7 2023 NCLEX-RN® Test Plan

Safe and Effective Care Environment

The nurse promotes achievement of client outcomes by providing and directing nursing care that enhances
the care delivery setting in order to protect clients and health care personnel.

Management of Care
‚ Providing and directing nursing care that enhances the care delivery setting to protect the client
and health care personnel.

Management of Care
Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Integrate advance directives into client plan of care

‚ Delegate and supervise care of client provided by others (e.g., LPN/VN, assistive
personnel, other RNs)
‚ Organize workload to manage time effectively
‚ Practice and advocate for cost effective care
‚ Initiate, evaluate and update client plan of care
‚ Provide education to clients and staff about client rights and responsibilities
‚ Advocate for client rights and needs
‚ Collaborate with multi-disciplinary team members when providing client care
(e.g., physical therapist, nutritionist, social worker)
‚ Manage conflict among clients and health care staff
‚ Maintain client confidentiality and privacy
‚ Provide and receive hand off of care (report) on assigned clients
‚ Use approved terminology when documenting care
‚ Perform procedures necessary to safely admit, transfer and/or discharge a client
‚ Prioritize the delivery of client care based on acuity
‚ Recognize and report ethical dilemmas
‚ Practice in a manner consistent with the nurses’ code of ethics
‚ Verify the client receives education and client consents for care and procedures
‚ Receive, verify and implement health care provider orders
‚ Utilize resources to promote quality client care (e.g., evidence-based research,
information technology, policies and procedures)
‚ Recognize limitations of self and others and utilize resources
‚ Report client conditions as required by law (e.g., abuse/neglect and communicable
diseases)
‚ Provide care within the legal scope of practice
‚ Participate in performance improvement projects and quality improvement processes
‚ Assess the need for referrals and obtain necessary orders

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Safety and Infection Control

‚ Protecting clients and health care personnel from health and environmental hazards.

Safety and Infection Control

Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Assess client for allergies and intervene as needed

‚ Assess client care environment
‚ Promote staff safety
‚ Protect client from injury
‚ Properly identify client when providing care
‚ Verify appropriateness and accuracy of a treatment order
‚ Participate in emergency planning and response
‚ Use ergonomic principles when providing care
‚ Follow procedures for handling biohazardous and hazardous materials
‚ Educate client on safety issues
‚ Acknowledge and document practice errors and near misses
‚ Report, intervene, and/or escalate unsafe practice of health care personnel
(e.g., substance abuse, improper care, staffing practices)
‚ Facilitate appropriate and safe use of equipment
‚ Follow security plan and procedures (e.g., newborn security, violence,
controlled access)
‚ Apply principles of infection prevention (e.g., hand hygiene, aseptic technique,
isolation, sterile technique, universal/standard enhanced barrier precautions)
‚ Educate client and staff regarding infection prevention measures
‚ Follow requirements when using restraints

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Health Promotion and Maintenance

The nurse provides and directs nursing care of the client that incorporates the knowledge of expected
growth and development principles, prevention and/or early detection of health problems, and strategies
to achieve optimal health.

Health Promotion and Maintenance

Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Provide care and education for the newborn, infant, and toddler client
from birth through 2 years
‚ Provide care and education for the preschool, school age and adolescent
client ages 3 through 17 years
‚ Provide care and education for the adult client ages 18 through 64 years
‚ Provide care and education for the adult client ages 65 years and over
‚ Provide prenatal care and education
‚ Provide care and education to an antepartum client or a client in labor
‚ Provide post-partum care and education
‚ Assess and educate clients about health risks based on family, population,
and community
‚ Assess client’s readiness to learn, learning preferences, and barriers to
learning
‚ Plan and/or participate in community health education
‚ Educate client about preventative care and health maintenance
recommendations
‚ Provide resources to minimize communication barriers
‚ Perform targeted screening assessments (e.g., vision, nutrition,
depression)
‚ Educate client about prevention and treatment of high risk health
behaviors
‚ Assess client ability to manage care in home environment and plan
care accordingly
‚ Perform comprehensive health assessments

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Psychosocial Integrity
The nurse provides and directs nursing care that promotes and supports the emotional, mental and
social well-being of the client experiencing stressful events as well as clients with acute or chronic
mental illness.

