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CJE BENCHMARK EXAM 1 Patient Care Fundamentals | 2026/2027 NCLEX Study
Guide Questions with Detailed Rationales
Question 1
A nurse is assessing a client who reports shortness of breath.
Which finding requires immediate intervention?
A. Respiratory rate 18 breaths/min
B. Oxygen saturation 88% on room air
C. Occasional dry cough
D. Clear breath sounds bilaterally
Answer: B
Rationale: An SpO₂ of 88% indicates hypoxemia and requires
immediate oxygen therapy and further assessment. Other
findings are less urgent.
Question 2
Which of the following is the first action when a client develops
sudden confusion and disorientation?
A. Administer a sedative
B. Assess vital signs and oxygenation
C. Apply restraints
D. Document the behavior
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Answer: B
Rationale: Sudden confusion may indicate hypoxia, infection, or
metabolic disturbance. Assess vital signs and oxygenation first;
restraints and sedatives are not first-line.
Question 3
A client has a blood pressure of 80/50 mmHg and heart rate
120 bpm. Which nursing action is priority?
A. Ambulate the client
B. Notify the provider and initiate measures to improve
perfusion
C. Offer oral fluids
D. Wait for repeat vital signs
Answer: B
Rationale: Hypotension with tachycardia suggests shock or
hypovolemia; immediate provider notification and perfusion
support are required.
Question 4
Which of the following is the correct order for donning personal
protective equipment (PPE)?
A. Gloves, gown, mask, goggles
B. Gown, mask, goggles, gloves
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C. Mask, gloves, gown, goggles
D. Goggles, gown, mask, gloves
Answer: B
Rationale: The correct donning order is gown first, then
mask/respirator, goggles/face shield, and gloves last.
Question 5
A nurse is caring for a client with Clostridium difficile infection.
Which hand hygiene method is most appropriate?
A. Alcohol-based hand rub
B. Soap and water
C. Hand sanitizer only if visibly clean
D. No hand hygiene if gloves worn
Answer: B
Rationale: C. difficile spores are not killed by alcohol rubs; soap
and water must be used to physically remove spores.
Question 6
Which of the following is a sign of localized infection?
A. Fever and chills
B. Redness, warmth, swelling, and pain at the site
C. Tachycardia
D. Malaise
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Answer: B
Rationale: Localized infection presents with erythema, warmth,
swelling, and pain. Fever, chills, and tachycardia are systemic
signs.
Question 7
A client is on droplet precautions. Which PPE is required within
3 feet of the client?
A. N95 respirator
B. Surgical mask
C. Goggles only
D. No mask needed
Answer: B
Rationale: Droplet precautions require a surgical mask within 3
feet of the client. N95 is for airborne precautions.
Question 8
Which client is at highest risk for developing a pressure injury?
A. A 30-year-old with a fractured arm
B. A 70-year-old who is immobile and incontinent
C. A 50-year-old who ambulates daily
D. A 40-year-old with good nutrition
CJE BENCHMARK EXAM 1 Patient Care Fundamentals | 2026/2027 NCLEX Study
Guide Questions with Detailed Rationales
Question 1
A nurse is assessing a client who reports shortness of breath.
Which finding requires immediate intervention?
A. Respiratory rate 18 breaths/min
B. Oxygen saturation 88% on room air
C. Occasional dry cough
D. Clear breath sounds bilaterally
Answer: B
Rationale: An SpO₂ of 88% indicates hypoxemia and requires
immediate oxygen therapy and further assessment. Other
findings are less urgent.
Question 2
Which of the following is the first action when a client develops
sudden confusion and disorientation?
A. Administer a sedative
B. Assess vital signs and oxygenation
C. Apply restraints
D. Document the behavior
, Page |2
Answer: B
Rationale: Sudden confusion may indicate hypoxia, infection, or
metabolic disturbance. Assess vital signs and oxygenation first;
restraints and sedatives are not first-line.
Question 3
A client has a blood pressure of 80/50 mmHg and heart rate
120 bpm. Which nursing action is priority?
A. Ambulate the client
B. Notify the provider and initiate measures to improve
perfusion
C. Offer oral fluids
D. Wait for repeat vital signs
Answer: B
Rationale: Hypotension with tachycardia suggests shock or
hypovolemia; immediate provider notification and perfusion
support are required.
Question 4
Which of the following is the correct order for donning personal
protective equipment (PPE)?
A. Gloves, gown, mask, goggles
B. Gown, mask, goggles, gloves
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C. Mask, gloves, gown, goggles
D. Goggles, gown, mask, gloves
Answer: B
Rationale: The correct donning order is gown first, then
mask/respirator, goggles/face shield, and gloves last.
Question 5
A nurse is caring for a client with Clostridium difficile infection.
Which hand hygiene method is most appropriate?
A. Alcohol-based hand rub
B. Soap and water
C. Hand sanitizer only if visibly clean
D. No hand hygiene if gloves worn
Answer: B
Rationale: C. difficile spores are not killed by alcohol rubs; soap
and water must be used to physically remove spores.
Question 6
Which of the following is a sign of localized infection?
A. Fever and chills
B. Redness, warmth, swelling, and pain at the site
C. Tachycardia
D. Malaise
, Page |4
Answer: B
Rationale: Localized infection presents with erythema, warmth,
swelling, and pain. Fever, chills, and tachycardia are systemic
signs.
Question 7
A client is on droplet precautions. Which PPE is required within
3 feet of the client?
A. N95 respirator
B. Surgical mask
C. Goggles only
D. No mask needed
Answer: B
Rationale: Droplet precautions require a surgical mask within 3
feet of the client. N95 is for airborne precautions.
Question 8
Which client is at highest risk for developing a pressure injury?
A. A 30-year-old with a fractured arm
B. A 70-year-old who is immobile and incontinent
C. A 50-year-old who ambulates daily
D. A 40-year-old with good nutrition
