of my friends. God bless you😊

Hi Matt, Thank you for this, indeed very helpful practice questions. Just a query though it says here to limit wrong answers to 15 or less? So is that the passing mark ? about 75-80%

Yes, that is correct. :)

Thank you so much for the practice questions. I learned a lot and it helped me to understand why I was getting my answers wrong. I used Kaplan and Saunders but it wasn’t helping me. I feel more confident than ever to retake my boards.

thank you…. wish this help a lot to my daughter to passed please pray for her God bless!!!

hi Matt, can l still use these question banks to study for the new NGN questions

Hi nurse Matt, May I gave all the questions please, need to prepare study for exam after been off school over 30 years, realize it for not giving up not try again, thank you 🙏

Thank you so much Nurselabs! I passed my NCLEX-RN exam using only your practice 75 question per day questions bank. I have a tight budget and not able to purchased online review and I just focused in answering your practice questions in just 2 weeks!!! Thank you for helping nurses! God Bless you more!

I want to practices questions

Hello Thanks so much for your good heart and good wish for us to practice and pass the NCLEX. Well appreciated. Please after your update I can’t get the answers and rationale to the 75 questions. This will help me to know my ability and where am lagging behind. Please how can this be rectified Thanks Hope

Hi Hope, did you finished all of the questions for the quiz? Your score together with the correct answers and rationale will only show after you’ve completed the whole quiz.

Hello Vera I finished all 75 questions submitted but no answer or rationale came up. I tried upto 3 times same. Even my friend I shared your content with complained of same thing, answers not coming. Please what can we do to access the answers and rationale Thanks Hope

What particular quiz?

Hello, great resource! I am a nurse that wants to help student nurses reach their full potential as nurses and pass the nclex. I would like to utilize your tests and quizzes to help my students learn to critically think through the questions and learn how to put their nursing knowledge to use. Would you allow me to utilize your questions in my content?

Thank you for the kind words! It’s awesome to hear that you’re dedicated to helping student nurses thrive. 🌟

Absolutely, you’re more than welcome to utilize our tests and quizzes for your students! We believe in collaborative efforts to strengthen the nursing community. Just ensure to give appropriate credit when using the content.

Out of curiosity, are there specific areas or topics you find students struggle with the most when preparing for the NCLEX? Maybe we can work together to create even more targeted resources!

Best of luck with your mission to guide the next generation of nurses!

Hi, I am studying for med surg 1 and med surg 2 upcoming exam. Need to pass both exams.

Sounds like you’ve got a busy study schedule ahead! MedSurg can be challenging, but with the right resources and dedication, you’ve got this. If you need specific materials, tips, or just a morale boost, don’t hesitate to reach out. Else, you can do practice all MedSurg exams on our Nursing Test Banks . Rooting for you to ace both exams! 💪

thank you so much… a big help

Hi Glacier and what a nice name!

You’re welcome! Really glad to hear the NCLEX practice questions were a big help. If you’ve got any other areas you’re prepping for or need more practice with, just let me know. Here to support your journey!

Thanks a lot @nurseslabs for this initiative I really believe by the time I sit my exam I will be a great nurse than ever before. I am learning a lot from the questions and explanation.

Hey Charles, You’re very welcome! I’m thrilled to hear that you’re finding our initiative helpful in your journey to becoming a great nurse. Remember, continuous learning is a key part of nursing practice, and it’s fantastic to see your dedication to it. If you ever come across any challenging topics or have questions about specific nursing concepts, please don’t hesitate to reach out. We’re here to support you every step of the way. Keep up the excellent work, and you’ll do great on your exam! 📖🏥🌟

Much help for beginners like us

Thank you so much Nurseslabs, I made it!!! Your practice exams, especially the rationales helped me a LOT…thank you!!!

Wow, that’s awesome news! 🌟 Huge congrats on making it through – your hard work and dedication really paid off. It’s super cool to hear how our practice exams and rationales played a part in getting you across the finish line.

Remember, this is just the beginning of an amazing journey in nursing. The field’s always changing and growing, and so will you. Keep that enthusiasm and curiosity going strong!

If you ever need a hand or just want to share your journey as you dive into your nursing career, give us a shout. We’re always here to cheer you on and lend support.

Big congrats again and best of luck out there!

Thanks for the information

thanks for the guide

Thank you for your kindness.

Thank you very much!

Thanks a lot for this whole range of knowledge; it’s now upon me to work extra hard to be a better nurse outside there or help other nurses be better at service delivery.

Hi Evans, You’re so welcome! I’m glad to hear that the range of knowledge from the NCLEX practice questions is empowering you to aim for excellence in nursing. Remember, every bit of effort counts towards becoming not just a better nurse but also a great mentor to others in the field. If you need more resources or advice along the way, I’m here to help. Keep up the fantastic work!

Please how can I practice questions please 🙏

In practice exam 5 question 22 asks about hyperemesis…. wouldn’t that cause alkalosis (rather than acidosis), since its acid from the stomach that is leaving the body?

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The National Council Licensure Examination is more commonly known as the NCLEX exam. This test is for the licensing of nurses in the U.S. and Canada, and it is taken after graduating from nursing school. There are two different versions of this nursing exam, the NCLEX-PN and the NCLEX-RN.

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Educational strategies and nursing theory to prepare leaners for NCLEX‐RN

Khalid bandar almasloukh.

1 Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park Pennsylvania, USA

Melissa Miner

Kathleen phillips, michael evans, associated data.

The data that supports the findings of this study are available in the supplementary material of this article.

To identify teaching stategies, theories, and methods to enhance students' quality of life (QOL) that are used in preparing students for the NCLEX‐RN exam.

A scoping review was conducted.

Arksey and O'Malley's methodological framework and PRISMA‐ScR guidelines were utilized. Data were derived from four databases including CINAHL, ERIC, PsychINFO and Web of Science using specific keywords. Inclusion criteria were English language and articles published in the last 7 years.

Studies ( N  = 25) revealed that multiple educational strategies are used to prepare students for the NCLEX‐RN exam; however, there was not a consensus on a best practice. Eight theories were utilized in more than one article. QOL concerns of psychological, social, spiritual, financial and occupational dimensions may relate to the NCLEX‐RN results.

Public Contribution

Patterns in educational strategies and theories were noted among articles, but there was no focus on enhancing students' QOL.

1. INTRODUCTION

Although there are numerous preparation resources for the National Council Licensure Examination for the Registered Nurse (NCLEX‐RN), the focus on the quality of life (QOL) for nursing students during preparation for the licence exam is limited. In April 2023, The Next Generation NCLEX‐RN (NGN) was launched with new question types (National Council of State Boards of Nursing [NCSBN],  2019 , 2023 ), that have limited available resources compared to the accumulated resources for the former, traditional NCLEX‐RN. Students, professors and school officials may be focusing solely on preparing students for the NGN exam, which may increase the stress level of the students.

Almasloukh and Fahs ( 2021 ) conducted a QOL concept analysis based on Roy adaptation model (RAM). According to Roy ( 2009 ), one of the main nursing goals is to maintain and enhance QOL. According to Almasloukh and Fahs ( 2021 ), QOL is defined as “continuous process based on the degree of balance, self‐esteem, and satisfaction, among different life dimensions that are influenced by the perception of life events and are shown in positive or negative actions” (p. 72). This means nursing students' QOL may depend on many life dimensions that students should stay balanced in and maintain self‐esteem and satisfaction while preparing for NCLEX‐RN. Educators should use educational strategies to ensure academic and NCLEX‐RN success, while focusing on students' positive QOL.

Social relationships and social welfare may affect the QOL of students who are preparing for their NCLEX‐RN. For example, when students are identified at risk of failure or in need of remediation, or they receive low scores that threaten their success, they may isolate, withdraw and disengage from many educational activities because of feelings of hopelessness or shame (Maas,  2017 ). Faculty are urged to recognize those complex social, emotional and psychological effects on students when they may happen during the preparation of the NCLEX‐RN. Similarly, social welfare, relationships and external expectations should be assessed for adult learners to ensure well‐motivated learners (Maas,  2017 ). Students' social welfare may affect their chance to pass NCLEX‐RN, and schools should aim to keep their nursing students positively socially engaged and motivated. Williams ( 2018 ), who utilized Wenger's social learning systems and the community of practice, explained learning as competencies based on social processes and experiences based on the individual level. Furthermore, Wangerin ( 2015 ) conducted a qualitative analysis of 20 programme improvement plans and considered nursing education as an integral part of the educational system and the healthcare system, both of which have social structures that are continuously evolving and changing.

