Step by Step Writing Multiple Choice items (MCI)
Start with the appendices McDonald’s Appendix C, D, and E (E starts with sample item stems) All questions written for this course will be evaluated using this
style guide. Read this thoroughly and refer to it often as you develop test items and use it to critique items submitted by your peers in group discussions.
Exhibit 15.1-15.6 has 6 sample questions and how they were revised to be better questions.
Use only accepted abbreviations, as these are recently being recognized as a major source of
error in health care.
So, do not use NGT for nasogastric tube etc. You may use F for Fahrenheit and C for Celsius
temperature, cm for centimeters, ml for milliliters etc.
1. Familiarize yourself with the purpose, population of students
and test blueprint for the test.
2. Read the objective, determine the level of cognition of the
objective and determine what is required of the student to
master this objective.
3. Develop the stem of the question. Oftentimes, the objective
is a good starting point for the development of the stem.
Example stems to ask Critical Thinking questions
Objective: the student will instruct the client in self-administration of subcutaneous heparin
Then, think of the things that the student will need to be able to do to meet that objective,
such as Identify learning needs of the client Instruct the client in the proper technique Teach
the client about the adverse effects of heparin Evaluate the client’s understanding of the
teaching
Any of these (and more) could be a source of a good question to test this objective.
As a part of this step, consider the cognitive level and the step of the nursing process that is
to be tested. See resources in McDonald Chapter 6 Writing Critical Thinking MCIs
Which instruction should the nurse give the client when teaching the self-administration of
subcutaneous heparin?
Note: Don’t say “Which of the following instructions…”. The phrase “of the following” is not
needed, and just increases the time needed for the student to take the exam
Which intervention is most important?
Which intervention, plan, assessment data is/are most
critical to developing a plan of care?
Which intervention should be done first?
What action should the nurse take first?
Which intervention, plan, nursing action has the highest
priority?
What response is best?
4. Write the correct answer (key). What actual behavior
demonstrates mastery of the objective? There may be more
than one behavior that demonstrates mastery. If so, write all of
these. Then select the one that best demonstrates mastery.
5. Develop item distracters. To develop good distracters, think
about all the possible ways students go wrong in this situation.
Inject into the abdominal fat pad 2 inches below from the umbilicus.
Examples of possible distracters:
Massage after the injection to ensure absorption of the medication
Think about the mistakes you see in the clinical area related to
this. Think about the ways in which the action could result in
ineffective results. Think about actions that might be
appropriate in other situations, but not this one. Let your
creative ideas flow, thinking of as many possible options as
possible.
6. Review your question and possible answers to this point,
emphasizing the correctness of the key and the incorrectness of
the distracters. Spend time revising and completing the item.
7. Refine the item and answer choices. Make sure that the stem
and answer options are clear, concise and grammatically
correct. Work to make each answer option about the same
length (above example accomplishes this). Or, if not all the
same length, two options are longer, two options are shorter
(as below).
I.
Aspirate for a blood return prior to injecting the medication
Use a 19 gauge, 1.5 inch long needle to administer the heparin
Inject the heparin into the right or left vastus lateralis muscle
Now, place yourself in the student’s situation and assume that you do not know the answer
to the question. Here’s the question in its entirety, with 5 possible answers (for this exercise
only).
When teaching the client to self-administer subcutaneous heparin the nurse should instruct
the client to
a. inject into the abdominal fat pad 2 inches below from the umbilicus.
b. massage after the injection to ensure absorption of the medication.
c. aspirate for a blood return prior to injecting the medication.
d. use a 19 gauge, 1.5 inch long needle to administer the heparin.
Now you can develop rationale to explain the question and correct answer. In this case, the
faculty should check the primary textbook, pharmacology books, skills books and even
current online sources to be sure that the information is correct and current information.
Document the page numbers of sources. Find sources for both the correct answer and
distracters.
Here’s an example of a refined item:
The nurse is instructing an adult client in the proper injection technique for the
administration of subcutaneous heparin. The nurse should instruct the client to
a. aspirate for blood return prior to injecting the medication.
b. inject into the abdominal fat pad 5 cm (2 inches) below the umbilicus.
c. massage the area thoroughly to ensure absorption of the medication.
d. administer with a 20 or 21 gauge, 3.7 cm (1.5 inch) needle.
Writing Items to Address Cognitive Levels
It is important when developing test items to consider the level of thinking required of the student to answer the question correctly. Multiple-choice items are
very versatile and can be written to test memorization of simple facts as well as the ability to apply principles and solve problems.
Thinking skills or cognitive domains have been organized into the 6 levels of Bloom’s Taxonomy as discussed in module 1. The cognitive level to target in a test
item will depend on the level of knowledge and skills to be measured and the purpose of the test. A cognitive level alone does not make an item good or bad,
nor does it necessarily determine whether an item is easy or difficult.
