Outcomes Evaluation In Nursing Education and Multiple Choice, Multiple Response, Chart & Exhibit Questions and Fill-in-the-Blank

Understanding the Structure of Multiple Choice and
Alternative Format Test Questions

    Writing most types of test items
used by nurse educators involves creating a scenario, a description of a
nursing care situation that requires problem-solving, making judgments and
clinical decisions; a stem, or question; and a set of answers, or options, one
or more of which are correct and others that are incorrect (distractors).

Writing Multiple Choice and Alternative Format Test
Items

    The most common types of questions
used by nursing faculty are multiple-choice and alternative-format questions.
Alternative-format questions include chart and exhibit, short-answer and
fill-in-the blank, hotspot (rollover), drag and drop or ordered response,
graphic and graphic response, audio, video, and multiple choice. 

    Multiple
choice and alternative-format items are used on licensing exams.
Multiple-choice questions are typically used in certification exams. The
definitions, advantages, disadvantages, guidelines for writing, and an example
of each of these types of test items follow.

Multiple Choice Items for Test Format In Nursing Education

    A multiple-choice item consists of
a scenario, which provides data about a client situation; a stem, which can be
a question or an incomplete statement; and options (answers), one of which is
correct and three of which are incorrect (distractors). Multiple-choice items,
when carefully constructed, can measure critical thinking and higher levels of
the cognitive domain (McDonald, 2013; Su et al., 2009).

Advantages of Multiple Choice Questions

    Multiple-choice items allow faculty
to sample a large amount of content in a single test. Test items can be scored
easily and objectively. Scores on multiple-choice tests are less influenced by
guessing than are scores on true–false tests. These items are versatile because
they can measure learning of several levels of cognitive processes.

Disadvantages of Multiple Choice Questions

    Writing good articles with
plausible distractors can be time consuming. This item type takes more time for
the student to read and understand. These items may discriminate against the
creative, verbal student. Scores can be affected by students’ reading ability
and the instructor’s writing style. This item type can raise the score of the
student who can recognize rather than produce the correct answer.

    An older adult is admitted to the
hospital because of severe diarrhea. The client is thirsty and skin turgor is
poor. The blood pressure is 92/64 and pulse is 100. The serum sodium (Na+)
level is 165 mmol/L. The nurse should develop a plan to:

1. Protect the skin from friction.

2. Increase fluids.

3. Prevent excoriation of the
rectal area.

4. Place the client on “falls
alert.”

Multiple Response Items for Test Format In Nursing Education

    A multiple response item, like a
multiple choice item, has a scenario, stem, and options; However, there are
more than four options (usually five or six) and the options are written so
that two or more of the answers are correct. Students are instructed to choose
all correct answers (“select all that apply”) to receive credit for the
question.

Advantages of Multiple Response Items

    Multiple-response items allow for
several correct answers and require students to cluster correct responses.
There is less opportunity for choosing options by process of elimination than
with standard multiple-choice items. The use of multiple-response items avoids
using “all of the above” as an option. 

Disadvantages Multiple Response Items

    Multiple-response items require
more options (usually five or six) and thus more distractors than standard
multiple-choice items. Scoring, particularly by computer, may be more
difficult.

    The nurse implements a medication
safety teaching plan for an older adult. Which statements by the patient
indicate that the teaching has been effective? “I will” (Select all that
apply.)

1. throw away any medications I am
no longer using.”

2. have my prescriptions filled at
different pharmacies to get the best price.”

3. Tell my physician about any
nonprescription medications I am taking.”

4. crush any medications that I
have difficulty swallowing.”

5. take all of my medications with
food to avoid stomach upset.”

6. Report possible side effects of
my medications to my physician.”

Chart and Exhibit Questions for Test Format In Nursing Education

    These questions, an example of
interpretive questions, assess the test taker’s ability to seek and use data
presented on a client’s chart or health record. The data will be presented from
one or more chart “tabs”: prescriptions, history and physical, laboratory
results, miscellaneous reports, imaging results, flow sheets, intake and
output, medication administration record, progress notes, and vital signs. 

    When
the test is administered by computer, the test-taker will be required to search
in a way that simulates search through a client’s chart or computerized patient
record. The question may be similar to a multiple choice question with four
answers, with one correct answer, or a multiple-response question with more
than four options that asks the test taker to “select all that apply.”

Advantages of Chart and Exhibit Questions

    Chart and exhibit questions test
the ability to consider which data are needed for client care and to test in
higher levels of cognitive domain. These questions require test-takers to use
data for clinical decision making and use them to interpret a set of data, for
example, trend data on a vital signs record. 

    These questions also simulate
obtaining data from a client’s chart; test-takers can be timed to ascertain
whether they know what data to obtain and where on a chart to find it.

Disadvantages of Chart and Exhibit Questions

Chart and exhibit questions are
time consuming to develop. Chart and exhibit questions may require duplicating
chart forms to develop the test questions.

A parent has brought a 4-month-old
to the immunization clinic. The nurse is reviewing the immunization record on
the progress notes.

Which immunization(s) will the
infant receive at this visit? (Select all that apply.)

1. DTaP #3

2. HepB #2

3. IPA #2

4. MMR #1

5. Varicella

Fill-in-the-Blank Questions for Test Format In Nursing Education

    The short answer or
fill-in-the-blank item requires the student to produce an answer (Miller et
al., 2012). The question can have a scenario and a stem, but the “answer” is
constructed by the student. This item type is used when the instructor wants
the student to recall or calculate the answer (fill in the blank). 

    The student
could also be asked to visually represent the answer, for example, “Calculate a
drug dosage, then mark the answer on a picture of a syringe.” When fill-in the
blank questions are used on the licensing exam, the test-taker provides one
answer that can be noted to be either correct or incorrect, and typically
includes calculation of intake and output, drug dose, or drip rate for
intravenous infusions.

Advantages of Fill-in-the-Blank Questions

   This item type reduces guessing.
This item type works well for math problems because it requires the student to
work out the answer. A wide range of materials can be tested.

Disadvantages of Fill-in-the-Blank Questions

    It is difficult to phrase the
question so there is only one correct answer. Scoring can be time consuming
because the student may provide an answer the instructor had not considered.
The student’s spelling can make it difficult to score.

   The nurse is to give morphine
elixir, 4 mg, sublingually. The drug available is morphine, 20 mg/mL. How much
should the nurse give? (Round to the nearest tenth.)
_____________________________ mg.