Bow-Tie, Matrix, and Cloze: How to Answer Every NGN Question Format

Published: June 29, 2026 Updated: June 29, 2026 By NCLEX Deck Est. reading time: 9 minutes

If you are preparing for the Next Generation NCLEX (NGN), you already know the exam looks different from the old one. The NGN was designed to test clinical judgment — not just your ability to memorize facts but your capacity to think like a nurse at the bedside. That shift brought six new or redesigned question formats: Extended Multiple Response, Bow-Tie, Matrix/Grid, Cloze, Extended Drag-and-Drop, and Enhanced Hot Spot.

Each format measures a different layer of the NCSBN Clinical Judgment Measurement Model (CJMM), from recognizing cues to evaluating outcomes. Understanding these formats — how they look, how they are scored, and how to attack them — is one of the highest-yield strategies you can adopt in the weeks before your exam.

In this guide, we walk through every NGN question format with real clinical examples, scoring breakdowns, and battle-tested strategies so you walk into the testing center confident you can handle whatever the exam throws at you.

Extended Multiple Response (Partial Credit SATA)

Extended Multiple Response (EMR) is the NGN's revamped version of the old Select-All-That-Apply (SATA) question. The biggest change? Partial credit.

Under the old NCLEX, a SATA question was all-or-nothing: you had to pick every correct option and leave every incorrect option unchecked, or you earned zero points. That punishing binary scoring is gone. On the NGN, EMR questions are scored using item-level scoring: you receive credit for each option you correctly select or correctly leave unselected. That means even a partially correct answer earns points.

Clinical Example: EMR — Postoperative Complications

A nurse is caring for a 72-year-old patient 6 hours after an open cholecystectomy. The patient’s heart rate is 108 bpm, blood pressure is 98/62 mm Hg, urine output has been 18 mL over the past 2 hours, and the patient reports incisional pain of 6/10. Which findings require immediate intervention? Select all that apply.

Heart rate 108 bpm
Blood pressure 98/62 mm Hg
Urine output 18 mL over 2 hours
Incisional pain 6/10
Temperature 37.1°C (98.8°F)

Correct selections: A, B, C (tachycardia, hypotension, and low urine output suggest hypovolemia or hemorrhage; pain 6/10 and a normal temp are important but not immediately life-threatening). Under NGN scoring, selecting A, B, and C while leaving D and E unchecked earns full credit. Selecting A and B but missing C still earns partial credit.

How to Strategize EMR Questions

Treat each option independently. Do not ask yourself “which combination is right?” Instead, evaluate each option as a true/false statement.
Look for abnormal findings first. Labs, vitals, and assessment data outside normal range are almost always significant.
Educated guessing pays off now. Because of partial credit, if you are unsure about one or two options, go ahead and apply what you know — a wrong click costs less than it used to.
Beware of “normal” distractors. The NGN often includes values that look abnormal at first glance but are within normal limits for the patient population (e.g., an SpO₂ of 93% in a patient with COPD).

Bow-Tie Format

The Bow-Tie format is one of the most visually distinctive question types on the NGN. It is named for its layout: a central column flanked by two side columns, resembling a bow tie. It tests your ability to connect a client condition with the appropriate nursing actions and parameters to monitor.

A Bow-Tie question presents a clinical scenario and asks you to fill in three sections:

Condition (center) — Identify the condition the patient is most likely experiencing.
Two Actions (left column) — Select two nursing actions from a list of options.
Two Parameters to Monitor (right column) — Select two parameters (vitals, labs, assessments) you would monitor.

Scoring: Bow-Tie questions use a 0–3 scale:

1 point for correctly identifying the condition.
1 point for selecting at least one of the two correct actions.
1 point for selecting at least one of the two correct parameters to monitor.

Clinical Example: Bow-Tie — Acute Decompensated Heart Failure

Scenario: A 78-year-old male with a history of heart failure (HFrEF) is admitted with worsening dyspnea, orthopnea, and bilateral lower extremity edema (3+). His oxygen saturation is 88% on room air. Lung auscultation reveals crackles bilaterally up to the mid-fields. JVD is noted at 8 cm H₂O.