This scoping review is guided by Arksey and O'Malley's ( 2005 ) methodological framework and follows the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses‐Extension for Scoping Review (PRISMA‐ScR) guidelines as explained in the Joanna Briggs Institute (JBI) methodology (Peters et al.,  2020 ). Arksey and O'Malley's ( 2005 ) methodological framework consists of five required stages starting with stating the research question.

2.1. Stage 1: Identifying the research question

The research study is driven from the aims of this review. This scoping review research questions are as follows:

• What education strategies have been utilized when preparing students for the NCLEX‐RN? 2. What theories have been utilized as frameworks when preparing students for the NCLEX‐RN? 3. What is known about learners' QOL when preparing for the NCLEX‐RN?

2.2. Stage 2: Identifying relevant studies

Authors identified the following keywords, including all synonyms and corresponding controlled vocabulary: (1) teaching strategies or teaching methods or teaching approaches or classroom techniques or strategies or clinical reasoning or clinical judgement or critical thinking or wellness or quality of life, (2) AND theory or model or framework or concept, (3) AND NCLEX or nursing licens* exam*. The search includes results from the last 7 years, 2015–2022. On April 4, 2022, an updated search was conducted and initially resulted in 168 articles from four databases, CINAHL (81), ERIC (5), PsychINFO (29) and Web of Science (53). The exact keywords and controlled vocabulary were developed in collaboration with a coauthor, who is a librarian.

2.3. Stage 3: Study selection

After deleting duplicates, items decreased from 168 to 143. After manually removing additional duplicates, the number decreased from 143 to 137 items. The title and abstract screening removed an additional 93 items, resulting in 44 items for full‐text review. Each item was screened by two investigators independently, and when any item received different decisions, the final decision was made by a third investigator. Editorials and articles that did not include educational strategies to prepare nursing students for NCLEX‐RN were excluded. After a full article review, items decreased from 44 to 25 (Figure  1 ).

PRISMA‐ScR flow diagram modified for scoping review process.

2.4. Stage 4: Charting the data

Data from each article were charted in a shared Google Doc among authors. Data included authors, publication date, population of the study, sample size, study method and design, educational strategies, theories, relation to QOL and location of each study.

2.5. Stage 5: Collating and summarizing and reporting the results

Tables  1 , ​ ,2, 2 , ​ ,3 3 were extracted from the main shared charted data to highlight level of evidence, educational strategies and the commonly used theories, respectively. To ensure the breadth and depth of reporting results, the PRISMA‐ScR guidelines were used.

Level of evidence.

Result of individual sources.

Theories and models that were found in more than one reviewed article.

3.1. Selection and characteristics of source

The reviewed studies ( N  = 25) included dissertations ( n  = 9) and peer‐reviewed articles ( n  = 16). Among dissertations and all reviewed studies, similarities in methodologies were noted, including qualitative and quantitative methods of descriptive, cohort designs and pretest‐posttest studies. Qualitative designs were used in five out of the nine dissertations (Johnson,  2015 ; Joseph,  2017 ; Ryan,  2019 ; Wangerin,  2015 ; Williams,  2018 ). A case study was the design of three out of the five qualitative dissertations (Johnson,  2015 ; Joseph,  2017 ; Williams,  2018 ). Similarly, descriptive designs were found in eight studies (Brackney et al.,  2017 ; Eisenmann,  2021 ; Garwood,  2015 ; Harrison,  2018 ; Hensel & Billings,  2019 ; Myles,  2018 ; Pence & Wood,  2018 ; Sanderson et al.,  2022 ). Cohort studies were the design for six studies (Duncan & Schulz,  2015 ; Harris,  2018 ; Kinyon et al.,  2021 ; Myles,  2018 ; Romanowski et al.,  2021 ; Schlairet & Rubenstein,  2019 ). Finally, a pretest‐post‐test method was used in three studies (Blakeslee,  2019 ; Kinyon et al.,  2021 ; Zehler & Musallam,  2021 ), including a pilot pretest‐posttest study (Zehler & Musallam,  2021 ).

3.2. Critical appraisal: Level of evidence and significance

The level of research evidence was based on the criteria recognized by Grove and Gray ( 2019 ), consisting of seven levels from the highest to the lowest. Among the reviewed articles, there were no Level I (systemic review and meta‐analysis) or Level II (randomized control trial or experimental) studies. Similarly, there were no Level IV studies such as a mixed‐methods systematic review or qualitative meta‐synthesis. The highest article was Level III (Table  1 ). Editorials, Level VII, were excluded from this review.

Statistical significance among the reviewed articles was limited to five articles (Harris,  2018 ; Harrison,  2018 ; Pence & Wood,  2018 ; Schlairet & Rubenstein,  2019 ; Zehler & Musallam,  2021 ). The duration of those studies and sample sizes and designs played an important role in finding significance in quantitative studies. For example, Harrison ( 2018 ) conducted a descriptive retrospective correlational study on nursing students ( n  = 258) and found a statistically significant positive correlation between concept‐based curriculum and critical thinking ( p  < 0.001). A concept‐based curriculum examines concepts that link to the delivery of patient care. It challenges students to think more critically about topics and situations they encounter by applying prior knowledge (Duncan & Schulz,  2015 ; Harrison,  2018 ). Harrison also found that critical thinking ( p  = 0.009) can predict the probability of passing the NCLEX‐RN the first time.

The importance of the duration of the preparation was highlighted in a pilot cohort study. Schlairet and Rubenstein ( 2019 ) conducted a 6‐week study during the last semester to test the effect of NCLEX Coaching Model on the first‐time NCLEX‐RN passing rate. There was a mild improvement in the first‐time passing rate, from 89% ( n  = 101) to 90% ( n  = 107). According to the authors, if the study had been longer in time, the results might have detected statistically significant improvement. Although the authors did not find significant data on the first‐time passing rate, the authors found statistically significant ( p  < 0.001, n  = 114) improvements in confidence/readiness scores after the completion of the intervention when compared to before starting the intervention. The authors suggested a possible maturation effect on the sample as this study was conducted in the last semester (Schlairet & Rubenstein,  2019 ).

3.3. Educational strategies

Educational strategies (Table  2 ) varied within the current literature review. Active learning strategies were the most frequent ( n  = 11) educational strategy cited in this scoping review, followed by faculty coaching/support ( n  = 6), NCLEX‐RN‐style question exposure ( n  = 5), NCLEX‐RN review course and products ( n  = 4), remediation/tutoring for at‐risk students ( n  = 3), and simulation ( n  = 2).

3.4. Theories

The utilization of theories or models was noted in ( n  = 19) studies. Eight theories/models appeared in more than one article (Table  3 ); many theories were used once in one of the reviewed articles. Tanners clinical judgement model was frequently found in this review (Brackney et al.,  2017 ; Eisenmann,  2021 ; Gonzalez et al.,  2021 ). Similarly, Gonzalez et al. ( 2021 ) and Hensel and Billings ( 2019 ) discussed the NCSBN Clinical Judgement Measurement Model (NCJMM) and referred to the originality of Tanner's clinical judgement model.

Similarities between Tanner's clinical judgement model (Tanner,  2006 ) and the NCJMM are abundant. The first step in Tanner's clinical judgement model is noticing, which is explained as noticing important aspects of the situation. Similarly, the NCJMM starts with recognizing cues and then analysing cues. Likewise, interpreting is the second step in Tanners' clinical judgement model, which involves analysing reasoning patterns. In the interpreting and responding steps, Tanner ( 2006 ) discusses rolling out hypotheses; similarly, the third step in the NCJMM is prioritizing hypotheses. Finally, reflection is the last step in Tanner's clinical judgement model. Tanner's model depicts reflection‐in‐action and then reflection‐on‐action, whereas the second layer in the NCJMM includes refining hypotheses and then evaluation. According to Eisenmann ( 2021 ) and Tanner ( 2006 ), nursing students should still learn the nursing process in addition to other clinical judgement strategies. It was suggested that the NCJMM has higher advantages and available resources to prepare nursing students among other clinical judgement models (Hensel & Billings,  2019 ).

Additionally, Eisenmann ( 2021 ) referred to the Caputi‐think‐like‐a‐nurse theoretical framework and explained how it might assist in educating nursing students to make clinical decisions. Moreover, Eisenmann ( 2021 ) discussed Benner's novice‐to‐expert theory and suggested this theory may assist in combining educational knowledge with clinical experience to approach appropriate clinical reasoning. Furthermore, many authors referred to different theories, and some authors used more than one theory in a study. For example, Harris ( 2018 ) utilized Neuman system model and referenced RAM as another system theory.