A couple of caveats before we begin a discussion of writing test items at a higher cognitive level
It’s not fair to students to teach content at a comprehension level, and then expect that they are able to answer questions about the content at a higher level.
There is a major mismatch if the content is presented as disease definition, pathophysiology, signs and symptoms, diagnostic tests etc., then the student has to
plan nursing care, set priorities and determine methods to evaluate care.
Knowledge
Example: Identifying a normal blood value
Identifying a medication side effect
Asks if students can recall information presented
The adult female client has the following lab results. Which is abnormal?
Define, identify or recognize common terms, facts, procedures,
concepts
Test how well examinees can memorize and retain content
Are not necessarily easier items. Knowledge items can test difficult
concepts
Requires the fewest steps to determine the correct answer
Comprehension
Example
Recall and understand information at a basic level
The client asks the nurse “What causes high blood pressure?” The nurse explains
that risk factors for primary hypertension are
Knowing what is being communicated without relating to other
a. Obesity
material
b. Narrowing of the aorta
Select or identify examples of the fact, concept, principle or procedure
c. Alcohol consumption
Tests if students understand the information presented
d. Sodium retention
May require that students restate information in their own words
Requires basic understanding of a concept and takes it one step higher
Example: interpret abnormal lab test
Assess for disease manifestation
Application
Tests if students can apply newly learned information to a particular
client situation
Is part of the problem solving process
Remember and apply general ideas, rules and theories
Interpret demonstrate or predict situations, process or procedures
Requires the ability to prioritize information
Example: Evaluating client statements/responses
Determining which client data would require immediate action
Example
Which statement by the client indicates an understanding of a low sodium diet?
a) “I can still drink tomato juice for breakfast”
b) “I can have cheese on my sandwich for lunch.”
c) “At least I can continue to have a bowl of ice cream at bedtime.”
d) “ A bowl of oatmeal for breakfast would be a good choice.”
Example
Which statement by the client indicates an understanding of a low sodium diet?
a) “I can still drink tomato juice for breakfast”
b) “I can have cheese on my sandwich for lunch.”
c) “At least I can continue to have a bowl of ice cream at bedtime.”
d) “ A bowl of oatmeal for breakfast would be a good choice.”
Analysis
Requires analysis or break down of information into smaller
components
Example: Determining which client from a list of 4 should be seen and checked first
The following clients present to a walk-in clinic at the same time. Which client
should the nurse see first?
Tests if can identify critical from noncritical information
Requires processing more than two pieces of data to determine correct
response
Discriminate complex information (Multiple variables) by separating
and prioritizing info into smaller segments of data, show relationship of
ideas
Examine cause and effect relationships
Detect recurring themes
Synthesis
Difficult to measure this cognitive level in discrete multiple items
Requires student to arrange or combine separate elements or pieces
into a whole
Prioritizing complex patient situations
Generally, longer stems with more information to review
Case scenarios
a) 25 year old male with fever 1020, vomiting & diarrhea x 2 days
b) 34 year old female with abdominal pain, fever, headache
c) 40 year old male with severe headache, vomiting, stiff neck
d) 60 year old female who fell, has very swollen bruised ankle
Evaluation
Applies evidence based practice, clinical practice guidelines to novel
situations appropriately
Makes judgments about the value of ideas, methods, solutions
Critiques quality of care
Example
The client with congestive heart failure is prescribed furosemide (Lasix) to reduce
intravascular volume. Which measure will best determine the effectiveness of
therapy?
a) Record intake and output
b) Palpate peripheral pulses
c) Record daily weights
d) Assess mucous membranes
Example
The nurse is administering a unit of packed red blood cells, and has remained with
the client. After the first fifteen minutes of the infusion, the client complains of pain
in her back and side and chills. The nurse will perform all the following actions.
Place these in priority order, using the letter (a) for priority # 1, (b) for priority # 2,
etc.
___ Take vital signs
___ Start O2 at 2 liters nasal cannula
___ Stop transfusion
___ Collect a urine and blood specimens
___ Notify the physician
___Notify the blood bank
Chapter 6 McDonald, 2014
And Appendix D
Writing Critical Thinking (CT) Multiple-Choice Items (MCIs).
Targeting Cognitive Levels for Multiple Choice Item Writing
See also Appendix E Sample Item Stems for Phases of the Nursing Process
See also Chapter 5
NOTE: All Cognitive Levels are Application or Analysis or higher.
Ask 3 overarching questions:
What is the competency being assessed?
Is the competency important for safe entry-level practice?
Can the item be revised to challenge the students to thinking critically when demonstrating competency in the clinical setting?
