This article was prompted by an extended discussion in 2009, on the International Nursing Association for Clinical Simulation and Learning (INACSL) Listserv, about the use of simulation for high-stakes testing. That discussion led to a roundtable at the 2009 INACSL conference in St. Louis. This article comes from notes taken at that roundtable and further-developed thoughts of the lead discussants. Many of their conclusions were echoed in the recent Carnegie report on nursing education.