3.5. Quality of life

Although addressing QOL of students who are preparing to take the NCLEX‐RN test was one of the goals of this review, no clearly focused discussion about QOL in any of the reviewed articles was found, except elements that may relate to the QOL, such as social welfare and mindfulness. To illustrate, Sanderson et al. ( 2022 ) developed a model that focuses on non‐academic factors. They found that only 36% of NCLEX‐RN success is attributed to academic factors. Sanderson et al. ( 2022 ) designed a model for student success and tested it on 1500 students over four campuses in a multi‐campus university. Authors identified risk factors outside the classrooms and even before starting the nursing programme and reacted based on identified weaknesses (Sanderson et al.,  2022 ). Similarly, Brackney et al. ( 2017 ) and Moniyung ( 2015 ) utilized Astin's input‐environment‐outcome model. The input includes student characteristics upon admission (Moniyung,  2015 ).

Sanderson et al. ( 2022 ) examined psychosocial and socioenvironmental factors and test‐taking strategies on admission. The interventions included mindfulness resilience programs and NCLEX‐RN preparation materials. With these multidimensional interventions, the passing rate for the NCLEX‐RN continued to trend upward for four consecutive years. Training in mindfulness and coping strategies was provided based on student needs, and students and the faculty selected activities together (Sanderson et al.,  2022 ). Similarly, in another study, it was recommended measuring test anxiety and the effect of mindfulness activities before taking tests. This is because mindfulness has the potential to increase calmness, allows students to envision success, and consequently may increase students' probability of passing a test (Ryan,  2019 ).

4. DISCUSSION

Although various theories and educational strategies were found, limited discussion about students' QOL was noted. This may relate to the fact that some theories focused mainly on education rather than on enhancing the learner's experience and QOL during the educational process. Active learning strategies were the most found strategy among other valuable educational strategies.

4.1. Educational strategies to prepare nursing students for NCLEX‐RN

Active learning or integrative learning strategies support student engagement and application of new and previous knowledge. Unfolding case studies were frequently used as an active learning/educational strategy. Case‐based learning was found to stimulate rich student‐led discussion, foster critical thinking and enhance student content mastery on standardized exams (Johnson,  2015 ; Kinyon et al.,  2021 ; Romanowski et al.,  2021 ; Wangerin,  2015 ; Williams,  2018 ). Hensel and Billings ( 2019 ) claimed that all types of case studies (i.e. clinical scenarios, integrative, unfolding) could be used to teach clinical judgement because case studies “provide students the opportunity to link classroom learning with clinical practice” (p. 129). Game‐based learning was found to be a positive active educational strategy because it created a collegial culture in the classroom, fostered critical thinking and clinical judgement and prepared students for the NGN (Romanowski et al.,  2021 ; Zehler & Musallam,  2021 ).

Concept mapping was also frequently cited as an active learning/educational strategy. Concept mapping helps students to visualize and remember concepts, increases their ability to prioritize nursing care and improves critical thinking and clinical judgement (Eisenmann,  2021 ; Garwood,  2015 ; Wangerin,  2015 ). Based on this review and in particular the work of Eisenmann ( 2021 ), a concept map was designed (Figure  2 ). This concept map utilizes RAM framework (Roy,  2009 ) centrally to visualize some possible relationships among different aspects such as physiological adaptation and psychological integrity. Furthermore, the concept map incorporates the NCJMM (National Council of State Boards of Nursing [NCSBN],  2019 ) and parts of the NGN test plan (National Council of State Boards of Nursing [NCSBN],  2023 ). The figure depicts client‐centred care, as Blakeslee ( 2019 ) suggested that although students are encouraged to think critically, care should be patient‐centred.

Concept map and Roy adaptation model.

Faculty coaching and support were cited in this review of literature as a resource to assist students to successfully prepare for the NCLEX‐RN. Regular academic advising as a meaningful faculty‐student interaction fosters academic motivation in students and assists in the identification of potential and actual student barriers to successful learning throughout the nursing programme (Davis & Morrow,  2021 ; Hackney,  2017 ; Maas,  2017 ; Ryan,  2019 ). Schlairet and Rubenstein ( 2019 ) found that NCLEX‐RN coaching improved students' confidence (personal and professional) and readiness and promoted NCLEX‐RN success. Davis and Morrow ( 2021 ) emphasized the importance of creating a unified faculty attitude where “it was everyone's job to ensure students pass NCLEX‐RN” (p. 363). Furthermore, the cooperation among faculty, students and healthcare clinical members was valued by the students (Gonzalez et al.,  2021 ).

According to Davis and Morrow ( 2021 ), faculty members were committed to working unitedly and invested their time above and beyond the expected towards students' success in the NCLEX‐RN examination. This commitment allowed students to view faculty members as counsellors for their NCLEX‐RN success. When students have a higher quality of educational support, they are more likely to pass NCLEX‐RN (Sanderson et al.,  2022 ). However, dismissal decisions were made since those who fail two nursing courses are twice as likely to fail their first NCLEX‐RN compared to those who fail one nursing course or never fail a nursing course (Sanderson et al.,  2022 ). Thus, although supporting strategies and resources should be implemented, it may be reasonable to have a dismissal policy based on failing two nursing courses.

NCLEX‐RN‐style questions exposure was identified in the literature review as an important educational strategy to prepare nursing students for the NCLEX‐RN. Continually practising NCLEX‐RN‐style questions and rationales is a beneficial learning approach and should be implemented throughout the programme (Davis & Morrow,  2021 ). Early exposure to test‐taking strategies coupled with NCLEX‐RN‐style questions and rationales boosted students' confidence and readiness for standardized assessments and NCLEX‐RN readiness measures (Johnson,  2015 ; Joseph,  2017 ; Ryan,  2019 ). Williams ( 2018 ) claimed that continual exposure to NCLEX‐RN‐style questions and rationales assisted students to “think like a nurse” in classroom and clinical settings. A NCLEX‐RN review course was highly recognized as an important strategy to prepare students to have first‐attempt success on the NCLEX‐RN. Delivery formats differed from asynchronous online to live and in‐person and varied in length from 3 days to 8 weeks (Myles,  2018 ; Schlairet & Rubenstein,  2019 ; Wangerin,  2015 ).

Remediation plans and tutoring opportunities in nursing programs are effective educational strategies that are also recognized in this scoping review. Including academic support programs such as remediation and tutoring within a nursing programme can positively support students, especially those identified as at risk (Myles,  2018 ; Wangerin,  2015 ). Maas ( 2017 ) emphasized the importance of providing at‐risk students support and additional resources to participate positively in a remediation programme to support their success within the programme and the NCLEX‐RN. Sanderson et al. ( 2022 ) described the importance of providing students access to open skills and simulation labs for practice and remediation and peer support for supplemental instruction.

Simulation was also described as an effective educational strategy. Simulation has been used to increase students' critical thinking, clinical judgement, confidence in the clinical setting, and readiness for the RN role (Blakeslee,  2019 ; Brackney et al.,  2017 ). In this scoping review, simulation could have been included as a format for a case study. Multiple educational strategies to prepare nursing students for the NCLEX‐RN have been described in the literature. Blakeslee ( 2019 ) stated, “instead of focusing on a single teaching strategy, nursing education programs are encouraged to develop multiple comprehensive teaching strategies to help nursing students improve their critical thinking skills” (p. 6).

Garwood ( 2015 ) suggested that an effective educator must not only ascertain how students learn best but also motivate them to learn. Similarly, the self‐determination theory of motivation was suggested to positively correlate with the probability of passing the NCLEX‐RN. Self‐determination theory differentiates between intrinsic motivation such as personal interest and values and extrinsic motivation such as grades (Hackney,  2017 ; Ryan,  2019 ). Thus, nursing instructors may use different strategies to motivate students based on their gratification and deprivation, as learners are expected to experience gratification and deprivation during their educational journey. Therefore, faculty can play a vital role in motivating students to foster self‐determination, and students with higher levels of determination are more likely to pass NCLEX‐RN and continue a lifelong learning journey after graduation (Hackney,  2017 ).

