Multiple-choice questions are a common assessment method in nursing examinations. Few nurse educators, however, have formal preparation in constructing multiple-choice questions. Consequently, questions used in baccalaureate nursing assessments often contain item-writing flaws, or violations to accepted item-writing guidelines. In one nursing department, 2770 MCQs were collected from tests and examinations administered over a five-year period from 2001 to 2005. Questions were evaluated for 19 frequently occurring item-writing flaws, for cognitive level, for question source, and for the distribution of correct answers. Results show that almost half (46.2%) of the questions contained violations of item-writing guidelines and over 90% were written at low cognitive levels. Only a small proportion of questions were teacher generated (14.1%), while 36.2% were taken from testbanks and almost half (49.4%) had no source identified. MCQs written at a lower cognitive level were significantly more likely to contain item-writing flaws. While there was no relationship between the source of the question and item-writing flaws, teacher-generated questions were more likely to be written at higher cognitive levels (p
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