CJE MEDICAL-SURGICAL NURSING II EXAMINATION
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1
A 68-year-old patient arrives in the emergency department reporting crushing
substernal chest pain radiating to the left arm, accompanied by diaphoresis and
nausea, and the nurse suspects an acute myocardial infarction. Which nursing
action should receive the highest priority immediately after assessing airway and
breathing?
A. Encourage ambulation to reduce anxiety
B. Obtain a 12-lead ECG immediately
C. Offer oral fluids
D. Schedule an echocardiogram for later evaluation
Answer: B
Rationale:
A 12-lead ECG should be obtained within 10 minutes because it confirms
myocardial infarction and guides rapid reperfusion therapy. Ambulation increases
cardiac workload, oral fluids are inappropriate during acute chest pain, and an
echocardiogram is useful but not the immediate priority.
Question 2
,A patient with chronic heart failure suddenly develops worsening shortness of
breath, pink frothy sputum, and bilateral crackles throughout the lung fields
during hospitalization. Which nursing intervention should be performed first to
improve oxygenation and decrease pulmonary congestion?
A. Place the patient in high-Fowler's position
B. Encourage coughing exercises
C. Restrict all oral intake
D. Administer a stool softener
Answer: A
Rationale:
High-Fowler's positioning decreases venous return and improves lung expansion,
rapidly improving oxygenation. Coughing alone is insufficient, fluid restriction is
not the immediate priority, and stool softeners do not address acute pulmonary
edema.
Question 3
A nurse caring for a patient receiving intravenous heparin therapy for deep vein
thrombosis should recognize which laboratory value as the most appropriate
indicator for monitoring therapeutic anticoagulation?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Serum potassium
D. Hemoglobin A1C
,Answer: B
Rationale:
The activated partial thromboplastin time (aPTT) is the standard laboratory test
used to monitor unfractionated heparin therapy. Platelet count monitors for
heparin-induced thrombocytopenia but not therapeutic effectiveness. Potassium
and HbA1c are unrelated to anticoagulation monitoring.
Question 4
A patient diagnosed with chronic obstructive pulmonary disease is admitted for
an acute exacerbation requiring supplemental oxygen therapy. Which nursing
intervention best prevents suppression of the patient's respiratory drive while
maintaining adequate oxygenation?
A. Administer oxygen at the prescribed low-flow rate
B. Encourage oxygen at 100% continuously
C. Remove oxygen every hour
D. Restrict fluid intake completely
Answer: A
Rationale:
Patients with severe COPD may rely partially on hypoxic respiratory drive.
Administering low-flow oxygen as prescribed helps maintain adequate
oxygenation while minimizing the risk of carbon dioxide retention. The other
options either increase risk or are unrelated.
Question 5
, A hospitalized patient with bacterial meningitis suddenly becomes increasingly
restless, develops a decreasing level of consciousness, and exhibits unequal pupils
during neurological assessment. Which complication should the nurse suspect
first?
A. Increased intracranial pressure
B. Urinary tract infection
C. Dehydration
D. Constipation
Answer: A
Rationale:
Restlessness, declining consciousness, and unequal pupils strongly suggest
increased intracranial pressure, a life-threatening complication requiring
immediate intervention. The other options do not explain these acute
neurological changes.
CJE Medical-Surgical Nursing II Examination
Batch 1 (Continued): Questions 6–30
Question 6
A patient who underwent coronary artery bypass graft surgery six hours ago
suddenly has 250 mL of bright red chest tube drainage within one hour. Which
nursing action is the highest priority?
A. Continue monitoring because this drainage is expected after surgery.
B. Notify the surgeon immediately while assessing the patient's vital signs.
C. Clamp the chest tube to prevent further blood loss.
D. Remove the chest tube because excessive drainage indicates malfunction.
COMPLETE QUESTIONS AND DETAILED SOLUTIONS
LATEST UPDATE THIS YEAR JUST RELEASED
Question 1
A 68-year-old patient arrives in the emergency department reporting crushing
substernal chest pain radiating to the left arm, accompanied by diaphoresis and
nausea, and the nurse suspects an acute myocardial infarction. Which nursing
action should receive the highest priority immediately after assessing airway and
breathing?
A. Encourage ambulation to reduce anxiety
B. Obtain a 12-lead ECG immediately
C. Offer oral fluids
D. Schedule an echocardiogram for later evaluation
Answer: B
Rationale:
A 12-lead ECG should be obtained within 10 minutes because it confirms
myocardial infarction and guides rapid reperfusion therapy. Ambulation increases
cardiac workload, oral fluids are inappropriate during acute chest pain, and an
echocardiogram is useful but not the immediate priority.
Question 2
,A patient with chronic heart failure suddenly develops worsening shortness of
breath, pink frothy sputum, and bilateral crackles throughout the lung fields
during hospitalization. Which nursing intervention should be performed first to
improve oxygenation and decrease pulmonary congestion?
A. Place the patient in high-Fowler's position
B. Encourage coughing exercises
C. Restrict all oral intake
D. Administer a stool softener
Answer: A
Rationale:
High-Fowler's positioning decreases venous return and improves lung expansion,
rapidly improving oxygenation. Coughing alone is insufficient, fluid restriction is
not the immediate priority, and stool softeners do not address acute pulmonary
edema.
Question 3
A nurse caring for a patient receiving intravenous heparin therapy for deep vein
thrombosis should recognize which laboratory value as the most appropriate
indicator for monitoring therapeutic anticoagulation?
A. Platelet count
B. Activated partial thromboplastin time (aPTT)
C. Serum potassium
D. Hemoglobin A1C
,Answer: B
Rationale:
The activated partial thromboplastin time (aPTT) is the standard laboratory test
used to monitor unfractionated heparin therapy. Platelet count monitors for
heparin-induced thrombocytopenia but not therapeutic effectiveness. Potassium
and HbA1c are unrelated to anticoagulation monitoring.
Question 4
A patient diagnosed with chronic obstructive pulmonary disease is admitted for
an acute exacerbation requiring supplemental oxygen therapy. Which nursing
intervention best prevents suppression of the patient's respiratory drive while
maintaining adequate oxygenation?
A. Administer oxygen at the prescribed low-flow rate
B. Encourage oxygen at 100% continuously
C. Remove oxygen every hour
D. Restrict fluid intake completely
Answer: A
Rationale:
Patients with severe COPD may rely partially on hypoxic respiratory drive.
Administering low-flow oxygen as prescribed helps maintain adequate
oxygenation while minimizing the risk of carbon dioxide retention. The other
options either increase risk or are unrelated.
Question 5
, A hospitalized patient with bacterial meningitis suddenly becomes increasingly
restless, develops a decreasing level of consciousness, and exhibits unequal pupils
during neurological assessment. Which complication should the nurse suspect
first?
A. Increased intracranial pressure
B. Urinary tract infection
C. Dehydration
D. Constipation
Answer: A
Rationale:
Restlessness, declining consciousness, and unequal pupils strongly suggest
increased intracranial pressure, a life-threatening complication requiring
immediate intervention. The other options do not explain these acute
neurological changes.
CJE Medical-Surgical Nursing II Examination
Batch 1 (Continued): Questions 6–30
Question 6
A patient who underwent coronary artery bypass graft surgery six hours ago
suddenly has 250 mL of bright red chest tube drainage within one hour. Which
nursing action is the highest priority?
A. Continue monitoring because this drainage is expected after surgery.
B. Notify the surgeon immediately while assessing the patient's vital signs.
C. Clamp the chest tube to prevent further blood loss.
D. Remove the chest tube because excessive drainage indicates malfunction.
