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NCLEX Nursing Select All that Apply Alternative Questions

Updated on August 24, 2013

Over the past 5 years, the NCLEX-RN has been using alternative format questions in increasing amounts, in addition to standard multiple-choice questions. The type of question that trips students up the most is the “select all that apply format.” In this format, a patient scenario is given and the test-taker is asked to pick out of a list of up to 6-7 options, all of the options that are correct. In an effort to prepare graduates for these questions, many registered nursing (RN) programs across the country have begun using these types of questions on their exams as well.

In my course, I see students struggling with these on every exam. I have even seen students who would have passed the exam, until they get to the select all that apply questions. It is heart wrenching to watch someone struggle like this, but I know I must keep using these questions. It does not do the student much good to graduate from an RN program, but not be able to pass the licensing exam to become licensed in their state to practice nursing.

The suggestions I give my students can be used by any student taking these types of questions and by other teachers trying to help their students successfully master this type of question.


Are You Anxious?

The first thing I hear students saying is, “There is so much information. I just look at the question and freak out!” When a person reaches moderate levels of anxiety or higher, we know that the person can no longer effectively process information. A person who cannot process information will miss key points in the question, in addition to the responses.

To help combat the anxiety associated with these questions, try a few of these techniques:


Count backwards from 10

We have heard and seen this so much that it has become cliché. But it is common for a reason: it works. For students experiencing moderate levels of anxiety, this may not be enough, but it is a good starting point for other exercises.

  1. Close your eyes or focus your eyes on a place or thing (not the test).
  2. Count backwards from 10, allowing a beat between each number.
  3. Return to the test (or proceed to the next relaxation technique if this is ineffective).

Deep abdominal breathing (diaphragmatic breathing)

Deep abdominal breathing (diaphragmatic breathing) is a technique often taught to people who suffer from various anxiety disorders, such as post-traumatic stress disorder, social phobia, panic disorder, etc. Deep abdominal breathing focuses the user on breathing and body functions, in addition to more fully expanding the lungs and increasing oxygenation. To master this technique, the student should practice daily when in a calm environment. This way it becomes second nature when in an anxiety-producing situation.

  1. Relax your body.
  2. Put your hands on your abdomen.
  3. Close your eyes or focus your eyes on a place or thing (not the test).
  4. Take slow, deep breaths in through your mouth with your lips pursed (or nose if this helps slow you down) and out through your nose.
  5. Feel the rise and fall of your abdomen under your hands.
  6. Focus on the feeling of breathing.
  7. If you begin to feel faint, you are breathing too rapidly. Slow down.
  8. Continue until you notice a sense of calmness, about 5-10 full breaths.
  9. Return to the test.

Positive self-talk

We all have unconscious or subconscious tape recorders in our heads. We do not really hear voices, because over the years, they become background noise. Often, negative self-talk originated in childhood, from perceived or real criticism from a parent, other loved one, or authority figure. As adults, we continue to hear those criticisms in our subconscious mind. You may hear, “You’re not as smart as your sister. Why can’t you make straight A’s like her? You’ll never amount to anything.” If you hear this enough from yourself or from someone else, you begin to believe it. For many people, negative self-talk increases during times of stress, such as exams. The last thing you need to hear is that you are stupid or not capable of getting the answer correct.

Negative self-talk must be stopped, but to stop it, first we have to recognize it. When you are feeling stressed or incapable of something, STOP what you are doing and examine your feelings. To stop, you may visualize a large red stop sign in your mind or if you are alone, you may clap your hands and forcefully say, “Stop!” At this point, examine your own mind. What do you hear? What has led you to become upset? Are you telling yourself you are not capable? That you are stupid? That you can never do this?

If so, replace those thoughts with positive thoughts: “I can read this question. I can understand what it is asking me. I can answer this question. I have taken many tests before. I have studied this content. I can do this.” Repeat this to yourself when experiencing any self-doubt. You literally can talk yourself into failing or you can talk yourself into passing.