4.2. Theories

In this review, Knowles' adult learning theory was one of the most found among the reviewed articles. Knowles' adult learning theory of andragogy views adult learners as self‐directed and internally motivated who value activities focused on their goals, such as licence or certification (Garwood,  2015 ; Johnson,  2015 ; Maas,  2017 ). Furthermore, Moniyung ( 2015 ) noted the adult generational differences, including the millennial generation – those born from 1980 to 2000.

Although there are some common characteristics in adult learners, such as thriving in a respectful environment (Garwood,  2015 ) and the ability to cooperate with others (Garwood,  2015 ; Moniyung,  2015 ), millennials are more comfortable with using technology (Moniyung,  2015 ). Garwood ( 2015 ) suggested that nursing faculty should adapt to engage and motivate the millennial generation. Indeed, millennial students may corroborate successfully using technology to prepare for their NCLEX‐RN exam, and faculty may need to adapt to engage and motivate millennial students. Pence and Wood ( 2018 ) conducted a retrospective, descriptive correlational study on Bachelor of Science in Nursing (BSN) critical care course students ( n  = 195) and found a positive, statistically significant relationship ( p  < 0.001) between using software, including PassPoint and PrepU from publisher Wolters Kluwer, and NCLEX‐RN success. Davis and Morrow ( 2021 ) found that commercial NCLEX‐RN products are a necessary strategy to improve NCLEX‐RN first‐time pass rates as they supplement the program's curriculum and support faculty and students with a variety of NCLEX‐RN readiness resources. Pence and Wood ( 2018 ) noted that preparation started from the first semester in the nursing programme and should be continued to the NCLEX‐RN exam day.

4.3. Quality of life

When Peplau's theory was utilized to develop the NCLEX Coaching Model, the authors illustrated that advantages might extend socially even after passing NCLEX‐RN. The social confidence that students gain may allow students to confidently find an appropriate job (Schlairet & Rubenstein,  2019 ). Faculty commitment fostered the students' accountability. Davis and Morrow ( 2021 ) further discussed self‐accountability based on Peplau's theory and referred to the article that was found in this search (Schlairet & Rubenstein,  2019 ). Self‐accountability allowed students to have a higher level of responsibility, confidence, and consideration of further educational advancement in the nursing profession. Peplau's theory of interpersonal relations was useful and fit logically in implementing a Student NCLEX Coaching Model (Schlairet & Rubenstein,  2019 ). Thus, both social factors and self‐accountability may affect students' success.

In addition, spiritual factors may relate to the student's QOL during preparation for the NCLEX‐RN. To illustrate, Harris ( 2018 ) utilized Neuman's nursing system theory and Rotter's social learning theory. Harris found a significant relationship between spirituality and perceived NCLEX‐RN competency. Additionally, internal or external locus of control, which is part of Rotter's theory, has been found to relate positively to the NCLEX‐RN Test Plan. Finally, failing the NCLEX‐RN may lead to negative QOL, including financial difficulties, low self‐esteem and loss of employment (Pence & Wood,  2018 ). Thus, psychological, social, spiritual, financial and occupational dimensions may relate to the NCLEX‐RN results, either positively or negatively.

Similarly, Roy ( 2009 ) depicted that adaptation and coping occurs through four modes, including self‐concept, physiologic, role‐function, and interdependence modes. Most of the reviewed articles may be included under the role‐function mode and a few under the self‐concept mode. To clarify, none of the reviewed articles focused on the physiologic mode. Based on RAM (Roy,  2009 ), this review illustrates how different identified educational strategies may fit under the different modes, which may affect the students' QOL (Figure  3 ). The figure illustrates that education should be student‐centred because students should be active and responsible for their education (Joseph,  2017 ).

Roy's adaptation model and NCLEX preparation.

4.4. Summary of evidence

Multiple educational strategies to prepare students for the NCLEX‐RN were mentioned in the literature versus a single best practice. Suggested approaches included active learning strategies, faculty coaching and support, continuous exposure to NCLEX‐RN style questions, NCLEX‐RN review courses and products, remediation or tutoring and simulation. Different theories were used, and limited discussion about students' QOL was noted. No clearly defined theory that focuses on students' QOL while students are preparing for the NCLEX‐RN was discussed.

4.5. Limitations

One of the main limitations of this review is that it did not target specific educational strategies. Secondly, the used keywords were designed to gather articles that include theories and theoretical frameworks or “concepts” as part of the conceptual theory. However, five articles were picked by the research engine because they included educational strategies, such as concept‐based methods or curricula or concept maps (Duncan & Schulz,  2015 ; Gonzalez et al.,  2021 ; Harrison,  2018 ; Myles,  2018 ; Romanowski et al.,  2021 ). This may lead this scoping review to focus on the “concepts” as educational strategies more than other vital educational strategies. The review did not find focused papers on NGN, which may be related to the fact that the NGN had not been launched at the time of this review.

4.6. Recommendation

It is recommended to focus on multidisciplinary research with various majors, including education and nursing. Eight of the nine reviewed dissertations were conducted in departments of education and did not necessarily include a committee member from the nursing profession. In this review, authors who are nurses published many research articles mainly in educational peer‐reviewed journals. A cooperation between nursing and education professions is recommended to advance dissertations that bridge these fields. Also, researchers in this field should pursue conducting studies with higher levels of evidence. Conducting a grounded theory study is recommended because none of the theories in the review addresses student QOL. For example, conducting a study that is theoretically guided with RAM may fill this gap. Additionally, faculty should use a variety of teaching strategies, while also focusing on student QOL to enhance student outcomes. The authors also recommend testing the effect of the theoretically designed models. To illustrate, Figure  2 may be tested to study the effect of applying this concept map to student's clinical judgement. Similarly, a researcher may utilize Figure  3 to incorporate various teaching strategies and test their relationships to learners' QOL. Some researchers used more than one educational strategy, and the utilization of RAM may allow researchers to be more comprehensive. Finally, it is recommended to focus research on NGN instead of the traditional NCLEX‐RN.

5. CONCLUSION

This scoping review did not reveal a favoured theory or framework that should be used to guide preparation of students for the NCLEX‐RN. Different educational strategies were discussed, and active learning strategies were the most founded. Further interventional, theoretically guided research should be conducted with larger sample sizes and stronger research designs using various active learning strategies, while also focusing on student's QOL variables.

AUTHOR CONTRIBUTIONS

Khalid Bandar Almasloukh : conceptualization, writing original draft, and project administration. Melissa Miner : writing original draft, review, and editing. Kathleen Phillips : methodology and resources. Michael Evans : conceptualization, validation, supervision, writing‐review and editing.

CONFLICT OF INTEREST STATEMENT

Authors report no conflict of interest.

Supporting information

Acknowledgements.

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

Almasloukh, K. B. , Miner, M. , Phillips, K. , & Evans, M. (2023). Educational strategies and nursing theory to prepare leaners for NCLEX‐RN . Nursing Open , 10 , 7144–7153. 10.1002/nop2.1998 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

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100 Questions (and Answers) About Research Methods

• Neil J. Salkind
• Description

"How do I create a good research hypothesis?"

"How do I know when my literature review is finished?"

"What is the difference between a sample and a population?"

"What is power and why is it important?"

In an increasingly data-driven world, it is more important than ever for students as well as professionals to better understand the process of research. This invaluable guide answers the essential questions that students ask about research methods in a concise and accessible way.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

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"This is a concise text that has good coverage of the basic concepts and elementary principles of research methods. It picks up where many traditional research methods texts stop and provides additional discussion on some of the hardest to understand concepts."

"I think it’s a great idea for a text (or series), and I have no doubt that the majority of students would find it helpful. The material is presented clearly, and it is easy to read and understand. My favorite example from those provided is on p. 7 where the author provides an actual checklist for evaluating the merit of a study. This is a great tool for students and would provide an excellent “practice” approach to learning this skill. Over time students wouldn’t need a checklist, but I think it would be invaluable for those students with little to no research experience."

I already am using 3 other books. This is a good book though.

Did not meet my needs

I had heard good things about Salkind's statistics book and wanted to review his research book as well. The 100 questions format is cute, and may provide a quick answer to a specific student question. However, it's not really organized in a way that I find particularly useful for a more integrated course that progressively develop and builds upon concepts.

comes across as a little disorganized, plus a little too focused on psychology and statistics.

This text is a great resource guide for graduate students. But it may not work as well with undergraduates orienting themselves to the research process. However, I will use it as a recommended text for students.