Psychosocial Integrity
Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Assess client for abuse or neglect and report, intervene, and/or escalate
‚ Incorporate behavioral management techniques when caring for a client
‚ Assess client for substance abuse and/or toxicities and intervene as appropriate
(e.g., dependency, withdrawal)
‚ Assess client’s ability to cope with life changes and provide support
‚ Assess the potential for violence and use safety precautions
‚ Incorporate client cultural practices and beliefs when planning and
providing care
‚ Provide end-of-life care and education to clients
‚ Assess client support system to aid in plan of care
‚ Provide care for a client experiencing grief or loss
‚ Provide care and education for acute and chronic psychosocial health issues
(e.g., addictions/dependencies, depression, dementia, eating disorders)
‚ Assess psychosocial factors influencing care and plan interventions (e.g.,
occupational, spiritual, environmental, financial)
‚ Provide appropriate care for a client experiencing visual, auditory, and/or
cognitive alterations
‚ Recognize non-verbal cues to physical and/or psychological stressors
‚ Use therapeutic communication techniques
‚ Promote a therapeutic environment

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Physiological Integrity
The nurse promotes physical health and wellness by providing care and comfort, reducing client risk
potential and managing health alterations.

Basic Care and Comfort

‚ Providing comfort and assistance in the performance of activities of daily living.

Basic Care and Comfort

Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Assist client to compensate for a physical or sensory impairment (e.g., assistive

devices, positioning)
‚ Assess and manage client with an alteration in bowel and bladder elimination
‚ Perform irrigations (e.g., of bladder, ear, eye)
‚ Perform skin assessment and implement measures to maintain skin integrity
‚ Apply, maintain, or remove orthopedic devices
‚ Implement measures to promote circulation (e.g., active or passive range of
motion, positioning and mobilization)
‚ Assess client for pain and intervene as appropriate
‚ Recognize complementary therapies and identify potential benefits and
contraindications (e.g., aromatherapy, acupressure, supplements)
‚ Provide non-pharmacological comfort measures
‚ Evaluate the client’s nutritional status and intervene as needed
‚ Provide client nutrition through tube feedings
‚ Evaluate client intake and output and intervene as needed
‚ Assess client performance of activities of daily living and assist when needed
‚ Perform post-mortem care
‚ Assess client sleep/rest pattern and intervene as needed

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Pharmacological and Parenteral Therapies

‚ Providing care related to the administration of medications and parenteral therapies.

Pharmacological and Parenteral Therapies

Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Administer blood products and evaluate client response

‚ Access and/or maintain central venous access devices
‚ Perform calculations needed for medication administration
‚ Evaluate client response to medication
‚ Educate client about medications
‚ Prepare and administer medications using rights of medication administration
‚ Review pertinent data prior to medication administration (e.g., contraindications,
lab results, allergies, potential interactions)
‚ Participate in medication reconciliation process
‚ Titrate dosage of medication based on assessment and ordered parameters
‚ Dispose of medications safely
‚ Handle and maintain medication in a safe and controlled environment
‚ Evaluate appropriateness and accuracy of medication order for client
‚ Handle and administer high-risk medications safely
‚ Monitor intravenous infusion and maintain site
‚ Administer medications for pain management
‚ Handle and administer controlled substances within regulatory guidelines
‚ Administer parenteral nutrition and evaluate client response

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Reduction of Risk Potential

‚ Reducing the likelihood that clients will develop complications or health problems related to existing
conditions, treatments or procedures.

Reduction of Risk Potential

Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Assess and respond to changes and trends in client vital signs

‚ Perform testing within scope of practice (e.g., electrocardiogram, glucose
monitoring)
‚ Monitor the results of diagnostic testing and intervene as needed
‚ Obtain blood specimens
‚ Obtain specimens other than blood for diagnostic testing
‚ Insert, maintain, or remove a nasal/oral gastrointestinal tube
‚ Insert, maintain, or remove a urinary catheter
‚ Insert, maintain, or remove a peripheral intravenous line
‚ Maintain percutaneous feeding tube
‚ Apply and/or maintain devices used to promote venous return (e.g., anti-embolic
stockings, sequential compression devices)
‚ Use precautions to prevent injury and/or complications associated with a
procedure or diagnosis
‚ Evaluate client responses to procedures and treatments
‚ Recognize trends and changes in client condition and intervene as needed
‚ Perform focused assessments
‚ Educate client about treatments and procedures
‚ Provide preoperative and postoperative education
‚ Provide preoperative care
‚ Manage client during a procedure with moderate sedation
‚ Manage client following a procedure with moderate sedation

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Physiological Adaptation
‚ Managing and providing care for clients with acute, chronic or life-threatening physical
health conditions.

