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National Council Licensure Examination

The National Council Licensure Examination (NCLEX) is a standardized, computerized adaptive test developed by the National Council of State Boards of Nursing (NCSBN) to assess the entry-level competency of nursing graduates seeking licensure as registered nurses (RNs) or licensed practical/vocational nurses (LPNs/LVNs).^[1] The examination evaluates candidates' knowledge, skills, abilities, and clinical judgment required to provide safe and effective care to clients requiring the services of these entry-level nurses.^[2] Administered by Pearson VUE at testing centers worldwide, the NCLEX consists of two primary versions: the NCLEX-RN for aspiring registered nurses and the NCLEX-PN for practical/vocational nurses.^[3] Passing the relevant NCLEX is a mandatory requirement for nursing licensure in the United States and Canada, as well as for internationally educated nurses seeking registration in these jurisdictions and in Australia (although alternative pathways without the exam are available for some eligible candidates in Australia as of 2025).^[1]^[4]^[5] The NCLEX employs computerized adaptive testing (CAT) technology, which dynamically adjusts the difficulty of questions based on the candidate's performance to precisely measure their ability level, typically resulting in exams ranging from 75 to 145 items delivered over up to five hours.^[6] Content is organized around four major client needs categories—safe and effective care environment, health promotion and maintenance, psychosocial integrity, and physiological integrity—with an emphasis on clinical judgment and decision-making.^[7] In April 2023, NCSBN launched the Next Generation NCLEX (NGN), an enhanced version of the exam that introduces new item types such as case studies, stand-alone items with embedded graphics, and unfolding cases to better simulate real-world clinical scenarios and evaluate higher-order thinking skills.^[8] This update aligns with evolving healthcare demands, ensuring the exam remains psychometrically sound and legally defensible while maintaining a passing standard based on the minimum knowledge, skills, and abilities needed for safe practice.^[9] NCSBN, a not-for-profit organization comprising nursing regulatory bodies from all U.S. states, territories, and Canadian provinces, oversees the development, validation, and ongoing evaluation of the NCLEX to uphold public protection through rigorous licensure standards.^[10] The exams are offered year-round at domestic and international Pearson VUE centers, including locations in over 20 countries to accommodate candidates globally, though licensure eligibility is determined by individual nursing regulatory bodies.^[11] With millions of nurses licensed via the NCLEX since its inception, it serves as the world's premier nursing licensure examination, continually refined through research and stakeholder input to reflect current practice trends.^[9]

Overview and Administration

Purpose and Scope

The National Council Licensure Examination (NCLEX) serves as a standardized licensure examination for entry-level nurses primarily in the United States and Canada, as well as for internationally qualified nurses in Australia, designed to evaluate the essential knowledge, skills, and abilities required for safe and effective nursing practice at the beginning of a professional career.^[12] Developed through rigorous psychometric processes, the NCLEX ensures that only competent individuals are granted licensure, thereby upholding standards of care across diverse healthcare settings. The primary goal of the NCLEX is to measure the minimum competency levels necessary for newly licensed nurses to perform their roles without posing risks to patient safety, focusing on critical thinking, clinical judgment, and practical application of nursing principles.^[13] This assessment protects public health by verifying that candidates can deliver care in real-world scenarios, from basic patient monitoring to complex interventions, before they engage in independent practice. In scope, the NCLEX is mandated for nursing licensure as a registered nurse (RN) or licensed practical/vocational nurse (LPN/LVN) by all 50 U.S. states, the District of Columbia, and four territories—American Samoa, Guam, Northern Mariana Islands, and Virgin Islands—through the nursing regulatory bodies affiliated with the National Council of State Boards of Nursing (NCSBN), as well as by nursing regulatory bodies in all Canadian provinces except Quebec. Internationally, it is required for licensure in these jurisdictions among nurses educated abroad, including for occupational registration in Australia, and factors into certain occupational visa screenings for healthcare professionals seeking to work in the U.S.^[14]^[15]^[1]^[4] Administered by NCSBN in partnership with Pearson VUE, the exam is taken annually by over 380,000 candidates in the U.S., reflecting its central role in maintaining a qualified nursing workforce.^[16]

