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Next Generation NCLEX Case Studies and Partial Credit

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Next Generation NCLEX case studies are sets of six items about one client, each item matching one step of NCSBN's clinical judgment model, from recognizing cues to evaluating outcomes. Many of these items earn partial credit under one of three rules NCSBN publishes: zero/one, plus/minus and rationale scoring.

This post explains how a case study is built, what each item type asks you to do, and exactly how each scoring rule works, then grades a sample select-all-that-apply question under plus/minus scoring so you can see what a wrong extra pick costs. It applies to both the NCLEX-RN and the NCLEX-PN.

How Next Generation NCLEX case studies are built

Each case study opens with a client scenario and chart tabs, such as nurses' notes, vital signs, lab results and orders. The six items then follow layer 3 of the NCSBN Clinical Judgment Measurement Model in order, one step per item. The chart can change between items as the case unfolds, so read the tabs again on every item.

StepWhat the item asks
1. Recognize cuesWhich findings in the chart matter?
2. Analyze cuesWhich conditions are those findings consistent with?
3. Prioritize hypothesesWhich problem is most likely, or most urgent?
4. Generate solutionsWhich interventions fit the problem, and which do not?
5. Take actionWhich actions do you carry out now?
6. Evaluate outcomesWhich findings show care worked, or did not?
  • Each item is scored on its own. Missing step 2 does not cost you step 3.
  • You cannot go back to an earlier item in the case.
  • Items are written to avoid giving away earlier answers, so do not hunt later items for clues.
  • On both the NCLEX-RN and NCLEX-PN, three case studies (18 items) fall within the first 85 items.

Clinical judgment is also tested outside case studies by stand-alone items, which can use any item type. NCSBN's free Sample Pack includes three RN and two PN case studies if you want to see the real screens.

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Next Generation NCLEX item types

  • Extended multiple response: choose one or more options from a longer list. Select all that apply leaves the number open; select N tells you how many to pick.
  • Matrix or grid: a table where you mark one or more options in each row or column, such as effective or ineffective for each finding.
  • Drop-down (cloze): choose one option from each drop-down list inside a sentence, paragraph or table.
  • Highlight (enhanced hot spot): click words or phrases in a chart excerpt. Only some text can be selected.
  • Extended drag and drop: move options into answer spaces. Not every option has to be used, and there may be more options than spaces.
  • Bow-tie: drag in the condition the client most likely has, two actions to take and two parameters to monitor.

How Next Generation NCLEX partial-credit scoring works

Partial credit applies to items with more than one key. NCSBN uses three rules, and which one applies depends on what the item tells you to do.

RuleWhen it appliesHow points work
Zero/one (0/1)You are told how many to choose, or each row or drop-down has one answer1 point per correct choice; wrong choices earn 0 and cost nothing
Plus/minus (+/-)You may choose as many or as few as apply+1 per correct choice, -1 per wrong choice; the item never goes below 0
RationalePaired information, such as an action and the reason for itPoints only when both halves of the pair are correct
Item typeRuleDetail
Select all that applyPlus/minusMaximum equals the number of correct options; minimum 0
Select NZero/oneYou cannot pick more than N
Matrix multiple choice (one per row)Zero/one1 point per row
Matrix multiple response (many per column)Plus/minusEach column scored on its own, floored at 0
Drop-down cloze or tableZero/one1 point per drop-down
Bow-tieZero/one5 points, one per target; the two actions and two parameters can go in either of their slots
Paired items (an action and its reason)RationaleBoth parts right or no point

A sample select-all item, graded under plus/minus

This page cannot display matrix or drop-down items, so here is a select-all-that-apply item from the RN Basics bank. Select all that apply is scored plus/minus on the NCLEX, and the same rule grades each column of a matrix multiple response item.

Question 1 · Safety and Infection Prevention and Control · Select all that apply

A client receiving chemotherapy has an absolute neutrophil count of 400/mm³. Which instructions should the nurse include in teaching? Select all that apply.

  1. “Visitors with a mild cold are welcome if they wash their hands.”
  2. “Check your temperature daily and report 38 °C or higher right away.”
  3. “Changing the cat’s litter box yourself each day is safe to do.”
  4. “Use a rectal thermometer, since it gives the most accurate reading.”
  5. “Keep fresh flowers and vases of standing water out of the house.”
  6. “Everyone washes their hands before touching you or your food.”
Show the answer and rationale

Answer: B, E, F

  • A. Anyone with an infection, even a mild cold, stays away; hand washing does not stop respiratory spread.
  • B. Correct. Fever may be the only sign of infection in neutropenia and is an emergency requiring cultures and antibiotics within an hour.
  • C. Animal waste carries organisms such as Toxoplasma; someone else cleans the litter box while the client is neutropenic.
  • D. Rectal temperatures, suppositories and enemas are avoided because they can injure the mucosa and introduce bacteria.
  • E. Correct. Standing water and the soil of fresh flowers and plants harbor bacteria and fungi.
  • F. Correct. Hand hygiene by the client, family and staff is the most effective protection against infection.

