NURS 766 Week 2 Written Assignment 2: Item Writing Example

Writing and Reviewing Test Items for a Heart Failure Unit: Three-Option Multiple Choice, Multiple Response and a Clinical Judgment Case

Items Built From Objectives

The items below measure four of the six heart failure objectives rewritten in Written Assignment 1: identifying medication actions and priority assessments, classifying functional status, recognizing cues of fluid overload and prioritizing nursing actions in decompensation. McDonald (2018) treats items as the operational form of objectives, so every item states the objective it measures. The items follow McDonald's construction rules: a stem that poses a complete problem, one clearly best answer, options that are parallel in length and grammar, negatives in a stem only when the negative is itself being tested, no catch-all options that let a student answer by spotting two correct choices and distractors that represent real errors.

Why Three Options

Hartigan-Rogers et al. (2019) compared three-option and four-option multiple-choice questions at three Canadian schools of nursing and found no statistically significant differences in item discrimination, item difficulty or mean examination scores. Their findings replicate nearly a century of educational research. The practical gain is large: writing a fourth plausible distractor is the hardest part of item writing, and a weak fourth option adds reading time without adding measurement. The two multiple-choice items below use three options.

Item 1: Medications (Objective 2, Apply)

Stem: A client with heart failure with reduced ejection fraction is scheduled to receive furosemide 40 mg and digoxin 0.125 mg at 0900. The morning potassium level is 3.1 mEq/L. What should the nurse do first?

A. Give both medications as scheduled and recheck the potassium level tomorrow.

B. Hold the scheduled medications and notify the health care provider of the potassium level.

C. Give the furosemide, hold the digoxin and encourage foods high in potassium.

Key: B. Hypokalemia makes the myocardium more sensitive to digoxin, and the loop diuretic will push potassium lower still, so the provider needs the result before either drug is given. Option A ignores a dangerous value. Option C is attractive because it seems to act on the problem, but the nurse would be making a prescribing decision and still giving a potassium-wasting diuretic.

Item 2: Functional Classification (Objective 5, Apply)

Stem: A client with heart failure reports being comfortable at rest but becoming short of breath and tired when walking from the bedroom to the kitchen. Which New York Heart Association class best describes this client?

A. Class II

B. Class III

C. Class IV

Key: B. Class III describes marked limitation of physical activity, with symptoms during less than ordinary activity but comfort at rest. Class II involves only slight limitation, with symptoms during ordinary activity such as climbing stairs, and Class IV involves symptoms at rest. The distractors are the adjacent classes, which are the real errors students make.

Item 3: Multiple Response (Objective 3, Analyze)

Stem: A client hospitalized for heart failure is being assessed on the second morning. Which findings indicate worsening fluid overload? Select all that apply.

A. Weight increased 1.4 kg (3 lb) since yesterday

B. Crackles in both lung bases

C. Jugular venous distention at 45 degrees

D. Blood pressure 118/72 mm Hg, unchanged from admission

E. New need for three pillows to breathe comfortably at night

F. Urine output 1,600 mL over the past 24 hours

Key: A, B, C and E. Rapid weight gain, crackles, jugular venous distention and new orthopnea are cues of fluid overload. An unchanged blood pressure and adequate urine output are not. The item will be scored with the plus-minus rule: one point for each correct option selected and one point subtracted for each incorrect option selected, with a minimum of zero. Norton and Yockey (2026) compared traditional and partial credit scoring of unit exams for students repeating a prelicensure course and found significantly higher scores under partial credit without evidence of grade inflation, which supports its use when an item measures several related judgments.

Writing the Case Before the Items

Clinical judgment items depend on the case behind them. A case that is too thin forces students to guess what the writer meant; a case crowded with irrelevant detail turns the item into a reading test. The case below was written first, with each cue placed deliberately: the tachycardia, hypoxemia, crackles and frothy sputum point to acute pulmonary edema, the weight gain confirms fluid retention and the patient's age is included as a plausible but irrelevant detail that a student must learn to set aside. Only after the case was finished were the items written, each asking about something the case clearly shows. The key for each item was then checked against the case by a colleague who had not seen the key, which is the most reliable way to find a case that supports more than one answer.

Items 4 and 5: A Short Clinical Judgment Case (Objectives 3 and 6)

Case: Mr. Ellis, 72, was admitted two days ago with heart failure. At 0700 he is restless and says he "can't catch his breath." Vital signs: heart rate 112, respiratory rate 28, blood pressure 158/94, oxygen saturation 88% on 2 L by nasal cannula. He has crackles halfway up both lung fields and is coughing pink, frothy sputum. His weight is up 2 kg from yesterday.

Item 4, cue recognition (matrix): For each finding, indicate whether it is consistent with acute pulmonary edema or not consistent: heart rate 112; oxygen saturation 88%; pink, frothy sputum; crackles halfway up both lung fields; blood pressure 158/94; age 72. Key: the first five are consistent; age is not a cue to the current change. The item tests whether students separate relevant from irrelevant data, the first step of the clinical judgment model described by Dickison et al. (2019).

Item 5, prioritization: What is the nurse's first action for Mr. Ellis? A. Raise the head of the bed to high Fowler's position and increase oxygen per protocol. B. Call the provider to request an order for intravenous furosemide. C. Obtain a set of arterial blood gases. Key: A. Positioning and oxygen are immediate nursing actions that improve oxygenation while help is on the way; calling the provider is necessary but follows, and blood gases do not treat the problem.

Reviewing Items Before Use

Items are drafts until colleagues have taken them and data show they work. Hensel and Billings (2023) piloted a peer review process for Next Generation NCLEX-style items in which 18 faculty from 13 schools completed 55 reviews of 40 cases and 35 stand-alone items, taking about an hour per case and giving authors actionable feedback; both reviewers and authors learned from it. In a hospital education setting, Davidson et al. (2024) found that asynchronous training helped educators write better multiple-choice questions but that personalized mentorship produced more improvement. Our course team will adopt a simple version: each new item is answered and critiqued by one colleague using a short form, and after the exam, item statistics decide whether it is kept, revised or retired.

Conclusion

A good item rewards the student who knows the content and gives nothing away to the student who does not. The five items here measure four objectives at the levels the objectives set, use the three-option format where it saves effort without losing quality, score the multiple-response item with partial credit and present a case that asks students to recognize cues and act. Peer review before the exam and item analysis after it will show whether they work.

References

Davidson, J. E., Kalinowski, A., Makhija, H., Schneid, S. D., & Mandel, J. (2024). Using performance improvement methods to evaluate processes for writing multiple-choice test questions in the postlicensure clinical environment: A case study. Journal of Continuing Education in Nursing, 55(11), 535-542. https://doi.org/10.3928/00220124-20240829-02

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Hartigan-Rogers, J. A., Redmond, S., Cobbett, S., Cifuentes, K., Honan, D., Richard, E., Sheane, V., & VanTassell, T. (2019). A, B, or C? A quasi-experimental multi-site study investigating three option multiple choice questions. International Journal of Nursing Education Scholarship, 16(1). https://doi.org/10.1515/ijnes-2019-0061

Hensel, D., & Billings, D. M. (2023). Creating a peer review process for faculty-developed Next Generation NCLEX items. Nurse Educator, 48(2), 65-70. https://doi.org/10.1097/NNE.0000000000001322

McDonald, M. E. (2018). The nurse educator's guide to assessing learning outcomes (4th ed.). Jones & Bartlett Learning.

Norton, L. M., & Yockey, J. (2026). Partial credit scoring: A helping hand or a crutch? Journal of Nursing Education, 65(8), 502-504. https://doi.org/10.3928/01484834-20260224-05