Governing Organization and Delivery

The National Council of State Boards of Nursing (NCSBN), founded on March 15, 1978, as an independent not-for-profit organization, serves as the primary governing body for the National Council Licensure Examination (NCLEX). Representing nursing regulatory bodies across all U.S. states, territories, and internationally, the NCSBN develops the exam's content through periodic practice analyses that reflect current nursing competencies, establishes passing standards via rigorous standard-setting processes involving subject matter experts, and conducts comprehensive psychometric evaluations to validate item performance and overall test reliability.^[17]^[18]^[19] Pearson VUE, a global leader in computer-based testing with nearly 5,500 authorized test centers in more than 180 countries, has partnered with the NCSBN since 2002 to deliver the NCLEX examinations, utilizing its extensive infrastructure for secure administration at select locations, including in the United States, Canada, and approximately 20 other countries worldwide.^[20]^[21]^[22] The NCLEX is administered year-round, with candidates able to schedule appointments on demand through Pearson VUE's system, typically available within 30 days of registration approval. Exams are conducted exclusively via computer, adapting in real-time to the test-taker's ability level, and preliminary results via the Quick Results service are generated within 48 hours, providing immediate feedback while official licensure decisions are finalized by state boards within six weeks.^[16]^[23]^[24] Security protocols are integral to the NCLEX delivery process, featuring palm vein biometric scanning for precise candidate authentication, continuous audio and video surveillance throughout the testing session to deter misconduct, and a vast item bank of thousands of pre-calibrated questions that generates individualized exams, minimizing overlap and safeguarding content integrity.^[25]^[26]^[27]

History

Origins and Early Development

Prior to the establishment of a unified national examination, nursing licensure in the United States was managed independently by each state's board of nursing, which administered its own paper-and-pencil tests starting in the 1940s to assess candidates' knowledge and competency.^[28] This fragmented approach led to inconsistencies in standards and evaluation methods across jurisdictions. To address these issues and promote uniformity, the National League of Nursing Education (NLNE), a predecessor organization to the National League for Nursing (NLN), developed the State Board Test Pool Examination (SBTPE) in 1942 as a shared resource for state boards.^[28] The SBTPE was first administered in 1944 to candidates in 15 states, covering 13 subjects such as anatomy, physiology, and nursing fundamentals, and by 1950, all 48 states had adopted it, reducing the number of tests to six core areas while maintaining a paper-based format administered twice annually.^[29]^[28] The push for greater standardization intensified in the late 1970s, culminating in the formation of the National Council of State Boards of Nursing (NCSBN) on June 6, 1978, as an independent nonprofit organization separate from nursing practice associations like the American Nurses Association.^[30]^[31] This separation was driven by the need to protect public safety through consistent regulation, allowing state boards to collaboratively develop and oversee licensure processes without influence from professional advocacy groups.^[30] Upon its creation, NCSBN assumed responsibility for the SBTPE from the NLN and American Nurses Association, renaming it the National Council Licensure Examination (NCLEX) in 1982 to reflect its national scope and focus on entry-level nursing competency.^[29] The initial NCLEX-RN and NCLEX-PN versions retained the paper-and-pencil format of the SBTPE, featured criterion-referenced scoring with a passing scaled score of 1,600, and reduced the total questions from around 720 to 480, enabling year-round availability in some locations while still requiring 8-12 weeks for results.^[29]^[28] One of the primary early challenges for the NCLEX was transitioning from fixed-form, paper-based testing to a more efficient computerized adaptive testing (CAT) model to enhance security, accuracy, and accessibility.^[29] NCSBN began researching CAT in 1982, conducting pilot studies from 1986 to 1993 that demonstrated its ability to tailor question difficulty to individual performance, thereby shortening exam length and providing preliminary results within hours.^[29] The NCSBN Delegate Assembly approved the shift in 1991, and on April 1, 1994, CAT was fully implemented nationwide for both NCLEX-RN and NCLEX-PN, marking the last paper exam on February 2, 1994, and allowing over 155,000 candidates to test by year's end with immediate scoring and year-round scheduling.^[29] This adaptation addressed longstanding issues like cheating risks and logistical delays in paper testing, ultimately improving fairness and public protection by ensuring more precise competency measurement.^[29]

