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

Nurses are on the front lines of health care. They play a significant role in the day-to-day management of patients in multiple settings, from crowded hospitals to doctors’ offices to urgent care centers. The NCLEX is the test all future nurses must take before any US state will grant a nursing license. Because nurses require specific skills and knowledge to do their job, the test tries to accurately assess nursing ability by offering different types of questions.

In part one of this series, we discussed the basics of the NCLEX, diving deep into how the test works and providing an introduction to the types of alternate-format questions. Here in part two, we’ll begin to dissect each type of question, beginning with four of the simplest.

We’ve arranged the types of alternate-format questions in order from most-to-least similar to standard multiple-choice questions. Most people are familiar with multiple-choice questions, and it’s generally easier to start with what’s known before moving on to the really hard stuff. Here we will discuss the first four types of alternate-format NCLEX questions in detail: audio, chart/exhibit, graphics, and hot spot.

1.) Audio Questions

Think of audio questions as standard multiple-choice questions with a little audio clip tossed in to make things more interesting. You’ll have four possible answer choices, and you must choose only one, as expected. The only difference with audio questions is that reading the text alone does not give you sufficient information to correctly answer the question.

During the test, you will be instructed to put on the provided headphones and click on the audio file to hear the clip. Listening to the audio is required to come up with the right answer, so always listen carefully. But don’t worry about getting it right the first time; you can hear the clip more than once.

NCLEX audio clips may consist of dialogue or auscultation sounds. Be very familiar with normal heart, lung, and bowel sounds. Listening to sample auscultation audio clips online may be helpful during your studies.

Consider this example:

During a shift assessment, the nurse auscultates the patient’s breath sounds. The nurse uses which term to document the findings? Attach your headphones and click on the audio file to listen.

A. Crackles
B. Inspiratory wheezing
C. Expiratory wheezing
D. Stridor

You must listen to the audio file to answer the question. Remember, the NCLEX is designed to test your critical thinking. The test could simply describe the different types of breath sounds and ask you to select the correct answer. Instead, it is asking you to take your critical thinking skills a step further by testing your ability to listen and interpret—an essential skill in your future nursing practice.

When dealing with audio questions, you need to focus on what you’re hearing. Breath, heart, and bowel sounds are distinctly different. If you’re hearing breathing through the headphones and one of the answer choices relates to the “lub-dub” of the heart, you can easily eliminate that choice. Identify what makes the audio clip unique so you can name the sound. Once you’ve figured out what you are hearing, the correct answer is not far away.

2.) Chart/Exhibit Questions

NCLEX questions that use charts and exhibits are also similar to standard multiple-choice questions, with a little extra information. The test presents these questions to ensure that test-takers can evaluate and synthesize different types of information to solve a problem. In real life, nurses are expected to read and interpret the medical chart to plan treatment and guide nursing care. You should expect nothing less when it comes to taking the NCLEX.

It is essential to read all the information presented in the chart or exhibit. The information is there for a reason. You probably won’t be able to accurately answer the question without it. The chart or exhibit may contain several different tabs. Make sure you read through the entire document.

The test question itself will be a standard multiple-choice question with four answer choices. Simply select the single correct answer based on the information in the chart. Consider the following example:

Client Chart

The patient presents to the doctor’s office complaining of fatigue, hair loss, and cold sensitivity. The nurse anticipates that the physician will make a change to which of the patient’s home medications?

A. Metoprolol
B. Metformin
C. Levothyroxine
D. Aspirin

The correct answer is C. If you look at the information provided on the chart, you will see that the patient’s TSH is elevated and Free T4 is low, consistent with hypothyroidism. The patient has a known history of hypothyroidism and is already taking Levothyroxine. However, when you consider the lab work along with the patient’s symptoms, it is evident that the Levothyroxine dosage needs to be increased.

The key to deciphering chart/exhibit questions is to read everything and look for clues. You will have to sort through a lot of information; that’s the point. Some of the information is not pertinent to the question and is simply there to distract you. When you read the question, focus on what it’s asking. Then eliminate all the unnecessary information and consider only what is relevant. You’ll find the answer lurking within the details.

3.) Graphics Questions

Graphics questions use pictures, illustrations, or diagrams as answer choices instead of text. The question is set up like a standard multiple-choice question, but with four images as the answer options. You will be required to select the single correct choice.

Graphics questions may cover a wide range of topics, so it can be hard to know what to study in preparation for these questions. For example, a graphics question may provide you with four cardiac rhythm strips and ask you to select the correct one. A question might also present multiple diagrams of the heart and ask you to identify the one that demonstrates tetralogy of Fallot or a ventricular septal defect.

As a general rule, you should be familiar with normal and abnormal physical assessment findings, normal and abnormal blood circulation patterns, heart rhythms, and auscultation landmarks. The best way to study graphics questions is to answer as many as possible. Practice makes perfect!

Take a look at this example question:

Which anteroposterior chest radiograph is most consistent with the diagnosis of aspiration pneumonia?

A)   C) 

B)   D) 

The correct answer is B. Because of the way our lungs are structured, food and other aspirated particles typically enter the right upper lobe of the lung, resulting in consolidation and atelectasis, as seen in option B. The other x-rays are examples of viral or bacterial pneumonia, which usually cause x-ray changes within the lower lobes due to gravity.

When dissecting graphics questions, it helps to remember that it’s just like a standard multiple-choice question, except the answer is a picture instead of words. Your approach to answering the question doesn’t change. Consider each picture or graphic carefully. Look for similarities and differences. Through a simple process of elimination, you’ll end up with the best choice.

4.) Hot Spot Questions

Hot spot questions also involve pictures or diagrams—however, they are set up a little differently than graphics questions. Test-takers will be given a question and asked to identify a specific area within a single picture or diagram—the hot spot. These questions are used most often to assess whether a test candidate is familiar with anatomy and anatomical landmarks.

Here is an example of a hot spot question:

The abdominal x-ray below belongs to a premature neonate with a distended and firm abdomen as well as bilious emesis. Which marker indicates the patient has experienced intestinal perforation? Select the appropriate area.

The correct answer is A. This x-ray demonstrates free air near the liver, something you would only see with a bowel perforation. Options B, C, and D are all pointing to areas within the digestive tract. They may not look quite normal but do not by themselves suggest that a perforation is present.

A classic NCLEX strategy is to have test candidates identify auscultation landmarks. Brush up on your assessment skills and know where to put your stethoscope to auscultate heart sounds. It’s also a good idea to review auscultation and percussion techniques of the abdomen and lungs. Review landmarks for intramuscular injection sites. Not only will such a review help you on the NCLEX, a thorough knowledge of physical assessment will help you be a good nurse.

Conclusion

In this post, we’ve covered the first four types of alternate-format NCLEX questions: audio, chart/exhibit, graphic, and hot spot. These questions may seem tricky at first because they are different. The only way to become more familiar with these types of questions is to practice answering them.

You’ve been through nursing school, so you have the knowledge. Now you just need to apply it. Repetition is key. Now that you have some strategies to study and dissect these questions, you can prepare to face them on test day with no fear!

This series of NCLEX blog posts promises to discuss each of the seven types of alternate-format questions in detail with test strategies and examples. Read on to learn more about the three remaining question types: multiple response, ordered response, and fill-in-the-blank.