CJE BENCHMARK EXAM #2 QUESTIONS & ANSWERS |
300 VERIFIED QUESTIONS WITH COMPLETE
SOLUTIONS | NCLEX-STYLE NURSING PRACTICE |
UPDATED 2026
Question 1. The nurse prepares to insert a urinary catheter in a female patient. To
maintain sterility during the procedure, which action is essential?
A. Clean the perineal area with soap and water before starting the procedure.
B. Lubricate the catheter, insert it immediately, and avoid touching sterile supplies.
C. Use sterile gloves and maintain the sterile field throughout the procedure.
D. Position the patient in a supine position with knees slightly bent.
Correct Answer: C
Rationale: Maintaining sterility requires the use of sterile gloves and maintaining the
sterile field throughout the procedure . The perineal area must be cleansed with an
antiseptic solution, not plain soap and water . The catheter must be lubricated with
sterile lubricant to reduce trauma .
Question 2. The nurse is preparing a sterile field. A sterile gauze pad is dropped onto
the edge of the field, 1 inch from the border. What is the correct action?
A. Use the pad because it is within the sterile field.
B. Discard the pad and replace it.
C. Move the pad to the center of the sterile field.
D. Pour sterile saline over the pad to re-sterilize it.
Correct Answer: B
Rationale: The 1-inch border of a sterile field is considered contaminated because it
may have touched non-sterile surfaces . Anything touching this border is non-sterile and
must be discarded . Continuing would compromise the sterility of the entire field and
increase the patient's risk of infection .
,Question 3. An LPN finds a post-operative client's radial pulse weak and irregular at 110
beats/min. The client reports dizziness. What is the nurse's first action?
A. Offer the client a glass of orange juice for possible hypoglycemia.
B. Recheck the apical pulse for a full minute and assess blood pressure.
C. Document the finding and continue with the next task.
D. Administer the PRN antihypertensive immediately.
Correct Answer: B
Rationale: An irregular tachycardia with dizziness warrants immediate reassessment of
cardiac output via apical pulse and blood pressure . This is the first action before
considering interventions or documentation.
Question 4. The nurse observes a newly licensed nurse breaking sterile technique
during a dressing change. What is the most appropriate response?
A. Report the incident to the manager after the procedure is completed.
B. Immediately stop the procedure and correct the technique.
C. Ignore it unless the wound becomes infected.
D. Reassign the task to another nurse.
Correct Answer: B
Rationale: The appropriate response is to immediately stop the procedure and correct
the technique . Patient safety is the priority, and addressing the breach in sterility
prevents potential infection.
Question 5. A patient is on strict isolation for Clostridium difficile. Which hand hygiene
method is required?
A. Alcohol-based hand rub only.
B. Soap and water for handwashing.
,C. Either alcohol-based rub or soap and water.
D. No hand hygiene is required because of the gloves.
Correct Answer: B
Rationale: C. difficile spores are resistant to alcohol-based hand rubs. Soap and water is
required to physically remove the spores . Gloves alone are not sufficient for hand
hygiene; washing with soap and water is essential after glove removal.
Question 6. A nurse is applying a gait belt to a patient prior to ambulation. Where
should the belt be positioned?
A. Around the patient's chest, just below the axillae.
B. Around the patient's waist, over the clothing.
C. Around the patient's hips, below the greater trochanters.
D. Around the patient's lower legs for stability.
Correct Answer: B
Rationale: A gait belt is secured snugly around the waist (over clothing, not bare skin)
to provide a secure grip without compromising breathing or causing shear injury .
Question 7. A patient has a stage 2 pressure injury on the sacrum. Which wound care
product is most appropriate?
A. Transparent film dressing.
B. Hydrocolloid dressing.
C. Calcium alginate dressing.
D. Wet-to-dry saline gauze.
Correct Answer: B
Rationale: Stage 2 pressure injuries (partial-thickness skin loss) benefit from
hydrocolloid or foam dressings that maintain a moist wound environment and protect
from further friction .
, Question 8. When measuring a patient's orthostatic blood pressure, the nurse should
record the readings at which intervals?
A. Immediately, 1 minute, and 3 minutes after position change.
B. Immediately, 5 minutes, and 10 minutes after position change.
C. Only immediately after standing.
D. Before and 15 minutes after standing.
Correct Answer: A
Rationale: Orthostatic vitals are taken supine, then immediately upon standing, and
again at 1 and 3 minutes to detect delayed orthostatic hypotension .
Question 9. A patient with a nasogastric (NG) tube is awaiting feeding. Which finding
indicates proper placement before feeding?
A. pH of gastric aspirate is 6.5.
B. Patient is able to speak clearly.
C. pH of gastric aspirate is 3.5.
D. The external tube marking is at 45 cm.
Correct Answer: C
Rationale: Gastric aspirate pH ≤ 4.0 confirms gastric placement. pH > 6 suggests
intestinal or respiratory placement . A chest X-ray is considered the gold standard for
initial confirmation .
Question 10. A patient with an indwelling urinary catheter reports bladder fullness and
discomfort. The nurse notes that the drainage bag is empty. What is the first action?