Key Milestones and Evolutions

In 1994, the National Council of State Boards of Nursing (NCSBN) fully transitioned the NCLEX to Computerized Adaptive Testing (CAT) nationwide, replacing the previous paper-and-pencil format and becoming the first licensure examination to implement this technology for all candidates.^[30] This shift enabled dynamic question selection based on candidate performance, improving efficiency and precision in assessing entry-level nursing competency.^[29] During the 2010s, the NCLEX underwent iterative updates to reflect evolving nursing practice, including the expansion of alternate-format questions—such as select-all-that-apply items—to better evaluate complex cognitive skills beyond traditional multiple-choice formats.^[32] These enhancements were informed by NCSBN's practice analysis studies, conducted every three years to validate and refine the test plan, ensuring alignment with current job demands through annual reviews.^[33] The most significant evolution occurred in 2023 with the launch of the Next Generation NCLEX (NGN) on April 1, incorporating innovative clinical judgment items designed to more effectively measure decision-making abilities essential for safe patient care.^[8] This overhaul was driven by findings from NCSBN's 2021 practice analysis (spanning 2019-2021, delayed due to the COVID-19 pandemic), which highlighted the need to strengthen assessment of clinical judgment amid shifting healthcare complexities.^[7] As part of the 2023-2026 test plan cycle, informed by the 2021 analysis, NCSBN introduced minor refinements effective through March 31, 2026, preserving the overall structure while making subtle adjustments to subcategory weights.^[7] These changes maintain the exam's focus on client needs while adapting to contemporary nursing roles without altering core administration or scoring principles.^[34] In 2024, NCSBN conducted a practice analysis of entry-level RN practice to inform further updates to the test plan, effective April 2026.^[35]

Eligibility and Registration

Candidate Requirements

To qualify for the NCLEX-RN, candidates must graduate from a state-approved or accredited nursing education program, typically an associate degree in nursing (ADN) or bachelor of science in nursing (BSN) that meets the standards set by the relevant nursing regulatory body (NRB). For the NCLEX-PN, eligibility requires completion of a diploma or certificate program in practical or vocational nursing approved by the NRB. These educational prerequisites ensure candidates possess the foundational knowledge and clinical competencies necessary for entry-level practice, with programs varying in length from 12 months for PN to 2-4 years for RN.^[36]^[37] All U.S. jurisdictions mandate approval from the state board of nursing prior to testing, which often includes a criminal background check to verify eligibility and protect public safety. Background checks typically involve fingerprint-based federal and state searches for felony or misdemeanor convictions that could disqualify candidates, with decisions made on a case-by-case basis for any criminal history. Non-native English speakers must demonstrate proficiency through approved exams such as the TOEFL (minimum score of 79-87 iBT overall with at least 26 in speaking, depending on the state) or IELTS (minimum overall band of 6.5), unless educated in English-speaking countries or exempt by NRB policy. Requirements for English proficiency vary; some states exempt candidates educated in English-speaking countries or waive based on specific criteria.^[38]^[39]^[40] Candidates are generally required to be at least 18 years old, though some states set the minimum at 17 with parental consent or upon high school graduation. Legal requirements emphasize good moral character, prohibiting licensure for individuals with certain felony convictions that directly relate to nursing practice, such as those involving violence, fraud, or substance abuse, subject to NRB review and possible rehabilitation evidence.^[41] For international candidates, foreign-educated nurses must obtain a credentials evaluation from an approved agency like the Commission on Graduates of Foreign Nursing Schools (CGFNS) to confirm that their education is comparable to U.S. standards, often including passage of the CGFNS Qualifying Exam for RN applicants. They must also satisfy U.S. immigration and visa requirements for licensure and practice, such as obtaining appropriate work authorization. International nurses seeking multistate licensure must meet NLC uniform requirements. As of 2024, internationally educated candidates comprised about 19% of first-time NCLEX-RN test-takers for U.S. licensure, reflecting the exam's role in global nurse mobility.^[42]^[43]^[16]