One quick strategy is to MOVE the ACTION to the OPTIONS
Strategy
Sequential
Reasoning
Sequential
Reasoning:
Questions that do
not require unique
and complex
thinking do not
meet the criteria of
CT MCIs. See Exhibit
6.1 (p. 134). The
information needed
to answer the
question could be
memorized
See Exhibit 6.2: This
question requires
sequential
reasoning or at least
two logical steps of
thinking.
Asks for a nursing
action based on
their knowledge
Exhibit 6.3
Simply recognizing
dehydration
Revision includes 1.
Recognizing the
signs of
dehydration from
patient symptoms
AND relate it to a
corresponding lab
value (increased
urine specific
gravity)
Exhibit 6.4
Recall of objective
data
Revision includes a
list of observations
a nurse would see
in a clinical setting
then the student
has to interpret
Revising
recall to
Application
This strategy is used
when you have MCIs
from a test bank or
previous exam
Exhibit 6.7
Revision uses
sequential reasoning
to require the
student to identify
laryngeal nerve
damage as a
potential
complication and
how it is exhibited in
patients (inability to
speak)
Revising recall to
Analysis
Exhibit 6.8
Revision requires
more than knowing
definition of “high
specificity” but asks
the student to
interpret findings
based on their
understanding of
the definition
Exhibit 6.9
demonstrates bad
practice of teaching
in the stem. Instead
the revision
identifies when the
stroke occurred and
asks the students to
determine that ICP
is a priority.
Also all answers are
correct but
elevating the head
corresponds with <
ICP.
Recall item to
sequential
reasoning.
Exhibit 6.10
Also using
respiratory arrest
(one students could
Option A changes
option A. the
student does not
know what the
Option B example
parallel item that
can be used in
another version of
Exhibit 6.5
Recall
Revision
requires the
student to
interpret the
factors and
choose the one
that influences
health
Exhibit 6.6
Requires student
to recognize
desired outcome
of IV therapy for
hypovolemia
then match with
the therapeutic
response. They
have to think
about the
physiologic
reaction to
increased fluid/>
BP/> perfusion
to
kidney/increased
UOP
argue is always right complication is and
answers) is troubling has to know how to
monitor infection
(temperature)
Recall to
Application
Recall to
Analysis
Confusing to
analysis
Critical
thinking
Chart
interpretation
Exhibit 6.11 further
shows how to
develop parallel
items. The original’s
options are not
parallel. Only D is a
nursing action.
Exhibit 6.12 revises
the ability to recall
signs and symptoms
of hypoglycemia
Exhibit 6.13
Original is recall and
confusing
Need stage of heart
failure and options
have uneven
number of items
Exhibit 6.14
Original recall
Option A,B,C all use
the same stem but
for the right answer
use different actions
related to
therapeutic plan for
Lasix
Revision requires
students to think
about the cause and
hypoglycemia is not
even mentioned in
the stem. Student
has to connect that
too much insulin
causes
hypoglycemia and
figure out the signs
and symptoms.
Revision asks for
“worsening” signs
and options only
include 2
manifestations
which is less
confusing
Revision asks
student to interpret
the data and match
the action. The
content is basic but
there is sequential
the test. WBC is
another indicator of
infection. What else
could you watch
for? Pain, redness,
draininage?
Exhibit 6.15 and
6.16 show a more
complex question
with chart
interpretation
CHART
INTERPRETATION IS
COMMONLY SEEN
ON NCLEX SO THAT
MAKES IT
IMPORTANT!
Recall to
analysis
Exhibit 6.17 Original
only requires
memorization
Recall to
application
Exhibit 6.18 Original
has action in stem
Unique
situation
Exhibit 6.19
Best answer
Exhibit 6.20
Novel
Problems
A question cannot
be higher level if
students are familiar
with the situation
from a lecture or
clinical experience
Exhibits 6.25 and
6.26 illustrate how
to test ability to
prioritize and
Delegating
reasoning to
answer.
Revision converts
content to clinically
relevant. Applies
content to clinical
setting for safe
nursing care or
clinical competency.
THIS IS ESSENTIAL!~
MOVE ACTION to
Options! This is
basic content asked
in a higher level.
Revision creates a
unique situation
(patient having a
seizure in the BR) to
allow the student to
think through
actions (NOT giving
an injection
someone else drew
up!)
All answers vary in
degree of
correctness
Exhibit 6.23 and
6.24 are examples
Client’s ages are
included and
diagnoses are
serious.
Exhibit 6.21 and
6.22 add sequential
reasoning to
determine the
priority
All that apply
delegate
responsibility
Exhibits 6.27, 6.28,
and 6.29 illustrate
these examples