NCLEX bow-tie questions
A bow-tie item shows a client situation and a diagram shaped like a bow tie. You place one condition in the center, two actions on one side and two parameters to monitor on the other. Because the item asks for a set number of answers, each correct choice earns a point and wrong choices earn nothing.
Sources: NCSBN, Leader to Leader, Spring 2022 (PDF); NCLEX.com, Frequently Asked Questions; NCSBN, 2026 NCLEX-RN Test Plan (PDF); NCLEX.com, Prepare (tutorial and sample items). Checked against NCSBN as of October 29, 2026.
What it looks like
NCSBN lists the "bowtie" among the new item formats it built to measure clinical judgment for the Next Generation NCLEX.
The screen has a chart or client scenario and three groups of choices. You fill the knot of the bow tie with the condition the client is most likely experiencing, one side with the actions to take, and the other side with the parameters to monitor.
How to work one
- Read the whole chart first. The condition is the anchor for everything else.
- Pick the condition that the findings point to, not the one that would be most dangerous in general.
- Choose actions that treat that condition now, then parameters that would show whether those actions worked.
- Check the count: the instructions tell you exactly how many go in each part.
How it is scored
NCSBN gives partial credit on items that have more than one correct answer, under three rules, and ties each rule to what the instructions ask you to do. Its current pages do not publish a format-by-format table, so read the instructions on each item.
Zero/one (0/1)
NCSBN uses it when you are told to choose a specific number of responses. You earn a point for each correct response and nothing for an incorrect one. On an item worth several points, the item score is the sum of the correct responses.
A bow-tie tells you exactly how many to choose (in our example, 1 condition, 2 actions and 2 parameters), so it is the zero/one case: each correct choice earns a point, and the item score is the sum.
With 1 + 2 + 2 choices, an item like the example below is worth up to 5 points.
Sources: NCSBN, Leader to Leader, Spring 2022 (PDF); NCLEX.com, Frequently Asked Questions; NCSBN, 2026 NCLEX-RN Test Plan (PDF); NCLEX.com, Prepare (tutorial and sample items). Checked against NCSBN as of October 29, 2026.
Example
A practice item from our own NCLEX-RN practice exams, written to the published test plan. It is not a real NCLEX question. Try it before you open the answer.
Sudden Eye Pain and Vomiting in an Older Adult. 71-year-old female, emergency department: Emergency department visit for severe right eye pain, headache, and vomiting that began the previous evening.
Client chart up to this step
Nurses’ notes
- Triage note (Day 1, 0110)
- Arrives with her daughter. Reports severe right-sided eye pain and headache that began at about 2200 while watching television in a dim room, about an hour after taking her nonprescription sleep aid, followed by 2 episodes of vomiting. Rates pain 9/10. Wears glasses for farsightedness. Denies injury to the eye or head. Triage acuity level 2.
- ED primary health care provider exam (Day 1, 0140)
- Intraocular pressure by tonometry: right eye 62 mm Hg, left eye 17 mm Hg. Right anterior chamber shallow. Ophthalmology paged.
- Status note (Day 1, 0145)
- Vomited 100 mL of clear fluid. Rates right eye pain 9/10. Stood to use the bathroom and reached for the wall to steady herself. Asks why her "sleeping pill" would matter.
- Ophthalmology phone consult (Day 1, 0150)
- Ophthalmologist reviewed the findings by phone and will evaluate the client in the ED within the hour. Medication prescriptions to follow.
Vital signs
- Vital signs (Day 1, 0110)
- T 98.2°F (36.8°C), HR 94/min, RR 18/min, BP 172/92 mm Hg, SpO2 97% on room air
- Vital signs (Day 1, 0125)
- HR 96/min, RR 18/min, BP 170/90 mm Hg; pain 9/10
- Vital signs (Day 1, 0200)
- HR 92/min, BP 168/88 mm Hg, RR 18/min; pain 9/10
Laboratory results
- Point-of-care glucose (Day 1, 0115)
- 146 mg/dL
- Basic metabolic panel (Day 1, 0135)
- Sodium 138 mEq/L; potassium 4.2 mEq/L; chloride 102 mEq/L; bicarbonate 24 mEq/L; BUN 18 mg/dL; creatinine 0.9 mg/dL; glucose 152 mg/dL
Medications
- Home medication: lisinopril
- 20 mg orally once daily
- Home medication: metformin
- 1,000 mg orally twice daily
- Home medication: diphenhydramine (nonprescription sleep aid)
- 50 mg orally at bedtime, started 4 nights ago on her own for trouble sleeping; last dose about 2100 last night
- ED prescriptions
- None yet
- New prescriptions (Day 1, 0155)
- Timolol 0.5% ophthalmic solution, 1 drop in the right eye now. Acetazolamide 500 mg IV now. Ondansetron 4 mg IV now. Pilocarpine 2% ophthalmic solution, 1 drop in the right eye when directed by ophthalmology after the pressure begins to fall. Repeat right intraocular pressure every 30 to 60 minutes. Repeat basic metabolic panel at 0400. Discontinue diphenhydramine.
History
- Medical history
- Hypertension; type 2 diabetes mellitus (hemoglobin A1C 7.1% 3 months ago); farsightedness (hyperopia). No asthma, COPD, or heart block. No previous eye surgery or glaucoma diagnosis. No known drug allergies.
- Social history
- Lives with her daughter; independent in daily activities; does not drive at night.
It is 0200. The ophthalmologist has entered prescriptions, which are in the chart. Complete the diagram by selecting the condition the client is most likely experiencing, the 2 actions the nurse should take now, and the 2 parameters the nurse should monitor most closely after these actions.
Actions to take (choose 2)
- Instill cyclopentolate drops to dilate and rest the eye, per the uveitis protocol
- Administer the prescribed IV acetazolamide
- Instill the prescribed timolol drop into the right eye
- Request a prescription for sumatriptan for the headache
- Activate the stroke team for a sudden loss of vision
Condition most likely experiencing (choose 1)
- Acute angle-closure glaucoma
- Central retinal artery occlusion
- Migraine with aura
- Acute anterior uveitis
Parameters to monitor (choose 2)
- Erythrocyte sedimentation rate and C-reactive protein
- Headache frequency and aura pattern
- Right intraocular pressure on repeat tonometry
- Serum potassium
- Inflammatory cells in the anterior chamber
Show the answer and rationale
- Condition: Acute angle-closure glaucoma
- Action: Administer the prescribed IV acetazolamide
- Action: Instill the prescribed timolol drop into the right eye
- Parameter: Right intraocular pressure on repeat tonometry
- Parameter: Serum potassium
The client has acute angle-closure glaucoma: severe right eye pain with headache and vomiting, a shallow right anterior chamber, and a right intraocular pressure of 62 mm Hg (17 mm Hg on the left) after starting an anticholinergic antihistamine. The nurse gives the prescribed pressure-lowering drugs now, since they reduce aqueous production, and the timolol is appropriate for her because she has no asthma, COPD, bradycardia, or heart block. Repeat tonometry shows whether treatment is working, and serum potassium is the key safety check, because acetazolamide increases potassium loss in the urine and is contraindicated when serum sodium or potassium is low. Distractor actions and parameters belong to uveitis, migraine, and retinal artery occlusion.
The other formats
Practice the formats
Try NCLEX-style questions in these formats, with a rationale for every answer.
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