7 Types of Alternate-Format NCLEX Questions (and How to Dissect Them) – Part Four

If you’ve been with us since the beginning of this series on dissecting alternate-format NCLEX questions, you’ve probably noticed that the sequence of these questions has slowly evolved into something that barely resembles the standard multiple-choice questions we know and love. In part two of this series, we looked at alternate-format questions that featured only small differences, such as the addition of audio clips, charts, and pictures. They still look like multiple-choice questions, just a bit more… exotic. Then, things got a little interesting as we tackled multiple-choice questions with the potential for multiple correct answers in part three. It turns out multiple response questions aren’t that difficult after all, thanks to a simple test strategy. This time, we will focus on a question type that seems even more alien: the ordered response question.

If you’re new to this series, we encourage you to go back to part one, where we dig into the heart of the NCLEX test itself and learn what it’s all about. If you’re caught up, read on to learn strategies for dissecting ordered response questions.

6.) Ordered Response Questions

The NCLEX uses ordered response questions to test your ability to determine priority, an essential real-world nursing skill. Ordered response questions present several answer options and require you to drag and drop them into place to rank them in a certain order. They are difficult because all the options are correct. Instead of simply picking one answer choice, you must consider multiple true statements and then organize them appropriately, either in sequential order (which comes first?) or by importance. No small task.

Sequential Order

One of the first things you probably learned in your nursing clinicals is the importance of steps in a process. A process can be as simple as proper handwashing or as complicated as placing a foley catheter. The NCLEX wants to be sure you know how to perform these essential nursing skills. Let’s look at an ordered response question that focuses on sequential order (steps in a process).

The nurse prepares to place a nasogastric tube (NG tube) in an elderly male patient with a bowel obstruction. Arrange the following steps in the order the nurse should perform them. All options must be used.

A. Position patient in high-Fowler’s position.
B. Lubricate the tip of the tube with water-soluble lubricating jelly.
C. Instruct the patient to swallow as the tube is advanced.
D. Measure the length of the tube from the tip of the nose to the earlobe to the xiphoid process.
E. Anchor the tube with tape.
F. Insert the tube through the naris. Apply gentle downward pressure.

To answer this question, you must be familiar with the steps to place a nasogastric tube. Put the steps in proper order by mentally picturing the procedure. Ask yourself: what comes first?

You always prepare the patient and equipment before you begin. Therefore, any steps relating to preparation will come first. Then, you perform the procedure. Picture yourself performing it. The correct order of steps will fall into place. Finally, consider if any post-procedure care is required.

You have the correct answer if you ranked the answer choices in this order: A, D, B, F, C, E.

Importance

Ordered response questions may also ask you to rank answer choices based on importance. To be honest, every person measures importance a little differently. It helps to remember that the NCLEX test is “by the book,” meaning it bases questions and answers on textbook information and evidence-based practice.

The NCLEX exists in a world of sufficient staff and limitless resources; the test will never ask you to make decisions from the perspective of a nurse working in less-than-optimal conditions. Never answer NCLEX test questions based on your experience in the hospital or at clinicals. Instead, try to remember what might be in the textbook. Luckily, even if you aren’t exactly sure what the textbook would recommend, you can live by this general principle:

Know Your ABCS

Whenever the NCLEX asks you to address priority, think about the ABCS:

• Airway
• Breathing
• Circulation
• Safety

Without an open airway, easy breathing, and flowing circulation, your patient is dead. Therefore, when considering how to rank ordered response answer choices, the first choice is always that which addresses one of these three things in order. A patent airway is the first priority because it must be open in order to get oxygen into the lungs. Breathing transports oxygen from the lungs into the bloodstream. And circulation carries blood and oxygen to the tissues. All three are necessary to maintain life.

Safety follows closely behind A, B, and C. Do no harm is an important tenet of medicine, even for nurses. Patient safety encompasses many different elements, from meeting basic needs (such as nutrition) to practicing proper infection control (never underestimate the importance of handwashing). Let’s take a look at this sample ordered response question:

The nurse just received report from the outgoing nurse on today’s patient assignments. The nurse prepares to visit each room and assess the patient. Rank the patients in the order in which each should be seen, from first to last, based on the following descriptions. All options must be used.

A. 63-year-old patient with COPD complaining of new-onset shortness of breath
B. 34-year-old patient post-cholecystectomy who requests a dressing change after noticing some blood on the dressing
C. 76-year-old surgical patient who needs instructions prior to discharge
D. 55-year-old patient with hypotension and fever

When attempting to answer this question, think first of the ABCS. Breathing (choice A) comes before circulation, and hypotension (choice D) is a circulation problem. Maintaining a clean surgical site and performing dressing changes (choice B) is good nursing care and promotes safety. The patient requiring discharge instructions (choice C) is stable and safe—the lowest priority. The correct sequence is A, D, B, C.

Ordered response questions are nothing like multiple choice questions. At this point, we’ve thrown everything familiar out the window. But these questions don’t need to feel intimidating. Remember, they are simply asking you to address priority. What is most important? For some ordered response questions, you’ll need to picture yourself performing a task to rank steps in the correct order. For others, your knowledge of ABCS will help you determine which patients are most likely in danger and need your urgent attention. And, of course, keep practicing.

We still have one final type of alternate-format question to cover before we finish up this series. Read on for tips to dissect the scariest of them all: fill-in-the-blank questions.