A. Irrigate the catheter with sterile saline.
B. Check the tubing for kinks or obstruction.
C. Notify the healthcare provider immediately.
D. Increase the patient's fluid intake.
300 VERIFIED QUESTIONS WITH COMPLETE
SOLUTIONS | NCLEX-STYLE NURSING PRACTICE |
UPDATED 2026
Question 1. The nurse prepares to insert a urinary catheter in a female patient. To
maintain sterility during the procedure, which action is essential?
A. Clean the perineal area with soap and water before starting the procedure.
B. Lubricate the catheter, insert it immediately, and avoid touching sterile supplies.
C. Use sterile gloves and maintain the sterile field throughout the procedure.
D. Position the patient in a supine position with knees slightly bent.
Correct Answer: C
Rationale: Maintaining sterility requires the use of sterile gloves and maintaining the
sterile field throughout the procedure . The perineal area must be cleansed with an
antiseptic solution, not plain soap and water . The catheter must be lubricated with
sterile lubricant to reduce trauma .
Question 2. The nurse is preparing a sterile field. A sterile gauze pad is dropped onto
the edge of the field, 1 inch from the border. What is the correct action?
A. Use the pad because it is within the sterile field.
B. Discard the pad and replace it.
C. Move the pad to the center of the sterile field.
D. Pour sterile saline over the pad to re-sterilize it.
Correct Answer: B
Rationale: The 1-inch border of a sterile field is considered contaminated because it
may have touched non-sterile surfaces . Anything touching this border is non-sterile and
must be discarded . Continuing would compromise the sterility of the entire field and
increase the patient's risk of infection .
,Question 3. An LPN finds a post-operative client's radial pulse weak and irregular at 110
beats/min. The client reports dizziness. What is the nurse's first action?
A. Offer the client a glass of orange juice for possible hypoglycemia.
B. Recheck the apical pulse for a full minute and assess blood pressure.
C. Document the finding and continue with the next task.
D. Administer the PRN antihypertensive immediately.
Correct Answer: B
Rationale: An irregular tachycardia with dizziness warrants immediate reassessment of
cardiac output via apical pulse and blood pressure . This is the first action before
considering interventions or documentation.
Question 4. The nurse observes a newly licensed nurse breaking sterile technique
during a dressing change. What is the most appropriate response?
A. Report the incident to the manager after the procedure is completed.
B. Immediately stop the procedure and correct the technique.
C. Ignore it unless the wound becomes infected.
D. Reassign the task to another nurse.
Correct Answer: B
Rationale: The appropriate response is to immediately stop the procedure and correct
the technique . Patient safety is the priority, and addressing the breach in sterility
prevents potential infection.
Question 5. A patient is on strict isolation for Clostridium difficile. Which hand hygiene
method is required?
A. Alcohol-based hand rub only.
B. Soap and water for handwashing.
,C. Either alcohol-based rub or soap and water.
D. No hand hygiene is required because of the gloves.
Correct Answer: B
Rationale: C. difficile spores are resistant to alcohol-based hand rubs. Soap and water is
required to physically remove the spores . Gloves alone are not sufficient for hand
hygiene; washing with soap and water is essential after glove removal.
Question 6. A nurse is applying a gait belt to a patient prior to ambulation. Where
should the belt be positioned?
A. Around the patient's chest, just below the axillae.
B. Around the patient's waist, over the clothing.
C. Around the patient's hips, below the greater trochanters.
D. Around the patient's lower legs for stability.
Correct Answer: B
Rationale: A gait belt is secured snugly around the waist (over clothing, not bare skin)
to provide a secure grip without compromising breathing or causing shear injury .
Question 7. A patient has a stage 2 pressure injury on the sacrum. Which wound care
product is most appropriate?
A. Transparent film dressing.
B. Hydrocolloid dressing.
C. Calcium alginate dressing.
D. Wet-to-dry saline gauze.
Correct Answer: B
Rationale: Stage 2 pressure injuries (partial-thickness skin loss) benefit from
hydrocolloid or foam dressings that maintain a moist wound environment and protect
from further friction .
, Question 8. When measuring a patient's orthostatic blood pressure, the nurse should
record the readings at which intervals?
A. Immediately, 1 minute, and 3 minutes after position change.
B. Immediately, 5 minutes, and 10 minutes after position change.
C. Only immediately after standing.
D. Before and 15 minutes after standing.
Correct Answer: A
Rationale: Orthostatic vitals are taken supine, then immediately upon standing, and
again at 1 and 3 minutes to detect delayed orthostatic hypotension .
Question 9. A patient with a nasogastric (NG) tube is awaiting feeding. Which finding
indicates proper placement before feeding?
A. pH of gastric aspirate is 6.5.
B. Patient is able to speak clearly.
C. pH of gastric aspirate is 3.5.
D. The external tube marking is at 45 cm.
Correct Answer: C
Rationale: Gastric aspirate pH ≤ 4.0 confirms gastric placement. pH > 6 suggests
intestinal or respiratory placement . A chest X-ray is considered the gold standard for
initial confirmation .
Question 10. A patient with an indwelling urinary catheter reports bladder fullness and
discomfort. The nurse notes that the drainage bag is empty. What is the first action?
A. Irrigate the catheter with sterile saline.
B. Check the tubing for kinks or obstruction.
C. Notify the healthcare provider immediately.
D. Increase the patient's fluid intake.