Application and Scheduling Procedures

To apply for the NCLEX, candidates must first submit an application for licensure or registration to the nursing regulatory body (NRB) in the jurisdiction where they intend to practice, which verifies eligibility based on criteria such as completion of an approved nursing program.^[44] This step includes paying an application fee to the NRB, which varies by jurisdiction (typically $0 to $450 as of 2024).^[45] Upon approval, the NRB notifies Pearson VUE, the official testing vendor, allowing the candidate to proceed with exam registration.^[44] Following NRB approval, candidates register for the exam directly with Pearson VUE by creating an online account at nclex.com or by phone at 1-866-496-2539, providing personal information, a program code from their nursing school, and payment of the $200 U.S. registration fee (or equivalent in other currencies for international candidates, such as $360 CAD for Canada).^[46] This registration is valid for one year from the date of payment, after which it expires if no ATT has been issued.^[47] Once registered, Pearson VUE generates and emails the Authorization to Test (ATT) to the candidate, usually within 2 to 4 weeks after NRB eligibility confirmation, though timelines can vary by jurisdiction.^[48] The ATT contains the candidate's eligibility details and is valid for a period set by the NRB, averaging 90 days but ranging from 60 to 180 days depending on the state or country.^[48] With the ATT in hand, candidates schedule their exam appointment through their Pearson VUE account online or by phone, selecting from available domestic or international test centers or the OnVUE remote proctored testing option where eligible (primarily for U.S. candidates). Appointments must be booked within the ATT validity dates, and testing must occur before expiration to avoid reapplication.^[48] Changes to scheduled appointments incur a $50 fee if requested more than one full business day before the original date, while cancellations or changes closer to the exam date may require full reregistration and the $200 fee.^[49] Candidates requiring testing accommodations due to disabilities, such as extra time, screen readers, or separate restrooms, must submit a formal request to their NRB at the time of licensure application, accompanied by professional documentation from a qualified healthcare provider verifying the need and recommended adjustments.^[50] The NRB reviews and approves or denies the request, typically within 4 to 6 weeks, and any approved accommodations are indicated on the ATT email for implementation during scheduling with Pearson VUE.^[3] Remote proctoring accommodations may have additional limitations compared to in-center testing.^[51]

Types of Examinations

NCLEX-RN

The NCLEX-RN (National Council Licensure Examination for Registered Nurses) is designed to assess the competency of entry-level nurses to practice safely and effectively as registered nurses in the United States and its territories. It targets graduates of accredited associate degree or baccalaureate nursing programs who seek initial licensure as registered nurses (RNs). The examination evaluates the ability to apply clinical judgment in providing care across diverse client populations, ensuring that candidates meet the minimum standards for safe nursing practice.^[52] Administered via computerized adaptive testing, the NCLEX-RN consists of a minimum of 85 questions and a maximum of 150 questions, including 15 pretest items that do not count toward the final score; the entire exam must be completed within a 5-hour time limit. This variable-length format allows the test to adapt in real-time to the candidate's performance, providing a precise measure of proficiency. The exam's broader scope reflects the RN role, with a significant emphasis on physiological integrity, which comprises 38-62% of the content, focusing on areas such as basic care, pharmacological therapies, risk reduction, and physiological adaptation. Additionally, it uniquely stresses skills in delegation, leadership, and management, particularly within the management of care category (17-23%), where candidates demonstrate abilities in supervising care, prioritizing tasks, and collaborating in multidisciplinary settings to ensure client safety and efficient healthcare delivery.^[52]^[53] Pass rates for the NCLEX-RN vary by candidate background, highlighting differences in preparation and educational contexts. In 2024, first-time U.S.-educated candidates achieved a pass rate of 91.2%, reflecting strong performance among domestic nursing graduates. In contrast, international first-time candidates had a pass rate of approximately 53.8% during the same period, often due to challenges in aligning with U.S. nursing standards and English-language proficiency. These figures underscore the exam's role in maintaining high licensure standards while accommodating global applicants.^[16]

NCLEX-PN

The NCLEX-PN (National Council Licensure Examination for Practical Nurses) is designed for graduates of approved practical or vocational nursing programs who seek licensure as a licensed practical nurse (LPN) or licensed vocational nurse (LVN). These nurses practice under the supervision of registered nurses (RNs), physicians, or other authorized healthcare providers, focusing on delivering basic, supportive care to promote patient health and well-being.^[54] The examination assesses entry-level competencies essential for safe and effective practice in diverse healthcare settings, such as hospitals, long-term care facilities, and community health environments.^[2] The exam is administered year-round through Pearson VUE testing centers using computerized adaptive testing (CAT). It consists of a minimum of 85 questions and a maximum of 150 questions, including 15 unscored pretest items used to evaluate future exam questions; candidates have up to 5 hours to complete the test.^[54] Content emphasizes foundational skills like providing basic care and comfort, performing data collection through observation and reporting, and assisting with diagnostic and therapeutic procedures, all within the scope of collaborative practice.^[2] Specific areas such as pharmacological and parenteral therapies are weighted at 10-16% of the exam, while reduction of risk potential, including safety measures and complications prevention, accounts for 9-15%.^[54] This structure underscores the LPN/LVN's role in supporting interdisciplinary teams to achieve therapeutic outcomes.^[2] Pass rates for U.S.-educated, first-time NCLEX-PN candidates reflect strong performance, with an overall rate of 88.4% in 2024 (44,693 passers out of 50,570 candidates).^[16] Quarterly rates varied from 82.6% in Q4 to 91.1% in Q1, highlighting consistent success among prepared examinees in this supportive nursing role.^[16]