Key Features

· The entire research process is covered from start to finish: Divided into nine parts, the book  guides readers from the initial asking of questions, through the analysis and interpretation of data, to the final report

· Each question and answer provides a stand-alone explanation: Readers gain enough information on a particular topic to move on to the next question, and topics can be read in any order

· Most questions and answers supplement others in the book: Important material is reinforced, and connections are made between the topics

· Each answer ends with referral to three other related questions: Readers are shown where to go for additional information on the most closely related topics

Sample Materials & Chapters

Question #16: Question #16: How Do I Know When My Literature Review Is Finished?

Question #32: How Can I Create a Good Research Hypothesis?

Question #40: What Is the Difference Between a Sample and a Population, and Why

Question #92: What Is Power, and Why Is It Important?

For instructors

Select a purchasing option.

This paper is in the following e-collection/theme issue:

Published on 16.4.2024 in Vol 26 (2024)

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study

Authors of this article:

Original Paper

• Kate J Wahl 1 , MSc   ; 
• Melissa Brooks 2 , MD   ; 
• Logan Trenaman 3 , PhD   ; 
• Kirsten Desjardins-Lorimer 4 , MD   ; 
• Carolyn M Bell 4 , MD   ; 
• Nazgul Chokmorova 4 , MD   ; 
• Romy Segall 2 , BSc, MD   ; 
• Janelle Syring 4 , MD   ; 
• Aleyah Williams 1 , MPH   ; 
• Linda C Li 5 , PhD   ; 
• Wendy V Norman 4, 6 * , MD, MHSc   ; 
• Sarah Munro 1, 3 * , PhD  

1 Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada

2 Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada

3 Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States

4 Department of Family Practice, University of British Columbia, Vancouver, BC, Canada

5 Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada

6 Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom

*these authors contributed equally

Corresponding Author:

Kate J Wahl, MSc

Department of Obstetrics and Gynecology

University of British Columbia

4500 Oak Street

Vancouver, BC, V6H 3N1

Phone: 1 4165231923

Email: [email protected]

Background: People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive—there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices.

Objective: We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

Methods: We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers’ decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy (“patient” participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses.

Results: A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly.

Conclusions: We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

Introduction

In total, 1 in 3 pregnancy-capable people in Canada will have an abortion in their lifetimes, and most will seek care early in pregnancy [ 1 ]. Medication abortion (using the gold-standard mifepristone/misoprostol regimen) and procedural abortion are common, safe, and effective options for abortion care in the first trimester [ 2 , 3 ]. The choice between using medications and presenting to a facility for a procedure is a preference-sensitive decision; there is no clinically superior option and the choice depends on what matters most to the individual patient regarding the respective treatments and the features of those options [ 4 - 6 ].

The choice of method of abortion can involve a process of shared decision-making, in which the patient and health care professional share the best available evidence about options, and the patient is supported to consider those options and clarify an informed preference [ 7 ]. There are many types of interventions available to support shared decision-making, including interventions targeting health care professionals (eg, educational materials, meetings, outreach visits, audit and feedback, and reminders) and patients (eg, patient decision aids [PtDA], appointment preparation packages, empowerment sessions, printed materials, and shared decision-making education) [ 8 ]. Of these interventions, PtDAs are well-suited to address challenges to shared decision-making about the method of abortion, including limited patient knowledge, public misinformation about options, poor access to health care professionals with sufficient expertise, and apprehension about abortion counseling [ 9 ].

PtDAs are widely used interventions that support people in making informed, deliberate health care choices by explicitly describing the health problem and decision, providing information about each option, and clarifying patient values [ 10 ]. The results of the 2023 Cochrane systematic review of 209 randomized controlled trials indicate that, compared to usual care (eg, information pamphlets or webpages), the use of PtDAs results in increases in patient knowledge, expectations of benefits and harms, clarity about what matters most to them, and participation in making a decision [ 11 ]. Of the studies included in the systematic review, 1 tested the effect of a PtDA leaflet for method of abortion and found that patients eligible for both medication and procedural abortion who received the PtDA were more knowledgeable, and had lower risk perceptions and decisional conflict than those who were in the control group [ 12 ]. However, that PtDA was developed 20 years ago in the UK health system and was not publicly available. A recent environmental scan of PtDAs for a method of abortion found that other available options meet few of the criteria set by the International Patient Decision Aid Standards (IPDAS) collaboration and do not include language and content optimized for end users [ 9 , 13 ].

Consequently, no PtDAs for method of abortion were available in Canada at the time of this study. This was a critical gap for both patients and health care professionals as, in 2017, mifepristone/misoprostol medication abortion came to the market, offering a new method of choice for people seeking abortion in the first trimester [ 14 ]. Unlike most jurisdictions, in Canada medication abortion is typically prescribed in primary care and dispensed in community pharmacies. Offering a PtDA in preparation for a brief primary care consultation allows the person seeking abortion more time to digest new information, consider their preferences, be ready to discuss their options, and make a quality decision.

In this context, we identified a need for a high-quality and publicly available PtDA to support people in making an informed choice about the method of abortion that reflects what is most important to them. Concurrently, our team was working in collaboration with knowledge users (health care professionals, patients, and health system decision makers) who were part of a larger project to investigate the implementation of mifepristone in Canada [ 15 , 16 ]. We, therefore, aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

Study Design

We performed a mixed methods user-centered development and evaluation study informed by principles of integrated knowledge translation. Integrated knowledge translation is an approach to collaborative research in which researchers and knowledge users work together to identify a problem, conduct research as equal partners to address that problem, and coproduce research products that aim to impact health service delivery [ 17 ]. We selected this approach to increase the likelihood that our end PtDAs would be relevant, useable, and used for patients and health care professionals in Canada [ 17 ]. The need for a PtDA was identified through engagement with health care professionals. In 2017, they highlighted the need for patients to be supported in choosing between procedural care—which historically represented more than 90% of abortions in Canada [ 18 ]—and the newly available medication option [ 19 , 20 ]. This need was reaffirmed in 2022 by the Canadian federal health agency, Health Canada, which circulated a request for proposals to generate “evidence-based, culturally-relevant information aimed at supporting people in their reproductive decision-making and in accessing abortion services as needed” [ 21 ].

We operationalized integrated knowledge translation principles in a user-centered design process. User-centered design “grounds the characteristics of an innovation in information about the individuals who use that innovation, with a goal of maximizing ‘usability in context’” [ 22 ]. In PtDA development, user-centered design involves iteratively understanding users, developing and refining a prototype, and observing user interaction with the prototype [ 23 , 24 ]. Like integrated knowledge translation, this approach is predicated on the assumption that involving users throughout the process increases the relevance of the PtDA and the likelihood of successful implementation [ 24 ].

Our design process included the following steps ( Figure 1 ): identification of evidence about abortion patients’ decisional needs and the attributes of medication and procedural abortion that matter most from a patient perspective; development of a paper-based prototype; usability testing via think-aloud interviews with potential end users; refinement of the PtDA prototype into an interactive website; usability testing via a survey with potential end users and abortion health care professionals; and final revisions before launching the PtDA for real-world testing. Our systematic process was informed by user-centered methods for PtDA development [ 23 , 24 ], guidance from the IPDAS collaboration [ 25 - 27 ], and the Standards for Universal Reporting of Patient Decision Aid Evaluation checklist [ 10 ].

Our multidisciplinary team included experts in shared decision-making (SM and LT), a PhD student in patient-oriented knowledge translation (KJW), experts in integrated knowledge translation with health care professionals and policy makers (WVN and SM), clinical experts in abortion counseling and care (WVN and MB), a medical undergraduate student (RS), a research project coordinator (AW), and family medicine residents (KD-L, CMB, NC, and JS) who had an interest in abortion care. Additionally, a panel of experts external to the development process reviewed the PtDA for clinical accuracy following each revision of the prototype. These experts included coauthors of the national Society for Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guidelines for abortion care in Canada. They were invited to this project because of their knowledge of first-trimester abortion care as well as their ability to support the implementation of the PtDA in guidelines and routine clinical practice.

Ethical Considerations

The research was approved by the University of British Columbia Children’s and Women’s Research Ethics Board (H16-01006) and the Nova Scotia Health Research Ethics Board (1027637). In each round of testing, participants received a CAD $20 (US $14.75) Amazon gift card by email for their participation.