Physiological Adaptation
Related Activity Statements from the 2021 RN Practice Analysis:
Linking the NCLEX-RN® Examination to Practice

‚ Assist with invasive procedures (e.g., central line, thoracentesis, bronchoscopy)

‚ Implement and monitor phototherapy
‚ Maintain optimal temperature of client
‚ Monitor and care for clients on a ventilator
‚ Monitor and maintain devices and equipment used for drainage (e.g., surgical
wound drains, chest tube suction, negative pressure wound therapy)
‚ Perform and manage care of client receiving peritoneal dialysis
‚ Perform suctioning
‚ Perform wound care and dressing change
‚ Provide ostomy care and education (e.g., tracheal, enteral)
‚ Provide pulmonary hygiene (e.g., chest physiotherapy, incentive spirometry)
‚ Provide postoperative care
‚ Manage the care of the client with a fluid and electrolyte imbalance
‚ Monitor and maintain arterial lines
‚ Manage the care of a client with a pacing device
‚ Manage the care of a client on telemetry
‚ Manage the care of a client receiving hemodialysis or continuous renal
replacement therapy
‚ Manage the care of a client with alteration in hemodynamics, tissue perfusion,
and hemostasis
‚ Educate client regarding an acute or chronic condition
‚ Manage the care of a client with impaired ventilation/oxygenation
‚ Evaluate the effectiveness of the treatment plan for a client with an acute or
chronic diagnosis
‚ Perform emergency care procedures
‚ Identify pathophysiology related to an acute or chronic condition
‚ Recognize signs and symptoms of client complications and intervene

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III. Administration of the NCLEX-RN®

The NCLEX-RN® is administered to candidates by computerized adaptive testing (CAT). CAT is a method of
delivering examinations that uses computer technology and measurement theory. With CAT, each candidate’s
examination is unique because it is assembled interactively as the examination proceeds. Computer
technology selects items that match the candidate’s ability. The items, which are stored in a large item pool,
have been classified by test plan category and level of difficulty as well as clinical judgment steps. After
the candidate answers an item, the computer calculates an ability estimate based on all of the candidate’s
previous answers. The next item administered is chosen based on that ability estimate and is selected from
an appropriate test plan category. This process is repeated for each item, creating an examination tailored to
the candidate’s knowledge and skills while fulfilling all NCLEX-RN Test Plan requirements. The examination
continues with items selected and administered in this way until a pass or fail decision is made.

Examination Length
All registered nurse (RN) candidates must answer a minimum of 85 items. The maximum number of items that
an RN candidate may answer is 150 during the allotted five-hour period. Of the minimum-length examination,
52 of the items will come from the eight content areas listed above in the stated percentages. Eighteen of
the items will comprise three clinical judgment case studies. Case studies are item sets composed of six
items that measure each of the six domains of the NCSBN Clinical Judgment Measurement Model (NCJMM)
mentioned earlier: recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking
action and evaluating outcomes. Since clinical judgment is an integrated process, the case studies will span
any number of content areas and are therefore counted independently of the content-area-specific items.
The remaining 15 items will be unscored pretest items. The five-hour limit to complete the examination
includes all breaks.
The length of the examination is determined by the candidate’s responses to the items. Depending upon the
particular pattern of correct and incorrect responses, candidates will receive different numbers of items and
therefore use varying amounts of time. The candidate should select and maintain a reasonable pace that will
allow them to complete the examination within the allotted time should the maximum number of items be
administered. In general, it is recommended that the candidate spend approximately one to two minutes per
item in order to maintain this pace.
Each candidate is given an examination that adheres to the test plan and is therefore given the opportunity to
demonstrate their ability. The length of the candidate’s examination is not an indication of a pass or fail result.
A candidate may pass or fail regardless of the length of the examination. Additional information on passing
and failing rules is included in further detail in this section.

The Passing Standard

The NCSBN® Board of Directors (BOD) reevaluates the passing standard once every three years. The criterion
that the BOD uses to set the standard is the minimum level of ability required for safe and effective entry-level
nursing practice. Due to COVID-19, the passing standard was reevaluated in 2022.
To assist the BOD in making this decision, they are provided information on:
1. The results of a standard-setting exercise performed by a panel of experts with the assistance of
psychometricians;
2. The historical record of the passing standard with summaries of the candidate performance
associated with those standards; and
3. Information describing the educational readiness of high school graduates who express an interest
in nursing.

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Once the passing standard is set, it is applied uniformly to every examination according to the procedures laid
out in the Scoring the NCLEX section. To pass the NCLEX, a candidate must perform at or above the passing
standard. There is no fixed percentage of candidates that pass or fail each examination.

Similar Items
Occasionally, a candidate may receive an item that seems to be very similar to an item received earlier in
the examination. This may happen for a variety of reasons. Items may contain content pertaining to similar
symptoms, diseases or disorders, yet address different phases of the nursing process. Alternatively, a pretest
(unscored) item may contain content similar to an operational (scored) item. Candidates should not assume
they received a second item similar in content to a previously administered item because the candidate
answered the first item incorrectly. The candidate is instructed to always select the answer believed to be
correct for each item administered.