Neutropenic precautions: hand hygiene by everyone, no sick visitors, no fresh flowers or standing water, no rectal temperatures or procedures, washed or cooked produce, no handling of litter boxes or other animal waste, and daily temperature checks. A temperature of 38 °C or more in a neutropenic client is treated as sepsis until proven otherwise, so the client reports it at once and cultures and antibiotics follow within an hour.

Bottom line: In a neutropenic client, a temperature of 38 °C or higher may be the only sign of infection and is treated as an emergency.

Sources: Ignatavicius, Med-Surg Nursing, 11th ed.; Lewis's Medical-Surgical Nursing, 13th ed.

Reasoning to the keys

An absolute neutrophil count of 400 means the client has very few cells to fight infection, so judge every option by whether it lowers or raises infection risk. The CDC tells people on chemotherapy to call right away for a temperature of 38 C (100.4 F) or higher and to clean hands often, which gives two keys. Keeping fresh flowers and standing water out of the house is the third key in the bank's rationale. Each distractor adds an exposure: a visitor who is already sick, a rectal thermometer, and the cat's litter box.

How plus/minus scoring would grade it

There are three keys, so the item is worth up to 3 points. Each key you pick adds 1, and each distractor you pick subtracts 1.

Choices madeCalculationScore
The three keys only3 - 03 of 3
The three keys plus the mild-cold visitor3 - 12 of 3
Two keys only (fever and hand washing)2 - 02 of 3
Two keys plus the rectal thermometer2 - 11 of 3
One key plus two distractors1 - 2 = -1, raised to 00 of 3
All six options3 - 30 of 3

Two lessons follow. Leaving out a key you are unsure of costs the same as adding a wrong option, so pick what you can defend and stop. And selecting everything never pays, because the distractors cancel the keys.

Strategy for case studies and partial-credit items

  1. Name the step before you answer. Recognize cues wants findings; take action wants interventions.
  2. Open every chart tab on every item, since the chart can change as the case unfolds.
  3. Judge each option on its own merits under plus/minus. There is no set number of keys.
  4. On a matrix, decide each row separately; one hard row does not spoil the rest.
  5. On a bow-tie, choose the condition first, then the actions and parameters that fit it.
  6. Keep a steady pace. Case studies are scored item by item, so a difficult item is only one item.

Frequently asked questions

How many case studies are on the Next Generation NCLEX?

Three case studies of six items each, 18 items in all, fall within the first 85 items on both the NCLEX-RN and NCLEX-PN.

Do you get partial credit on NCLEX select all that apply questions?

Yes. Select all that apply is scored plus/minus: one point for each correct option you choose, one point off for each wrong one, and never below zero.

Can you get a negative score on an NCLEX item?

No. Under plus/minus scoring, any negative total is rounded up to zero, and for matrix items each column or row is floored at zero on its own.

Does a wrong answer early in a case study affect later items?

No. NCSBN scores each case study item independently, and items are written so that later ones do not depend on getting earlier ones right.

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Sources

  1. NCSBN. Frequently Asked Questions: How are items scored? (NCLEX.com). Link
  2. NCSBN Help Center. What are the current scoring models? (updated July 2026) Link
  3. NCSBN Help Center. What is the current format and item types for the NCLEX? (updated June 2026) Link
  4. NCSBN Help Center. Are items in case studies dependent on the correct response to a prior item in the same set? Link
  5. NCSBN Help Center. What are stand-alone items? Link
  6. NCSBN Help Center. What should a candidate expect when they see an NCLEX Highlight item? Link
  7. NCSBN Help Center. What is an alternate item format? Link
  8. NCSBN Help Center. Is there a certain percentage of alternate items on the NCLEX? Link
  9. NCSBN. Clinical Judgment Measurement Model (NCLEX.com). Link
  10. NCSBN. Next Generation NCLEX (NCLEX.com). Link
  11. NCSBN. Prepare for Success (NCLEX.com). Link
  12. CDC. Information for Patients Who Are Getting Chemotherapy. Link