Test Content Outline

Client Needs Framework

The Client Needs Framework serves as the foundational structure for the content of the National Council Licensure Examination (NCLEX), categorizing test items according to key priorities in patient-centered nursing care. Developed by the National Council of State Boards of Nursing (NCSBN), this framework ensures that the examination evaluates entry-level nurses' ability to address essential client needs across diverse healthcare settings and populations. It emphasizes practical competencies derived from empirical data on nursing practice, providing a consistent basis for item development and test construction.^[55] The framework comprises four major categories, with content distribution outlined in percentages that reflect the relative importance of each area based on job analyses of practicing nurses. For the NCLEX-RN, the Safe and Effective Care Environment category, which encompasses management of care coordination, safety protocols, and infection control, accounts for 25-37% of the test items (Management of Care: 15-21%; Safety and Infection Control: 10-16%). Health Promotion and Maintenance, focusing on lifestyle guidance, disease prevention, and growth milestones, represents 6-12%. Psychosocial Integrity, addressing mental health support, coping mechanisms, and therapeutic communication, also constitutes 6-12%. The largest category, Physiological Integrity, covering body system functions and related interventions, spans 38-62% and includes four subcategories: Basic Care and Comfort (6-12%, e.g., mobility assistance and nutrition); Pharmacological and Parenteral Therapies (13-19%, e.g., medication administration and dosage calculations); Reduction of Risk Potential (9-15%, e.g., diagnostic assessments and complications prevention); and Physiological Adaptation (11-17%, e.g., managing acute changes in health status).^[55]^[34] For the NCLEX-PN, the framework applies the same categories but with adjusted percentages to align with the scope of practical nursing, such as greater emphasis on direct care and less on advanced delegation; for instance, Safe and Effective Care Environment totals 28-40% (Coordinated Care: 18-24%; Safety and Infection Control: 10-16%), while Physiological Integrity ranges from 35-50%. Health Promotion and Maintenance is 6-12%, and Psychosocial Integrity is 9-15%. The 2023-2026 test plan, effective through March 31, 2026, derives these distributions from the 2021 Practice Analysis, a comprehensive job analysis surveying newly licensed nurses to identify critical activities, knowledge, and skills. This process ensures balanced coverage across cognitive levels—recall, analysis, and application—while prioritizing high-impact areas for safe practice.^[56] Test items within the framework are constructed from real-world clinical scenarios to simulate authentic nursing decisions, promoting relevance to contemporary practice. The NCSBN updates the test plan periodically through practice analyses and stakeholder input, maintaining alignment with evolving healthcare demands without altering the core Client Needs structure.^[54]

Integrated Processes

The integrated processes in the National Council Licensure Examination (NCLEX) represent fundamental nursing actions and concepts that are interwoven throughout all client needs categories, ensuring candidates demonstrate comprehensive application of nursing practice rather than isolated knowledge. Derived from the National Council of State Boards of Nursing (NCSBN)'s practice analyses, these processes emphasize holistic competency; the 2023 NCLEX test plan, for instance, is based on the 2021 RN Practice Analysis, which validated their relevance to entry-level nursing roles across the United States and Canada.^[33]^[57] The five core integrated processes are Caring, Communication and Documentation, Culture and Spirituality, Teaching/Learning, and Nursing Process. Caring involves providing compassionate, patient-centered care that builds trust and respects individual dignity, often incorporating cultural competence and spirituality to address diverse patient backgrounds. Communication and Documentation focuses on effective verbal and nonverbal interactions with patients, families, and interdisciplinary teams, alongside accurate, timely recording of care to ensure continuity and compliance with legal standards such as the Health Insurance Portability and Accountability Act (HIPAA). Culture and Spirituality addresses respecting clients' cultural beliefs, values, and spiritual practices in care delivery. Teaching/Learning entails assessing learning needs and delivering education to empower patients in disease management, health promotion, and lifestyle modifications, with principles embedded in a significant portion of items to evaluate educational competencies. The Nursing Process follows the ADPIE model—Assessment (gathering data), Diagnosis (analyzing needs), Planning (setting goals), Implementation (delivering interventions), and Evaluation (measuring outcomes)—and integrates evidence-based practice to guide systematic, ethical decision-making. Clinical judgment is measured through Next Generation NCLEX items across these processes.^[54]^[53] Unlike client needs categories, which outline content areas, the integrated processes are not tested as discrete sections but appear in 100% of examination items, reinforcing their role as cross-cutting methodologies essential to safe, effective nursing. Special considerations, including ethical dilemmas, legal responsibilities, and cultural sensitivity, are embedded across all processes to reflect real-world complexities. The 2026 NCLEX test plan, approved in August 2025 based on the 2024 practice analysis and effective April 1, 2026, updates these processes to explicitly incorporate telehealth delivery and health informatics, addressing evolving healthcare technologies and remote care demands.^[54]^[58]