Preliminary Work: Identification of Evidence

We identified the decisional needs of people seeking early abortion care using a 2018 systematic review of reasons for choosing an abortion method [ 28 ], an additional search that identified 1 study conducted in Canada following the 2017 availability of mifepristone/misoprostol medication abortion [ 29 ], and the SOGC clinical practice guidelines [ 2 , 3 ]. The review identified several key factors that matter most for patient choice of early abortion method: perceived simplicity and “naturalness,” fear of complication or bleeding , fear of anesthesia or surgery , timing of the procedure , and chance of sedation . The additional Canadian study found that the time required to complete the abortion and side effects were important factors. According to the SOGC clinical practice guidelines, the key information that should be communicated to the patient are gestational age limits and the risk of complications with increasing gestational age [ 2 , 3 ]. The guidelines also indicate that wait times , travel times , and cost considerations may be important in a person’s choice of abortion method and should be addressed [ 2 , 3 ].

We compiled a long list of attributes for our expert panel and then consolidated and refined the attribute list through each stage of the prototype evaluation. For evidence of how these factors differed for medication and procedural abortion, we drew primarily from the SOGC clinical practice guidelines for abortion [ 2 , 3 ]. For cost considerations, we described the range of federal, provincial, and population-specific programs that provide free coverage of abortion care for people in Canada.

Step 1: Developing the Prototype

Our goal was to produce an interactive, web-based PtDA that would be widely accessible to people seeking an abortion in Canada by leveraging the widespread use of digital health information, especially among reproductive-aged people [ 30 ]. Our first prototype was based on a previously identified paper-based question-and-answer comparison grid that presented evidence-based information about the medication and procedural options [ 9 , 31 ]. We calculated readability by inputting the plain text of the paper-based prototype into a Simple Measure of Gobbledygook (SMOG) Index calculator [ 32 ].

We made 2 intentional deviations from common practices in PtDA development [ 33 ]. First, we did not include an “opt-out” or “do nothing” option, which would describe the natural course of pregnancy. We chose to exclude this option to ensure clarity for users regarding the decision point; specifically, our decision point of interest was the method of abortion, not the choice to terminate or continue a pregnancy. Second, we characterized attributes of the options as key points rather than positive and negative features to avoid imposing value judgments onto subjective features (eg, having the abortion take place at home may be beneficial for some people but may be a deterrent for others).

Step 2: Usability Testing of the Prototype

We first conducted usability testing involving think-aloud interviews with patient participants to assess the paper-based prototype. Inclusion criteria included people aged 18-49 years assigned-female-at-birth who resided in Canada and could speak and read English. In January 2020, we recruited participants for the first round of think-aloud interviews [ 34 ] via email and poster advertising circulated to (1) a network of parent research advisors who were convened to guide a broader program of research about pregnancy and childbirth in British Columbia, Canada, and (2) a clinic providing surgical abortion care in Nova Scotia, Canada, as well as snowball sampling with participants. We purposively sought to advertise this study with these populations to ensure variation in age, ethnicity, level of education, parity, and abortion experience. Interested individuals reviewed this study information form and provided consent to participate, before scheduling an interview. The interviewer asked participants to think aloud as they navigated the prototype, for example describing what they liked or disliked, missing information, or lack of clarity. The interviewer noted the participant’s feedback on a copy of the prototype during the interview. Finally, the participant responded to questions adapted from the System Usability Scale [ 35 ], a measure designed to collect subjective ratings of a product’s usability, and completed a brief demographic questionnaire. The interviews were conducted via videoconferencing and were audio recorded. We deidentified the qualitative data and assigned each participant a unique identifier. Then, the interviewer listened to the recording and revised their field notes with additional information including relevant quotes.

For the analysis of think-aloud interviews, we used inductive content analysis to describe the usability and acceptability of different elements of the PtDA [ 36 ]. Further, 3 family medicine residents (KD-L, CMB, and NC) under guidance from a senior coauthor (SM) completed open coding to develop a list of initial categories, which we grouped under higher-order headings. We then organized these results in a table to illustrate usability issues (categories), illustrative participant quotes, and modifications to make. We then used the results of interviews to adapt the prototype into a web-based format, which we tested via further think-aloud interviews and a survey with people capable of becoming pregnant and health care professionals involved with abortion care.

Step 3: Usability Testing of the Website

For the web-based format, we used DecideApp PtDA open-source software, which provides a sustainable solution to the problems of low quality and high maintenance costs faced by web-based PtDAs by allowing developers to host, maintain, and update their tools at no cost. This software has been user-tested and can be accessed by phone, tablet, or computer [ 37 , 38 ]. It organizes a PtDA into 6 sections: Introduction, About Me, My Values, My Choice, Review, and Next Steps. In the My Values section, an interactive values clarification exercise allows users to rank and make trade-offs between attributes of the options. The final pages provide an opportunity for users to make a choice, complete a knowledge self-assessment, and consider the next steps to access their chosen method.

From July to August 2020, we recruited patient and health care professional participants using Twitter and the email list of the Canadian Abortion Providers Support platform, respectively. Participants received an email with a link to the PtDA and were redirected to the survey once they had navigated through the PtDA. As above, inclusion criteria included people aged 18-49 years assigned as female-at-birth who resided in Canada. Among health care professionals, we included eligible prescribers who may not have previously engaged in abortion care (family physicians, residents, nurse practitioners, and midwives), and allied health professionals and stakeholders who provide or support abortion care, who practiced in Canada. All participants had to speak and read English.

The survey included 3 sections: usability, implementation, and participant characteristics. The usability section consisted of the System Usability Scale [ 35 ], and purpose-built questions about what participants liked and disliked about the PtDA. The implementation section included open- and close-ended questions about how the PtDA compares to other resources and when it could be implemented in the care pathway. Patient participants also completed the Control Preference Scale, a validated measure used to determine their preferred role in decision-making (active, collaborative, or passive) [ 39 ]. Data on participant characteristics included gender, abortion experience (patient participants), and abortion practice (health care professional participants). We deidentified the qualitative data and assigned each participant a unique identifier. For the analysis of survey data, we characterized close-ended responses using descriptive statistics, and, following the analysis procedures described in Step 2 in the Methods section, used inductive content analysis of open-ended responses to generate categories associated with usability and implementation [ 36 ]. In 2021, we made minor revisions to the website based on the results of usability testing and published the PtDA for use in routine clinical care.

In the following sections, we outline the results of the development process including the results of the think-aloud interviews and survey, as well as the final decision aid prototype.

Our initial prototype, a paper-based question-and-answer comparison grid, presented evidence-based information comparing medication and procedural abortion. The first version of the prototype also included a second medication abortion regimen involving off-label use of methotrexate, however, we removed this option following a review by the clinical expert panel who advised us that there is very infrequent use of this regimen in Canada in comparison to the gold standard medication abortion option, mifepristone. Other changes at this stage involved clarifying the scope of practice (health care professionals other than gynecologists can perform a procedural abortion), abortion practice (gestational age limit and how the medication is taken), the abortion experience (what to expect in terms of bleeding), and risk (removing information about second- and third-trimester abortion). The updated prototype was finalized by a scientist (SM) and trainee (KJW) with expertise in PtDA development. The prototype (see Multimedia Appendix 1 ) was ultimately 4 pages long and described 18 attributes of each option framed as Frequently Asked Questions, including abortion eligibility (How far along in pregnancy can I be?), duration (How long does it take?), and side effects (How much will I bleed?). The SMOG grade level was 8.4.

Participant Characteristics

We included 11 participants in think-aloud interviews between January and July 2020, including 7 recruited through a parent research advisory network and 4 individuals who had recently attended an abortion clinic. The mean interview duration was 36 minutes (SD 6 minutes). The participants ranged in age from 31 to 37 years. All had been pregnant and 8 out of 11 (73%) participants had a personal experience of abortion (4 participants who had recently attended an abortion clinic and 4 participants from the parent research advisory who disclosed their experience during the interview). The characteristics of the sample are reported in Table 1 .

Overall, participants had a positive view of the paper-based, comparison grid PtDA. In total, 1 participant who had recently sought an abortion said, “I think this is great and super helpful. It would’ve been awesome to have had access to this right away … I don’t think there’s really anything missing from here that I was Googling about” (DA010). The only participant who expressed antichoice views indicated that the PtDA would be helpful to someone seeking to terminate a pregnancy (DA001). Another participant said, “[The PtDA] is not biased, it’s not like you’re going to die. It’s a fact, you know the facts and then you decide whether you want it or not. A lot of people feel it’s so shameful and judgmental, but this is very straightforward. I like it.” (DA002). Several participants stated they felt more informed and knowledgeable about the options.