Guided imagery

Another option similar to positive self-talk is guided imagery. In guided imagery you are doing more than having a conversation with yourself; you are actually visualizing yourself doing something successfully. I find closing my eyes and playing out the scenario in my head to be the best method.


  • Always end the scenario being successful.
  • Practice frequently in a calm environment, so it will be easier during an exam.

**If you are going to do any of these techniques with your eyes closed, you may want to send your instructor a note or talk to him/her before class, so he/she knows what you are doing and does not become worried. (Yes, we are concerned about you!)**

Conquering the Questions!

As far as the questions, these are the suggestions I give my students.

In this order:

  1. Cover up all the answers and read only the question.
  2. Reread the question for clarity.
  3. If you are allowed to mark on your test booklet, underline the important parts.
  4. Uncover only one response at a time.
  5. As you uncover each response, read it.
  6. Reread the response.
  7. Compare the response to the question. Is the response true or false as it relates specifically to the question?
  8. If it is true (correct), mark a small “T” beside it. If it is false (incorrect), mark a small “F” beside it.
  9. Move on to the next response. Continue in this manner until you have individually evaluated each of the answers.
  10. When you have finished, the “T” responses go on your answer sheet and the “F” responses do not.
  11. Try to avoid marking a response with a question mark. If you use a lot of question marks, you may end up feeling just as confused as you would without the T/F marks. If an answer does not sound right, then it probably isn’t. Mark it “F” and move on.
  12. Select all that apply questions increase self-doubt and paranoia, so only return to these questions if you have an epiphany later in the exam or if another test question gives you a clue that you were not aware of before.

Additionally, you should be practicing these types of questions by the dozens at home. Your brain is trained to find one correct response to each question. You have spent your educational career taking multiple choice question tests with only one correct response to each question. It is likely that select all that apply questions are new to you. It is simply a new skill to master. Treat it like you would any other skill. Practice until you can do it with ease.


Tips for Educators

  1. Clearly identify the alternative format questions (bold, italics, a separate area on the exam). We are not trying to trick the students into not seeing the directions. What we want to know is if they know the content and can apply it.
  2. Don’t start the exam with alternative format questions. I find it best to get them into test mode with some moderate level questions in the beginning, then the alternative format at the end.
  3. If you put alternative format questions at the end of the exam and students say their brains are tired by the time they get to the questions, advise them to do a couple of regular multiple choice first to get into test mode, then flip to wherever the alternative format questions are. Complete those before they’ve used up all their mental energy, then go back to the multiple choice questions to finish up.
  4. Remember, there are lots of varieties of alternative format questions.
  • Consider using word banks with fill-in-the-blank questions. I do not advise straight fill in the blank questions, as the anxiety associated with those make it nearly impossible for students to think of the correct answer even when they know it. If I give a word bank, I usually give more terms than are needed to answer the questions. This provides a better assessment of knowledge, since students who do not know the content cannot simply guess and easily get the answers correct.
  • Short answer and essay type questions can be great indicators of whether or not students understand a concept. The downside is there can be subjectivity involved in grading, as well as the amount of time involved in grading.
  • Matching is another option, especially with concrete concepts. Similar to the word bank style, you can always give more options than there are correct answers to prevent those who are guessing from inflating their grade without learning the content.

The Kaplan NCLEX-RN book, according to several of my previous students, has been a life-saver throughout the nursing program and for NCLEX prep.

I suggest you use a couple of different publishers and/or authors to give a variety of questions and suggestions for testing. To save money (because nursing school is expensive!), you and a close friend in class could each buy one or the other then trade off.

© 2012 Leah Wells-Marshburn


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    • nurseleah profile image

      Leah Wells-Marshburn 4 years ago from West Virginia

      I hope so too!

    • profile image

      KVCTC student 5 years ago

      I applied those techniques during my last exam, and can't wait to see the results. Any improvement would be great. Covering really did help! Hope it shows.