This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
Why item quality matters
Multiple-choice exams are used for many high-stakes decisions in nursing programs, including progression. A poorly written item can measure test-taking skill or reading speed rather than nursing knowledge, and it can be unfair to students. Nurse educators need both rules for writing items and data for judging them after the exam.
Research-based item-writing guidelines
Haladyna et al. (2002) reviewed textbooks on educational measurement and the research on item writing, and organized their findings into a taxonomy of 31 multiple-choice item-writing guidelines for classroom assessment. Guidelines that apply directly to nursing exams include:
- Put the central idea in the stem, so the question can be answered before reading the options.
- Word the stem positively, and if a negative word is unavoidable, such as "except," emphasize it.
- Make all distractors plausible, so that the item tests knowledge rather than elimination.
- Keep options similar in length and grammatical form, because the longest or most detailed option is often the correct one.
- Avoid "all of the above," and use "none of the above" with care.
- Vary the position of the correct answer.
Revising a weak item
Original item:
Which is true about potassium? A. It is mostly inside the cells B. Normal is 3.5 to 5.0 mEq/L, and high levels can cause dangerous heart rhythms, so patients need cardiac monitoring C. It is excreted by the lungs D. All of the above
Problems: the stem doesn't pose a question, option B is longer and more detailed than the others, and "all of the above" lets students answer from partial knowledge.
Revised item:
A patient's serum potassium is 6.4 mEq/L. Which action should the nurse take first? A. Place the patient on a cardiac monitor B. Encourage foods high in potassium C. Prepare to give a potassium supplement D. Recheck the level at the next routine blood draw
The stem now presents a clinical situation, the options are parallel, and the item tests prioritization, not recall.
Item analysis after the exam
| Statistic | What it shows | How educators commonly use it |
|---|---|---|
| Difficulty (p value) | The proportion of students who answered correctly | Very easy or very hard items give little information about differences between students |
| Discrimination (point-biserial or upper–lower index) | Whether students with higher total scores were more likely to answer correctly | Low or negative values suggest a flawed item or a miskeyed answer |
| Distractor analysis | How many students chose each wrong option | A distractor no one chooses isn't working; a distractor chosen by many high scorers may be arguably correct |
A worked example
On the revised potassium item, 72% of 60 students chose the correct answer, A, and the item discriminated well: 90% of the top-scoring third answered correctly, compared with 50% of the bottom third. Option D drew 20% of students, mostly from the bottom group, suggesting a real misconception about urgency that is worth teaching. Option B drew no one, so it should be replaced with a more plausible distractor. The figures are illustrative.
Recommendations for a nursing program
- Review new items with a colleague against item-writing guidelines before use.
- Run item analysis after every exam and review items with low or negative discrimination before finalizing grades.
- Keep an item bank with each item's statistics and revision history.
- Write items that test application and analysis, which better reflect clinical judgment.
Reference
Haladyna, T. M., Downing, S. M., & Rodriguez, M. C. (2002). A review of multiple-choice item-writing guidelines for classroom assessment. Applied Measurement in Education, 15(3), 309–333. https://doi.org/10.1207/S15324818AME1503_5