In response to questions adapted from the System Usability Scale, all 11 participants agreed that the PtDA was easy to use, that most people could learn to use it quickly, and that they felt very confident using the prototype, and disagreed that it was awkward to use. In total, 8 (73%) participants agreed with the statement that the components of the PtDA were well-integrated. A majority of participants disagreed with the statements that the website was unnecessarily complex (n=8, 73%), that they would need the support of an expert to use it (n=8, 73%), that it was too inconsistent (n=9, 82%), and that they would need to learn a lot before using it (n=8, 73%). Further, 2 (18%) participants agreed with the statements that the PtDA was unnecessarily complex and that they would need to learn a lot before using it. Furthermore, 1 (9%) participant agreed with the statement that the PtDA was too inconsistent.

Through inductive analysis of think-aloud interviews, we identified 4 key usability categories: design, language, process, and experience.

Participants liked the side-by-side comparison layout, appreciated the summary of key points to remember, and said that overall, the presented information was clear. For example, 1 participant reflected, “I think it’s very clear ... it’s very simplistic, people will understand the left-hand column is for medical abortion and the right-hand column is for surgical.” (DA005) Some participants raised concerns about the aesthetics of the PtDA, difficulties recalling the headers across multiple pages, and the overall length of the PtDA.

Participants sought to clarify language at several points in the PtDA. Common feedback was that the gestational age limit for the medication and the procedure should be clarified. Participants also pointed out inconsistent use of language (eg, doctor and health care professional) and medical jargon.

Several participants were surprised to learn that family doctors could provide abortion care. Others noted that information about the duration—including travel time—and number of appointments for both medication and procedural abortion could be improved. In addition to clarifying the abortion process, several participants suggested including additional information and resources to help identify an abortion health care professional, understand when to seek help for abortion-related complications, and access emotional support. It was also important to participants that financial impacts (eg, hospital parking and menstrual pads) were included for each option.

Participants provided insight into the description of the physical, psychological, and other consequences associated with the abortion medication and procedure. Participants who had both types of abortion care felt that the description of pain that “may be worse than a period” was inaccurate. Other participants indicated that information about perceived and real risks was distressing or felt out of place, such as correcting myths about future fertility or breast cancer. Some participants indicated that patient stories would be valuable saying, for example, “I think what might be nice to help with the decision-making process is reading stories of people’s experiences” (DA006).

Modifications Made

Changes made based on these findings are described in Table 2 . Key user-centered modifications included transitioning to a web-based format with a consistent color scheme, clarifying who the PtDA is for (for typical pregnancies up to 10 weeks), adding information about telemedicine to reflect guidelines for the provision of abortion during pandemics, and developing brief first-person qualitative descriptions of the pain intensity for each option.

Through analysis of the interviews and consultation with our panel of clinical experts, we also identified that, among the 18 initial attributes in our prototype, 7 had the most relative importance to patients in choosing between medication and procedural abortion. These attributes also represented important differences between each option which forced participants to consider the trade-offs they were willing to make. Thus we moved all other potential attributes into an information section (My Options) that supported the user to gain knowledge before clarifying what mattered most to them by considering the differences between options (My Values).

a PtDA: patient decision aid.

b SOGC: Society of Obstetricians and Gynaecologists of Canada.

Description of the PtDA

As shown in Figure 2 , the revised version of the PtDA resulting from our systematic process is an interactive website. Initially, the title was My Body, My Choice ; however, this was changed to avoid association with antivaccine campaigns that co-opted this reproductive rights slogan. The new title, It’s My Choice or C’est Mon Choix , was selected for its easy use in English and French. The PtDA leads the user through 6 sections:

• The Introduction section provides the user with information about the decision and the PtDA, as well as grids comparing positive and negative features of the abortion pill and procedure, including their chance of benefits (eg, effectiveness), harms (eg, complications), and other relevant factors (eg, number of appointments and cost).
• The About Me section asks the user to identify any contraindications to the methods. It then prompts users to consider their privacy needs and gives examples of how this relates to each option (eg, the abortion pill can be explained to others as a miscarriage; procedural care can be completed quickly).
• The My Values section includes a values clarification exercise, in which the user selects and weights (on a 0-100 scale) the relative importance of at least three of 7 decisional attributes: avoiding pain, avoiding bleeding, having the abortion at home, having an experience that feels like a miscarriage, having fewer appointments, less time off for recovery, and having a companion during the abortion.
• The My Choice section highlights 1 option, based on the attribute weights the user assigned in the My Values section. For instance, if a user strongly preferred to avoid bleeding and have fewer appointments, the software would suggest that a procedural abortion would be a better match. For a user who preferred having the abortion at home and having a companion present, the software would suggest that a medication abortion would be a better match. The user selects the option they prefer.
• The Review section asks the user to complete the 4-item SURE (Sure of Myself, Understand Information, Risk-Benefit Ratio, Encouragement) screening test [ 41 ], and advises them to talk with an expert if they answer “no” to any of the questions. This section also includes information phone lines to ensure that users can seek confidential, accurate, and nonjudgmental support.
• Lastly, in the Next Steps section, users see a summary of their choice and the features that matter most to them, instructions for how to save the results, keep the results private, and find an abortion health care professional. Each section of the PtDA includes a “Leave” button in case users need to navigate away from the website quickly.

We calculated readability by inputting the plain text of the web-based PtDA into a SMOG Index calculator [ 32 ], which assessed the reading level of the web-based PtDA as grade 9.2.

To ensure users’ trust in the information as accurate and unbiased we provided a data declaration on the landing page: “the clinical information presented in this decision aid comes from Society of Obstetricians and Gynaecologists best practice guidelines.” On the landing page, we also specify “This website was developed by researchers at the University of British Columbia and Dalhousie University. This tool is not supported or connected to any pharmaceutical company.”

A total of 50 participants, including 25 patients and 25 health care professionals, reviewed the PtDA website and completed the survey between January and March 2021. The majority of patient (n=23, 92%) and health care professional (n=23, 92%) participants identified as cisgender women. Among patient participants, 16% (n=4) reported one or more previous abortions in various clinical settings. More than half (n=16, 64%) of health care professionals offered care in private medical offices, with other locations including sexual health clinics, community health centers, and youth clinics. Many health care professionals were family physicians (n=11, 44%), and other common types were nurse practitioners (n=7, 28%) and midwives (n=3, 12%). The mean proportion of the clinical practice of each health care professional devoted to abortion care was 18% (SD 13%). Most health care professional respondents (n=18, 72%) were involved with the provision of medication, but not procedural, abortion care. The characteristics of patient and health care professional participants are reported in Table 3 .

a In total, 4 participants reported a history of abortion care, representing 6 abortion procedures.

b Not available.

The mean System Usability Score met the threshold for good usability among both patient (mean 85.7, SD 8.6) and health care professional (mean 80, SD 12) participants, although some health care professionals agreed with the statement, “I found the website to be unnecessarily complex,” (see Multimedia Appendix 3 for the full distribution of responses from patient and health care professionals). All 25 patients and 22 out of 25 (88%) health care professional respondents indicated that the user-friendliness of the PtDA was good or the best imaginable. When asked what they liked most about the PtDA, both participant groups described the ease of use, comparison of options, and the explicit values clarification exercise. When asked what they liked least about the PtDA, several health care professionals and some patients pointed out that it was difficult to use on a cell phone. A summary of usability results is presented in Table 4 .

In total, 21 (84%) patients and 18 (72%) health care professionals felt that the PtDA was not missing any information needed to decide about the method of abortion in early pregnancy. While acknowledging that it is “hard to balance being easy to read/understand while including enough accurate clinical information,” several health care professionals and some patients indicated that the PtDA was too long and repetitive. Among the 4 (16%) patient participants who felt information was missing, the most common suggestion was a tool for locating an abortion health care professional. The 7 (28%) health care professionals who felt information was missing primarily made suggestions about the medical information included in the PtDA (eg, listing midwives as health care professionals with abortion care in scope of practice and the appropriateness of gender-inclusive terminology) and the accessibility of information for various language and cultural groups.

a Not available.

Implementation

Participants viewed the PtDA as a positive addition to current resources. Patients with a history of abortion care described looking for the information on the internet and speaking with friends, family members, and health care professionals. Compared with these sources of information, many patients liked the credibility and anonymity of the PtDA, whereas some disliked that it was less personal than a conversation. Further, 18 (72%) health care professional participants said that the PtDA would add to or replace the resources they currently use in practice. Compared with these other resources, health care professionals liked that the PtDA could be explored by patients independently and that it would support them in thinking about the option that was best for them. The disadvantages of the PtDA compared with existing resources were the length—which health care professionals felt would make it difficult to use in a clinical interaction—and the lack of localized information. In total, 23 each (92%) of patient and health care professional participants felt that they would use the PtDA before a consultation.