Condition: Acute decompensated heart failure (ADHF) / acute pulmonary edema

Actions (select 2):

✓ Administer furosemide (Lasix) 40 mg IV
✓ Place patient on 2 L O₂ via nasal cannula; titrate to SpO₂ ≥ 92%
✗ Administer metoprolol 25 mg PO now (β-blockers are typically held in acute decompensation)
✗ Place patient in supine position (semi- to high-Fowler’s is indicated)

Parameters to Monitor (select 2):

✓ Daily weight and strict intake/output
✓ Oxygen saturation and lung sounds q1h
✗ Serum troponin
✗ Capillary refill time

Even if you miss the correct condition but correctly identify one action and one parameter, you still earn 2 out of 3 points.

Bow-Tie Strategy

Start with the condition. Read the scenario and identify the most likely diagnosis before looking at the answer options. Then match your answer to the choices.
Actions come first. The left column (actions) typically involves immediate or priority interventions — think ABCs (airway, breathing, circulation) and Maslow’s hierarchy.
Parameters should be relevant and measurable. The right column asks what you will monitor to evaluate your interventions. Choose parameters directly tied to the condition (e.g., SpO₂ for a respiratory problem, urine output for renal perfusion).
Remember partial credit psychology. If you are 100% sure about the condition and one action, you already have 2 points. Use the remaining effort to pick the best second action or parameter, but do not overthink it at the expense of running out of time.

Matrix / Grid

The Matrix or Grid format presents information in a table of rows and columns, with checkboxes at the intersections. You select the correct box or boxes to complete the table. Common uses include matching signs and symptoms to conditions, linking nursing interventions to patient goals, or identifying which clinical findings are associated with which diagnosis.

Scoring: Each row is typically scored independently, so you earn partial credit for rows you answer correctly even if you miss others. This makes Matrix questions a good opportunity to pick up points if you know some of the material well.

Clinical Example: Matrix — Electrolyte Imbalances

Scenario: A nurse is reviewing lab results on four patients. For each electrolyte imbalance, select one expected assessment finding from the options shown.

Imbalance	Muscle cramps	Bradycardia	Trousseau sign	Hyperactive bowel sounds
Hypercalcemia	☐	☑	☐	☐
Hypocalcemia	☐	☐	☑	☐
Hyperkalemia	☐	☑	☐	☐
Hypokalemia	☐	☐	☐	☑

Checkmarked cells indicate the correct matches: Hypercalcemia → Bradycardia; Hypocalcemia → Trousseau sign; Hyperkalemia → Bradycardia; Hypokalemia → Hyperactive bowel sounds. Each row scored independently.

Matrix Strategy

Work row by row. Focus on one row at a time rather than trying to see the whole grid at once. This reduces cognitive load and helps you apply specific knowledge to each case.
Use process of elimination. If a finding cannot possibly apply to a condition (e.g., bounding pulses with hypovolemia), eliminate it and move on.
Check for “always true” patterns. Some signs are pathognomonic (e.g., Chvostek sign for hypocalcemia). If you spot one, lock it in quickly.
Do not overcorrect. If you are confident in four out of five rows, submit what you have. The partial credit for the rows you do know is better than second-guessing yourself into mistakes.

Cloze (Drop-Down Blanks)

Cloze questions present a clinical passage — a nurse’s note, a patient handoff report, or a chart entry — with blank spaces that you fill using drop-down menus. Each blank has a set of plausible options, and you select the one that best completes the statement.

Scoring: Each drop-down blank is scored independently. If a passage has three blanks and you get two of them right, you earn credit for those two. This format tests your ability to apply clinical knowledge in context — you are not just picking an answer in isolation but integrating it into a real clinical narrative.

Clinical Example: Cloze — Septic Patient

Chart entry:

A 65-year-old female admitted from the ED with suspected urosepsis. On admission, temperature 39.2°C, HR 112 bpm, RR 24, BP 88/52 mm Hg, and WBC count of 18,500/mm³. Based on these findings, the patient meets criteria for [severe sepsis / septic shock / SIRS without infection / MODS]. The nurse should initiate [norepinephrine drip / metoprolol 5 mg IV / sodium nitroprusside drip / furosemide 40 mg IV] per protocol for hypotension refractory to fluid resuscitation. The nurse should monitor the patient’s [serum potassium / lactate level / hemoglobin A1c / bilirubin] to assess tissue perfusion and the adequacy of resuscitation.

Correct answers: Septic shock (hypotension + infection + elevated lactate is shock); norepinephrine drip (first-line vasopressor in septic shock); lactate level (marker of tissue hypoperfusion). Each blank is scored independently.