Reviewing Answers and Guessing

Examination items are presented to the candidate one at a time on a computer screen. There is no time limit
for a candidate to spend on each individual item. Once an answer to an item is selected, the candidate is able
to consider the answer and change it, if necessary. However, once the candidate confirms the answer and
proceeds to the next item by pressing the <NEXT> button, the candidate will no longer be able to return to
a previous item. Every item must be answered even if the candidate is not sure of the correct answer. If the
candidate is unsure of the correct answer, the candidate should consider all response options and provide
their best answer in order to proceed to the next item. The computer will not allow the candidate to proceed
to the next item without answering the current item on the screen. The best advice is to maintain a reasonable
pace (one item every minute or two) and carefully read and consider each item before answering.

Scoring the NCLEX®

Computerized Adaptive Testing

The NCLEX is different from a traditional fixed-length examination, which administers the same items to
every candidate. Fixed-length examinations ensure that the difficulty of the examination is constant for every
candidate; therefore, the percentage correct is the indicator of the candidate’s ability. This approach requires
high-ability candidates to answer all easy items on the examination and low-ability candidates to guess on
difficult items. This method provides less accurate information about the candidate’s true ability.
The NCLEX uses CAT to administer items. CAT is able to produce results that are more precise and efficient,
using fewer items by targeting items to the candidate’s ability. The computer (i.e., CAT scoring algorithm)
estimates the ability of the candidate in relation to the passing standard. Every time the candidate answers
an item, the computer re-estimates the candidate’s ability. With each additional answered item, the ability
estimate becomes more precise.
Each item that the candidate receives is selected from a large pool of items using three criteria.
1. The item is limited to the content area that will produce the best match to the test plan percentages.
CAT ensures that each candidate’s exam contains enough items from each content area to match
the required test plan percentages. Regarding clinical judgment items, three case study sets and
approximately 10% stand-alone items will be selected depending on the exam length.
2. An item is selected that the candidate is expected to find challenging. The computer estimates the
candidate’s ability based on all previous answers and the difficulty of those items and then selects an
item that the candidate should have a 50% chance of answering correctly. This ensures the next item

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should not be too easy or too difficult and the examination can obtain maximum information about the
candidate’s ability from the item.
3. Items are excluded that a repeat candidate has seen in the current item pool.
For more information on CAT, visit NCLEX.com.

Pretest Items
For CAT to function properly, the difficulty of each item must be known in advance. The degree of difficulty
is determined by administering the items as pretest items to a large sample of NCLEX candidates. Since
the difficulty of pretest items is unknown in advance, these items are not included when estimating the
candidate’s ability and subsequently making pass-fail decisions. When enough responses are collected,
the pretest items are statistically analyzed and calibrated. If the pretest items meet the NCLEX statistical
standards, they can be administered on future examinations as operational items. There are 15 pretest items
on every NCLEX-RN. Pretest items appear identical to operational items; therefore, it is recommended that
candidates give their best effort for every item.

Passing and Failing

The decision as to whether a candidate passes or fails the NCLEX is governed by three scenarios.

Scenario #1: The 95% Confidence Interval Rule

This scenario is the most common for NCLEX candidates. The computer will stop administering items when it
is 95% certain that the candidate’s ability is either clearly above or clearly below the passing standard.

Scenario #2: Maximum-Length Exam

Some candidates’ ability levels will be very close to the passing standard. When this is the case, the computer
continues to administer items until the maximum number of items is reached. At this point, the computer
disregards the 95% confidence interval rule and considers only the final ability estimate.
‚ If the final ability estimate is at or above the passing standard, the candidate passes.
‚ If the final ability estimate is below the passing standard, the candidate fails.

Scenario #3: Run-Out-of-Time Rule (R.O.O.T.)

If a candidate runs out of time before reaching the maximum number of items and the computer has not
determined with 95% certainty whether the candidate has passed or failed, alternate criteria are used.
‚ If the candidate has not answered the minimum number of required items, the candidate
automatically fails.
‚ If at least the minimum number of required items were answered, then the final ability estimate will
be based on all responses given before the exam time expired. If the score is at or above the passing
standard, the candidate will pass; otherwise, the candidate will fail.

Scoring Items
NCLEX items have multiple item formats. There is partial credit scoring for items for which more than
one key exists. There will be three methods for scoring items for partial credit: plus/minus, zero/one, and
rationale scoring.
For information on scoring NCLEX items, be sure to access NCSBN.org for newsletters and articles,
particularly the newsletter on Next Generation NCLEX: Scoring Models.

National Council of State Boards of Nursing, Inc. (NCSBN) | 2023