CJE BENCHMARK EXAM 1 PATIENT CARE FUNDAMENTALS COMPREHENSIVE EXAM QUESTIONS COMPLETE WITH DETAILED RATIONALES AND CORRECT VERIFIED ANSWERS

CJE BENCHMARK EXAM 1 PATIENT CARE FUNDAMENTALS COMPREHENSIVE EXAM QUESTIONS COMPLETE WITH DETAILED RATIONALES AND CORRECT VERIFIED ANSWERS 1. A nurse is assessing a patient's pain level using a 0-10 numeric rating scale. The patient reports a 7. Which action should the nurse take first? A. Administer prescribed analgesic immediately B. Document the pain score and reassess in 4 hours C. Ask the patient to describe the pain characteristics D. Notify the healthcare provider E. Apply a cold compress to the painful area Correct Answer: C. Ask the patient to describe the pain characteristics EXPERT RATIONALE: A comprehensive pain assessment includes location, intensity, quality, onset, duration, and aggravating/alleviating factors. The nurse should first gather complete pain data before intervening. Documenting alone is insufficient, and notifying the provider or administering medication requires a complete assessment first. ________________________________________ 2. A patient is receiving continuous enteral tube feeding. Which position should the nurse maintain to reduce the risk of aspiration? A. Supine position B. Left lateral position C. Semi-Fowler's position D. Trendelenburg position E. Prone position Correct Answer: C. Semi-Fowler's position EXPERT RATIONALE: Semi-Fowler's position (30-45 degrees) promotes gastric emptying and reduces the risk of aspiration during continuous tube feeding. Supine position increases aspiration risk due to gastric reflux. The head of the bed should remain elevated at all times during feeding. ________________________________________ 3. A nurse is caring for a patient with an indwelling urinary catheter. Which finding indicates a potential infection? A. Clear, yellow urine B. Urine output of 50 mL/hour C. Foul-smelling, cloudy urine D. pH of 6.0 E. Specific gravity of 1.015 Correct Answer: C. Foul-smelling, cloudy urine EXPERT RATIONALE: Cloudy, foul-smelling urine, along with fever, frequency, and urgency, indicates a potential catheter-associated urinary tract infection. Clear urine is normal. Output of 50 mL/hour is adequate. pH and specific gravity values provided are within normal range. ________________________________________ 4. A patient is diagnosed with hypokalemia. Which finding would the nurse expect to observe? A. Muscle spasms B. Bradycardia C. Muscle weakness and fatigue D. Hypertension E. Hyperactive reflexes Correct Answer: C. Muscle weakness and fatigue EXPERT RATIONALE: Hypokalemia (potassium 3.5 mEq/L) presents with muscle weakness, fatigue, and cardiac arrhythmias. Muscle spasms and hyperactive reflexes are associated with hypocalcemia. Bradycardia is not a typical finding; tachycardia or arrhythmias may occur. ________________________________________ 5. A nurse is preparing to administer a subcutaneous injection of heparin. Which site is preferred? A. Ventrogluteal site B. Deltoid muscle C. Abdomen, 2 inches away from the umbilicus D. Vastus lateralis E. Dorsogluteal site Correct Answer: C. Abdomen, 2 inches away from the umbilicus EXPERT RATIONALE: The abdomen is the preferred site for subcutaneous heparin injections due to adequate subcutaneous tissue and consistent absorption. Rotating sites within the abdomen is recommended to prevent bruising and lipodystrophy. Other sites can be used but are not preferred. ________________________________________ 6. A patient's laboratory results show a hemoglobin level of 8.2 g/dL. The nurse should prepare for which intervention? A. Administering iron supplements B. Blood transfusion C. Increasing fluid intake D. Dietary consultation E. Starting oxygen therapy Correct Answer: B. Blood transfusion EXPERT RATIONALE: Hemoglobin below 8 g/dL typically indicates severe anemia requiring blood transfusion. While iron supplements, diet changes, and oxygen therapy may be appropriate, transfusion is the immediate intervention for critically low hemoglobin levels. ________________________________________ 7. A patient with heart failure has an order for daily weights. When should the nurse obtain the weight? A. Before breakfast after voiding B. After breakfast C. Before bedtime D. After the evening meal E. Before administering morning medications Correct Answer: A. Before breakfast after voiding EXPERT RATIONALE: Daily weights should be obtained at the same time each day, typically before breakfast and after voiding, to ensure consistency and accuracy. This provides the most reliable comparison to detect fluid retention or loss. Using the same scale and wearing similar clothing is essential. ________________________________________ 8. A nurse is performing a neurological assessment and finds that a patient's pupils are unequal. Which term describes this finding? A. Miosis B. Mydriasis C. Anisocoria D. Nystagmus E. Photophobia Correct Answer: C. Anisocoria EXPERT RATIONALE: Anisocoria refers to unequal pupil size. Miosis describes constricted pupils. Mydriasis describes dilated pupils. Nystagmus refers to involuntary eye movements, and photophobia is sensitivity to light. Anisocoria may indicate increased intracranial pressure or neurological damage. ________________________________________ 9. A patient is prescribed a clear liquid diet. Which item can the patient consume? A. Orange juice with pulp B. Cream of mushroom soup C. Apple juice