Exam Format

Computerized Adaptive Testing

The National Council Licensure Examination (NCLEX) employs computerized adaptive testing (CAT), a methodology that dynamically adjusts the difficulty of questions based on the candidate's performance to efficiently assess competency. CAT integrates computer technology with item response theory (IRT), a psychometric framework that estimates a candidate's ability level on a continuous scale by analyzing the probability of correct responses relative to item difficulty. The examination begins with a question of medium difficulty, calibrated to have approximately a 50% chance of being answered correctly, providing an initial ability estimate.^[52]^[59] As the candidate responds, the CAT algorithm recalculates their ability estimate after each item, selecting subsequent questions from a large pool that are optimally challenging—typically those with a predicted 50% success probability based on prior performance. Correct answers prompt harder items to refine the upper bound of ability, while incorrect ones lead to easier items to assess the lower bound, ensuring content coverage across the test plan categories. The process continues until the algorithm achieves 95% confidence that the candidate's ability is either clearly above or below the passing standard, at which point the exam stops. If confidence is not reached by the maximum length, additional rules apply, such as the run-out-of-time provision within the five-hour limit.^[60]^[52] Logistically, NCLEX exams are administered at secure Pearson VUE testing centers. Remote proctored testing is under development, with plans for implementation in 2026.^[61] Each exam includes 15 pretest items, which are unscored and used solely for future calibration but are indistinguishable from scored items to preserve test integrity. There is no penalty for guessing, as the pass/fail outcome depends on overall ability estimation rather than deducting points for incorrect responses, encouraging candidates to answer every question.^[52]^[62] The adaptive nature of CAT offers key advantages, including shortened exam duration—typically averaging 1-2 hours for most candidates—and greater measurement precision compared to fixed-length tests, as it requires fewer items (minimum 85, maximum 150) to reach a reliable decision. This efficiency stems from IRT's ability to target questions precisely to the candidate's competency level, reducing unnecessary content exposure.^[52]^[60]

Traditional Question Types

The traditional question types on the NCLEX examinations form the core of the test and are designed to evaluate candidates' ability to apply nursing knowledge in clinical scenarios rather than simple recall. These formats have been a staple since the exam's inception and continue to be administered within the computerized adaptive testing (CAT) framework, where item difficulty adjusts dynamically based on candidate performance. Note that Next Generation NCLEX (NGN) exams include fixed case study items alongside traditional formats.^[63]^[3] The predominant format is the single-response multiple-choice question, which consists of a stem followed by four options, only one of which is correct. These questions require selecting the best answer among distractors that represent common errors or partial understandings. Alternate format items include multiple-response (select-all-that-apply or SATA) questions, where candidates must identify all correct options from a list of up to 10 choices; fill-in-the-blank calculations, such as determining IV drip rates or medication dosages; ordered response items that involve prioritizing nursing actions or sequencing procedures via drag-and-drop; hot spot questions requiring selection of a specific location on an anatomical diagram or image; and chart or exhibit items that demand interpretation of patient data from tables, graphs, or records.^[63]^[64] Audio and video enhancements may accompany some items to simulate real-world assessments, such as identifying abnormal heart sounds.^[63] All traditional items are scored dichotomously as correct or incorrect, with no partial credit, negative scoring, or penalties for guessing, which encourages comprehensive responses.^[63]^[3] Rationales explaining answers are not provided during the examination to maintain test integrity. Under the 2023 test plan, effective through March 31, 2026, these traditional types remain foundational alongside newer formats.^[54]^[65]