Cloze Strategy

Read the entire passage first. Before touching a single drop-down, read the full text. The context of later sentences often gives clues for earlier blanks.
Anchor on the clinical picture. Ask yourself: “What is the primary problem here?” The diagnosis drives the nursing interventions and monitoring parameters.
Use grammar as a tiebreaker. Occasionally the grammatical structure (plural vs. singular, verb tense, article choice) will help narrow down options.
Move in order. The blanks are arranged sequentially and the clinical logic usually flows that way. If you get stuck on blank #2, skip it, answer blank #3, and return — the downstream choice may clarify the upstream one.

Extended Drag-and-Drop (Ordering)

Extended Drag-and-Drop questions ask you to arrange items in the correct sequence. Common applications include ordering the steps of a clinical procedure (e.g., urinary catheter insertion, wound care), ranking nursing priorities from most to least urgent, or sequencing the steps of the Clinical Judgment Measurement Model.

Scoring: Scoring varies by question, but generally you earn points for correctly placing items in the correct relative positions. Some questions award credit for adjacent correct pairs, while others use an ordered-response model where position matters absolutely.

Clinical Example: Drag-and-Drop — Code Blue Response

Task: Place the following nursing actions during a code blue in the correct order (1 = first, 5 = last).

Call for help and activate the code team. ✓ (1)
Check for responsiveness and assess ABCs. ✓ (2)
Begin chest compressions at a rate of 100–120/min. ✓ (3)
Apply defibrillator pads and analyze rhythm. ✓ (4)
Administer epinephrine 1 mg IV push per ACLS protocol. ✓ (5)

The ordering mirrors real ACLS workflow: recognize the event → assess → start compressions → prepare for defibrillation → give medications. If you place “Give epinephrine” before “Begin compressions,” you lose points for that pair.

Drag-and-Drop Strategy

Identify the framework. Is the question asking for chronological order (procedure steps), priority order (Maslow, ABCs), or conceptual order (nursing process steps)? Knowing the framework makes the sequence predictable.
Anchor the first and last items. If you can identify what must happen first and what must happen last, you have already locked in those positions and narrowed the middle.
Look for logical pairs. Some items naturally come together (e.g., “clean the wound” before “apply a sterile dressing”). If you find a pair, place them in sequence and build outward.
Don’t second-guess common protocols. ACLS, fall prevention, infection control, and medication administration follow well-established algorithms. Trust what you have studied for these.

Enhanced Hot Spot (Highlighting Clinical Notes)

The Enhanced Hot Spot format looks unlike anything on the old NCLEX. You are presented with a clinical note, report, or chart entry and asked to click and drag your cursor across specific words, phrases, or sentences that support a given conclusion. Think of it as a digital highlighting exercise — exactly what nurses do every shift when they scan a chart for relevant data.

Scoring: You receive credit for each correct highlight you select. Selecting incorrect text may reduce your score (the NCSBN uses a formula that accounts for both correct selections and incorrect selections). The goal is to highlight all the relevant clinical cues and none of the irrelevant ones.

Clinical Example: Hot Spot — Identifying Signs of Neurogenic Shock

Task: Read the following nurse’s note from a patient who sustained a C5 spinal cord injury 6 hours ago. Highlight the findings that suggest the patient is developing neurogenic shock.

“Patient awake and alert. Reports neck pain 5/10. Heart rate 52 bpm. Blood pressure 82/50 mm Hg. Skin warm and dry. Respiratory rate 18, shallow. SpO₂ 94% on room air. Urine output 40 mL over the past hour. Patient unable to move lower extremities. Bowel sounds present.”

Highlights: HR 52 bpm (bradycardia), BP 82/50 (hypotension), skin warm and dry (loss of sympathetic tone — a hallmark of neurogenic shock), and inability to move lower extremities (spinal cord injury above T6). These four highlights together paint the picture of neurogenic shock. Highlighting the neck pain report or the normal urine output would be irrelevant and could cost points.

Hot Spot Strategy

Read the prompt first. The question always tells you what to look for (e.g., “Highlight the cues that indicate the patient is in respiratory distress”). Know the target before you highlight.
Highlight only clinically relevant data. Normal findings, patient demographics, and background history are usually not what the question is after. Focus on abnormal assessment data, critical lab values, and significant changes from baseline.
Use the “so what?” test. Before highlighting a phrase, ask yourself: “If I were the bedside nurse, would I act on this finding?” If yes, highlight it. If it is nice-to-know but not actionable, leave it alone.
Think in clusters. One abnormal vital sign is suspicious; a cluster of abnormal findings is diagnostic. The NGN often expects you to connect related cues across the clinical note.