Principal Results

We designed a web-based, interactive PtDA for the choice of method of abortion in early pregnancy [ 42 ], taking a user-centered approach that involved usability testing with 36 patients and 25 health care professionals. Both patient and health care professional participants indicated that the PtDA had good usability and would be a valuable resource for decision-making. This PtDA fills a critical need to support the autonomy of patients and shared decision-making with their health care professional related to the preference-sensitive choice of method of abortion.

Comparison With Prior Work

A 2017 systematic review and environmental scan found that existing PtDAs for the method of abortion are of suboptimal quality [ 9 ]. Of the 50 PtDAs identified, all but one were created without expertise in decision aid design (eg, abortion services, reproductive health organizations, and consumer health information organizations); however, the development process for this UK-based pamphlet-style PtDA was not reported. The remaining PtDAs were noninteractive websites, smartphone apps, and PDFs that were not tested with users. The authors found that the information about methods of abortion was presented in a disorganized, inconsistent, and unequal way. Subsequent work has found that existing PtDAs emphasize medical (versus social, emotional, and practical) attributes, do not include values clarification, and can be biased to persuade users of a certain method [ 13 ].

To address some of the challenges identified in the literature, we systematically structured and designed elements of the PtDA following newly proposed IPDAS criteria (eg, showing positive and negative features with equal detail) [ 33 ]. We included an explicit values-clarification exercise, which a recent meta-analysis found to decrease decisional conflict and values-incongruent choices [ 43 ].

We based the decision aid on comprehensive and up-to-date scientific evidence related to the effectiveness and safety of medication abortion and procedural abortion; however, less evidence was available for nonmedical attributes. For example, many existing PtDAs incorrectly frame privacy as a “factual advantage” of medication abortion [ 13 ]. To address this, we included privacy in the About Me section as something that means “different things to different people.” Similarly, evidence suggests that patients who do not feel appropriately informed about the pain associated with their method of abortion are less satisfied with their choice [ 44 , 45 ]; and the degree of pain experienced varies across options and among individuals. Following the suggestion of patient participants to include stories and recognizing that evidence for the inclusion of narratives in PtDAs is emerging [ 46 ], we elected to develop brief first-person qualitative descriptions of the pain experience. The inclusion of narratives in PtDAs may be effective in supporting patients to avoid surprise and regret, to minimize affective forecasting errors, and to “visualize” their health condition or treatment experience [ 46 ]. Guided by the narrative immersion model, our goal was to provide a “real-world preview” of the pain experience [ 47 ].

In addition to integrating user perspectives on the optimal tone, content, and format of the PtDA, user testing provided evidence to inform the future implementation of the PtDA. A clear barrier to the completion of the PtDA during the clinical encounter from the health care professional perspective was its length, supporting the finding of a recent rapid realist review, which theorized that health care professionals are less likely to use long or otherwise complex PtDAs that are difficult to integrate into routine practice [ 48 ]. However, 46 out of 50 (92%) participants endorsed the use of the PtDA by the patient alone before the initial consultation, which was aligned with the patient participant’s preference to take an active role in making the final decision about their method of abortion as well as the best practice of early, pre-encounter distribution of PtDAs [ 48 ].

A unique feature of this PtDA was that it resulted from a broader program of integrated knowledge translation designed to support access to medication abortion once mifepristone became available in Canada in 2017. Guided by the principle that including knowledge users in research yields results that are more relevant and useful [ 49 ], we developed the PtDA in response to a knowledge user need, involved health care professional users as partners in our research process, including as coauthors, and integrated feedback from the expert panel. This parallels a theory of PtDA implementation that proposes that early involvement of health care professionals in PtDA development “creates a sense of ownership, increases buy-in, helps to legitimize content, and ensures the PtDA (content and delivery) is consistent with current practice” thereby increasing the likelihood of PtDA integration into routine clinical settings [ 48 ].

Viewed through an integrated knowledge translation lens, our findings point toward future areas of work to support access to abortion in Canada. Several patient participants indicated a need for tools to identify health care professionals who offer abortion care. Some shared that their primary health care professionals did not offer medication abortion despite it being within their scope of practice, and instead referred them to an abortion clinic for methods of counseling and care. We addressed this challenge in the PtDA by including links to available resources, such as confidential phone lines that link patients to health care professionals in their region. On the website we also indicated that patient users could ask their primary care providers whether they provide abortion care; however, we acknowledge that this may place the patient in a vulnerable position if their health care professional is uncomfortable with, or unable to, provide this service for any reason. Future work should investigate opportunities to shorten the pathway to this time-sensitive care, including how to support patients who use the decision aid to act on their informed preference for the method of abortion. This work may involve developing a tool for patients to talk to their primary care provider about prescribing medication abortion.

Strengths and Limitations

Several factors affect the interpretation of our work. Although potential patient users participated in the iterative development process, the patient perspective was not represented in a formal advisory panel in the same way that the health care professional experts were. Participant characteristics collected for the think-aloud interviews demonstrated that our patient sample did not include people with lower education attainment, for whom the grade level and length of the PtDA could present a barrier [ 50 ]. Any transfer of the PtDA to jurisdictions outside Canada must consider how legal, regulatory, and other contextual factors affect the choice of the method of abortion. Since this study was completed, we have explored additional strategies to address these concerns, including additional user testing with people from equity-deserving groups, drop-down menus to adjust the level of detail, further plain language editing, and videos illustrating core content. Since the focus of this study was usability, we did not assess PtDA effectiveness, including impact on knowledge, decisional conflict, choice predisposition and decision, or concordance; however, a randomized controlled trial currently underway will measure the impact of the PtDA on these outcomes in a clinical setting. Finally, our integrated knowledge translation approach added to the robustness of our study by ensuring that health care professionals and patients were equal partners in the research process. One impact of this partnered approach is that our team has received funding support from Health Canada to implement the website on a national scale for people across Canada considering their abortion options [ 51 ].

Conclusions

The PtDA provides people choosing a method of early abortion and their health care professionals with a resource to understand methods of abortion available in the Canadian context and support to make a values-aligned choice. We designed the PtDA using a systematic approach that included both patient and health care professional participants to help ensure its relevance and usability. Our future work will seek to evaluate the implementation of the PtDA in clinical settings, create alternate formats to enhance accessibility, and develop a sustainable update policy. We will also continue to advance access to abortion care in Canada with our broader integrated knowledge translation program of research.

Acknowledgments

The authors thank the participants for contributing their time and expertise to the design of this tool. Family medicine residents CMB, NC, KD-L, and JS were supported by Sue Harris grants, Department of Family Practice, University of British Columbia. KJW was supported by the Vanier Scholar Award (2020-23). SM was supported by a Michael Smith Health Research BC Scholar Award (18270). WVN was supported by a Canadian Institutes of Health Research and Public Health Agency of Canada Chair in Applied Public Health Research (2014-2024, CPP-329455-107837). All grants underwent external peer review for scientific quality. The funders played no role in the design of this study, data collection, analysis, interpretation, or preparation of this paper.

Data Availability

Our ethics approval has specified the primary data is not available.

Authors' Contributions

KJW, SM, and MB conceived of and designed this study. CMB, NC, and KD-L led interview data collection, analysis, and interpretation with input from SM. RS and JS led survey data collection, analysis, and interpretation with input from SM and MB. AW, LCL, and WVN contributed to the synthesis and interpretation of results. KJW, SM, and LT wrote the first draft of this paper, and all authors contributed to this paper’s revisions and approved the final version.

Conflicts of Interest

None declared.

Patient decision aid prototype.

Raw data for pain narratives.

Full distribution of System Usability Scale scores for patients and providers.

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Abbreviations

Edited by T Leung; submitted 07.05.23; peer-reviewed by G Sebastian, R French, B Zikmund-Fisher; comments to author 11.01.24; revised version received 23.02.24; accepted 25.02.24; published 16.04.24.

©Kate J Wahl, Melissa Brooks, Logan Trenaman, Kirsten Desjardins-Lorimer, Carolyn M Bell, Nazgul Chokmorova, Romy Segall, Janelle Syring, Aleyah Williams, Linda C Li, Wendy V Norman, Sarah Munro. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.04.2024.

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