Next-Generation NCLEX

Implementation Timeline

The Next Generation NCLEX (NGN) project was publicly announced by the National Council of State Boards of Nursing (NCSBN) in 2017, building on prior clinical judgment research initiated in 2016 that identified the need for licensure exams to better evaluate nurses' decision-making abilities in complex scenarios.^[66] Development progressed through multiple phases, including simulation-based studies and item prototyping from 2018 onward, with pilot testing occurring between 2020 and 2022 to refine new question formats. Beta testing in April and December 2022 involved "friends and family" and live simulations, collecting over 100,000 responses to more than 1,000 pilot items to ensure validity and reliability before full rollout.^[67]^[68] The NGN officially launched on April 1, 2023, fully replacing the legacy computerized adaptive testing (CAT) format for both NCLEX-RN and NCLEX-PN exams, with immediate integration across all testing centers and no transitional elements; as of 2025, 100% of examinations utilize the NGN framework.^[8]^[3] This implementation addressed limitations in the legacy CAT's capacity to assess multifaceted clinical decision-making, driven by the 2021 practice analysis of entry-level nursing roles, which highlighted evolving responsibilities amid global health challenges such as the COVID-19 pandemic.^[69] The analysis, surveying thousands of nurses and educators, underscored the need for exam enhancements to reflect real-world demands like triage and prioritization in dynamic environments.^[33] Globally, the NGN format has been adopted for equivalent licensure exams, with Canada implementing it concurrently on April 1, 2023, to align with U.S. standards while accommodating regional terminology. Starting April 2025, Australia introduced a streamlined registration pathway for eligible internationally qualified registered nurses from comparable jurisdictions with at least 1,800 hours of practice, waiving the NCLEX/NGN requirement and facilitating faster credentialing; the exam remains mandatory for those not qualifying under the new standard.^[70]^[5]^[71] In the U.S., first-time pass rates for U.S.-educated candidates stabilized at approximately 88% by mid-2025, as evidenced by NCSBN's ongoing monitoring and adjustments to passing standards.^[72]

Clinical Judgment Model and New Items

The Clinical Judgment Measurement Model (NCJMM), developed by the National Council of State Boards of Nursing (NCSBN), serves as the foundational framework for the Next Generation NCLEX (NGN) to evaluate candidates' clinical judgment and decision-making abilities.^[73] This model conceptualizes clinical judgment as a dynamic process involving iterative cognitive operations, informed by patient context and environmental factors.^[74] At its core are six sequential steps: recognize cues (identifying relevant clinical data); analyze cues (interpreting their significance); prioritize hypotheses (ranking potential issues); generate solutions (developing possible interventions); take action (selecting and implementing the best option); and evaluate outcomes (assessing effectiveness and adjusting as needed).^[73] These steps are embedded within NGN items to mirror real-world nursing scenarios, ensuring the exam measures the full spectrum of judgment rather than isolated knowledge recall.^[8] To operationalize the NCJMM, the NGN incorporates innovative item types designed to test these cognitive processes across complex situations. Case studies present an evolving clinical vignette with up to six associated questions, allowing candidates to apply multiple NCJMM steps sequentially within one patient scenario.^[75] Bow-tie items employ a visual decision tree structure, displaying potential causes or risks on the left "bow" and corresponding interventions or outcomes on the right, requiring candidates to link elements accurately to demonstrate prioritization and solution generation.^[76] Trend questions focus on data shifts, such as vital sign changes over time, to assess cue analysis and hypothesis prioritization through graphical or tabular trends.^[77] The 405-line, or matrix, format uses a grid where rows represent patient variables (e.g., symptoms) and columns list options (e.g., assessments), enabling evaluation of multifaceted judgments via multi-select responses.^[76] Standalone cloze items feature drop-down menus for filling in discrete elements, like medication dosages or lab interpretations, to test action-taking in isolated contexts.^[77] These formats supplement traditional multiple-choice questions without replacing them, enhancing the exam's fidelity to nursing practice.^[8] Scoring for NGN items emphasizes nuanced assessment of clinical judgment through polytomous methods that award partial credit, differing from the binary scoring of legacy items. Bow-tie items use plus/minus scoring, granting points for correct connections while deducting for errors within the decision tree.^[3] Cloze items apply zero/one scoring per fill-in, allowing partial points for accurate individual selections amid potential multi-part responses. Extended multiple-response items, including those in case studies, employ rationale scoring, where candidates must justify selections to earn credit for partially correct reasoning.^[3] In 2025, these new item types comprise approximately 15-20% of the total exam content, integrated adaptively to maintain overall test reliability.^[76] The NCJMM and associated items underwent rigorous validation through NCSBN-led research, including simulations and psychometric analyses, confirming their ability to more effectively identify candidates with deficits in safe clinical judgment compared to prior formats.^[8] This evidence-based approach, refined over a decade, ensures the NGN better protects public safety by aligning assessment with entry-level nursing competencies.^[78]