General NGN Strategy Tips

Beyond the specific approach for each format, several high-level strategies will serve you well across the entire NGN:

Embrace partial credit. The NGN is fundamentally more forgiving than the old NCLEX. You do not need to get every single part of a question right to earn points. Answer confidently even when you are not 100% sure, because a partially correct answer is still a win.
Let the Clinical Judgment Measurement Model guide you. The NGN is built around the CJMM’s six cognitive steps: Recognize Cues → Analyze Cues → Prioritize Hypotheses → Generate Solutions → Take Actions → Evaluate Outcomes. If you are stuck, ask yourself which CJMM step the question is assessing. This will point you toward the type of answer required.
Read the question stem carefully. NGN questions are often longer and contain more clinical detail than old-format questions. Do not skim. Underline (mentally or physically, with scratch paper) key patient data: age, diagnosis, vital signs, change in status, and time course.
Manage your time actively. NGN case studies and multi-part questions can eat up time if you let them. If you are spending more than 90 seconds on a single part, make your best guess, flag the question if the interface allows, and move on. You can return later.
Use the same clinical reasoning you use in clinicals. The NGN is designed to mirror real nursing practice. When you approach a question, imagine you are standing at the patient’s bedside, report just ended, and you are about to round. What data matters? What would you do first? What would you watch for next?
Practice with official NCSBN materials. The NCSBN publishes sample NGN questions and case studies. Working through these familiarizes you with the interface, the scoring logic, and the depth of clinical reasoning expected. Pair this with a question bank like NCLEX Deck that offers NGN-style items in every format.
Prioritize safety and the nursing process. When in doubt, default to the option that maintains patient safety and follows the steps of the nursing process (assessment first, intervention second, evaluation third). This guiding principle will serve you across formats.

Final Thoughts

The Next Generation NCLEX represents a meaningful shift toward evaluating the clinical judgment skills that keep patients safe. The six question formats — Extended Multiple Response, Bow-Tie, Matrix/Grid, Cloze, Extended Drag-and-Drop, and Enhanced Hot Spot — each assess a different facet of your ability to think like a nurse.

The good news is that these formats reward the same kind of careful, systematic clinical reasoning you practice in nursing school and clinical rotations. They are not tricks; they are tools designed to measure what you already know how to do. By studying each format, understanding its scoring, and practicing with realistic clinical scenarios, you can walk into the NGN with confidence — no matter how the question is laid out on the screen.

Keep studying, trust your training, and remember: partial credit is your friend.

Frequently Asked Questions About NGN Question Formats

How is the Bow-Tie format scored on the NGN?

Bow-Tie questions use a 0–3 scoring scale. You earn 1 point for correctly identifying the condition, 1 point for marking at least one correct action (you must choose at least 1 of the 2 possible actions), and 1 point for correctly identifying at least one of the two parameters to monitor. Partial credit is awarded — you do not need all elements correct to earn some points.

What is a Matrix/Grid question on the NGN?

A Matrix/Grid question presents a table with rows and columns of checkboxes. You select the correct combination(s) across the grid. Common formats include selecting which signs/symptoms apply to which condition, or matching nursing interventions to patient scenarios. Each row is typically scored independently for partial credit.

How do Cloze (drop-down) questions work on the NCLEX?

Cloze questions present a clinical passage with blank spaces (drop-down menus). You choose the correct term from a set of options in each blank. Each drop-down is scored independently, so you can earn partial credit by choosing correctly on some blanks even if you miss others.

Does the NGN give partial credit on Extended Multiple Response (SATA) questions?

Yes. Unlike the old NCLEX where Select-All-That-Apply questions were scored all-or-nothing, NGN Extended Multiple Response questions award partial credit. You earn points for each correct option you select and each incorrect option you leave unselected. This makes educated guessing valuable — you are not penalized as harshly for selecting a wrong answer.

What is an Enhanced Hot Spot question on the NGN?

An Enhanced Hot Spot (highlighting) question presents a clinical note or chart entry. You click and drag to highlight specific words, phrases, or sentences that are clinically significant — such as abnormal vital signs, key assessment findings, or critical lab values. All correct highlights must be selected for full credit, and selecting incorrect text may reduce your score.