Scoring and Post-Exam Processes

Passing Standards

The National Council Licensure Examination (NCLEX) employs a criterion-referenced, pass/fail outcome determination, where success is based on whether a candidate demonstrates the minimum competency required for safe and effective entry-level nursing practice, rather than a fixed percentage of correct answers or comparison to other test-takers. No numerical score is released to candidates; instead, the exam concludes with a binary result once sufficient evidence of competency (or lack thereof) is established. The passing threshold is determined through computerized adaptive testing (CAT) that utilizes Item Response Theory (IRT) to estimate candidate ability on a logit scale, stopping the exam when there is 95% confidence that the candidate's true ability is either above or below the passing standard.^[79] A candidate passes if their estimated ability meets or exceeds the passing standard of 0.00 logits for the NCLEX-RN or -0.18 logits for the NCLEX-PN.^[80] For candidates near the threshold (borderline cases), the system administers additional questions—up to the maximum of 150 for both the NCLEX-RN and NCLEX-PN—to refine the confidence interval and confirm the outcome. The passing standards are periodically reviewed and set by the National Council of State Boards of Nursing (NCSBN) Board of Directors every three years to align with current entry-level nursing practice requirements, incorporating input from expert panels of nursing educators, regulators, and clinicians via a modified Angoff procedure.^[18] This process includes surveys of stakeholders such as educators and employers to gauge minimal competency levels, followed by psychometric adjustments like the Beuk compromise method to finalize the logit value.^[81] For the 2023-2026 examination cycle, standards were reviewed in 2022 and upheld without change, ensuring continuity for 2025 administrations.^[14] IRT ensures equity by calibrating item difficulty and candidate ability on a common scale, allowing fair comparisons regardless of the specific questions encountered, while the uniform passing standards apply to all U.S. and international candidates taking the exam in English.^[82] Although preparation quality and educational background influence pass rates—which vary across candidate types such as first-time U.S.-educated (91.2% for RN in 2024) versus international (53.8% for RN in 2024)—the competency threshold remains consistent to maintain licensure integrity.^[16]

Results, Retesting, and Licensure

Candidates receive unofficial results through the Quick Results Service provided by Pearson VUE, accessible via their online account approximately two business days after completing the exam, for a fee of $7.95.^[24] This service is available in participating U.S. jurisdictions and provides a pass or fail indication but is not official.^[24] Official results, confirming pass or fail status, are issued exclusively by the candidate's nursing regulatory body (NRB) and mailed within six weeks of the exam date.^[83] Successful candidates do not receive a numerical score, only confirmation of passing; those who fail receive a pass/fail notification along with a Candidate Performance Report detailing strengths and weaknesses.^[84] Individuals who fail the NCLEX must wait a minimum of 45 days before retaking the exam, as stipulated by NCSBN policy, though some NRBs impose longer waiting periods.^[83] Most jurisdictions allow unlimited attempts, limited to a maximum of eight per calendar year, provided the candidate remains eligible within three years of nursing program completion.^[85] To retake, candidates must reapply through their NRB, obtain a new Authorization to Test (ATT), and pay the full registration fee of $200, plus any state-specific fees.^[86] Upon passing the NCLEX, the NRB processes the application for licensure, which typically results in issuance of a full nursing license within two to six weeks, depending on the jurisdiction's procedures.^[87] Some states offer a temporary permit to practice upon graduation or shortly after passing, valid for a limited period (e.g., 75 to 120 days) while awaiting full licensure, but this is not universal and requires NRB approval.^[88] Criminal background checks, often initiated during the initial licensure application, are finalized post-exam to ensure eligibility before granting the permanent license.^[89] Appeals of exam results are rare and limited to cases of administrative errors or invalidation without evidence of candidate misconduct, such as test security issues; candidates may request a review through their NRB, potentially leading to a free retest.^[83] In 2025, the Quick Results Service remains enhanced for faster access in supported areas, maintaining the $7.95 fee structure to aid timely planning for licensure.^[90]

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