CJE BENCHMARK CLINICAL JUDGEMENT EXAM #1-COLLEGE OF
NURSING 2026-2027 | ALL QUESTIONS AND ANSWERS
(CORRECT ANSWERS) PLUS DETAILED RATIONALES |
COMPLETE STUDYGUIDE| GUARANTEED PASS | DOWNLOAD
INSTANT PDF 2027-2028
1. A nurse in an outpatient clinic is preparing to administer an intramuscular injection to
an adult client. Which site is the safest and preferred location for administering this
medication?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid site
D. Vastus lateralis site
The ventrogluteal site is the safest and preferred site for intramuscular injections in adults
because it is located away from major blood vessels and nerves, reducing the risk of
accidental neurovascular injury.
2. A nurse is caring for a client who is 2 hours postoperative following abdominal surgery.
The nurse notes a heart rate of 120 bpm, blood pressure of 88/52 mmHg, and pale, cool
skin. What is the priority nursing action?
A. Administer the prescribed oral pain medication.
B. Elevate the head of the bed to 90 degrees.
C. Place the client in a modified Trendelenburg position and notify the surgeon.
D. Document the findings as an expected post-surgical recovery baseline.
The client is exhibiting classical signs of hypovolemic shock. Placing the client in a position
that optimizes blood flow to vital organs and immediately notifying the surgical team is the
priority intervention to prevent systemic collapse.
3. A staff nurse observes a nursing assistive personnel (NAP) using alcohol-based hand rub
after caring for a client with confirmed Clostridioides difficile infection. Which response by
the nurse is most appropriate?
A. Commend the NAP for adhering to routine hand hygiene guidelines.
B. Instruct the NAP to rewash their hands thoroughly using soap and warm water.
C. Instruct the NAP to apply sterile gloves before entering the room next time.
D. Advise the NAP to use an chlorhexidine gluconate scrub for at least 3 minutes.
,Clostridioides difficile spores are resistant to alcohol-based hand rubs. Proper handwashing
with soap and water is mechanically required to flush the bacterial spores from the hands.
4. A nurse receives a critical laboratory value for a client showing a serum potassium level
of 6.8 mEq/L. Which electrocardiogram (ECG) change should the nurse monitor for most
closely?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment elevation
D. Prolonged QT interval
Hyperkalemia alters cardiac cellular repolarization, directly resulting in tall, peaked T waves
on an ECG. Unmanaged hyperkalemia can quickly transition into lethal dysrhythmias like
ventricular fibrillation.
5. A nurse is teaching a client diagnosed with type 1 diabetes mellitus about foot care.
Which instruction should the nurse include in the educational plan?
A. Soak feet in warm water daily for 30 minutes to soften skin.
B. Apply moisturizing lotion between the toes after drying.
C. Inspect the bottoms of the feet daily using a mirror.
D. Cut toenails in a curved shape following the nail bed.
Daily inspection using a mirror allows early detection of unnoticed lesions, ulcers, or
breakdown due to peripheral neuropathy. Soaking causes maceration, lotion between toes
promotes fungal growth, and nails should be cut straight across.
6. A client admitted with heart failure is prescribed furosemide 40 mg intravenous push
once daily. Which assessment finding indicates that the medication is producing its
intended therapeutic effect?
A. Increase in blood pressure from 110/70 to 138/84 mmHg
B. Decrease in bilateral lower extremity edema from 3+ to 1+
C. Decrease in urine output over 24 hours
D. Weight gain of 2 kg over 24 hours
Furosemide is a loop diuretic that promotes fluid excretion. A decrease in peripheral edema,
along with weight loss and increased urine output, indicates successful management of fluid
volume overload.
7. A nurse is reviewing arterial blood gas (ABG) results for a client with acute respiratory
distress: pH 7.28, PaCO2 54 mmHg, HCO3- 24 mEq/L. How should the nurse interpret
these results?
,A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
The pH is acidic (less than 7.35) and the PaCO2 is elevated (greater than 45 mmHg) with a
normal bicarbonate level, indicating an uncompensated respiratory acidosis caused by carbon
dioxide retention.
8. An older adult client receiving continuous enteral tube feeding via a nasogastric tube
reports sudden dyspnea and coughing. The nurse observes coughing up feeding formula.
What immediate action must the nurse take?
A. Slow the rate of the enteral feeding infusion pump.
B. Stop the tube feeding immediately and position the client upright.
C. Auscultate lung sounds and administer oxygen at 2 L/min.
D. Flush the feeding tube with 30 mL of warm water.
Coughing up formula suggests tube displacement and pulmonary aspiration. Stopping the
feeding immediately prevents further aspiration into the lungs, protecting the airway.
9. A nurse is providing discharge instructions to a client prescribed warfarine. Which
dietary recommendation is essential for the nurse to emphasize?
A. Eliminate all green leafy vegetables from the daily diet completely.
B. Maintain a consistent daily intake of foods rich in Vitamin K.
C. Double the intake of citrus fruits to enhance drug absorption.
D. Take a daily over-the-counter vitamin E supplement.
Vitamin K antagonizes the anticoagulant effect of warfarin. Consistent dietary intake allows
stable dosing and therapeutic INR target levels, whereas drastic increases or decreases
disrupt anticoagulation therapy.
10. A nurse is assessing a client presenting with signs of appendicitis. Which specific
diagnostic assessment finding supports this clinical diagnosis?
A. Pain relieved by palpation in the left lower quadrant
B. Rebound tenderness at McBurney's point
C. Positive Murphy's sign
D. Absent bowel sounds in all four quadrants
McBurney's point (located halfway between the umbilicus and the right anterior superior iliac
spine) exhibits rebound tenderness in acute appendicitis due to localized peritoneal
inflammation.
, 11. A client diagnosed with severe major depressive disorder is initiated on phenelzine.
Which food selection from the client's dietary tray indicates a need for further teaching?
A. Fresh grilled chicken breast with steamed broccoli
B. Aged cheddar cheese and salami platter
C. White rice with baked salmon
D. Sliced apples with peanut butter
Phenelzine is a Monoamine Oxidase Inhibitor (MAOI). Consuming foods rich in tyramine, such
as aged cheeses and cured meats, can trigger a dangerous hypertensive crisis.
12. A newly admitted client presents with generalized edema, dark cola-colored urine, and
hypertension following a recent streptococcal pharyngitis infection. Which condition
should the nurse suspect?
A. Acute pyelonephritis
B. Acute glomerulonephritis
C. Nephrotic syndrome
D. Urolithiasis
Acute glomerulonephritis typically develops 1 to 2 weeks following a group A beta-hemolytic
streptococcal infection. It manifests as hematuria (cola-colored urine), hypertension,
proteinuria, and edema.
13. A charge nurse is assigning tasks to an experienced licensed practical nurse (LPN).
Which client care activity is within the legal scope of practice for the LPN?
A. Developing the initial nursing care plan for a client admitted with stroke.
B. Administering an intravenous push dose of cardiac resuscitation medication.
C. Administering subcutaneous insulin to a stable client with diabetes.
D. Completing the comprehensive physical assessment of a newly admitted client.
LPN scope of practice includes administering routine subcutaneous medications to stable
clients. Initial assessments, comprehensive plans of care, and IV push critical medications are
strictly reserved for Registered Nurses (RNs).
14. A nurse is caring for a postoperative total hip arthroplasty client. Which action is
essential to prevent joint dislocation during the immediate postoperative period?
A. Adduct the affected leg past the midline when turning.
B. Place an abduction pillow between the client's legs when turning.
C. Flex the affected hip greater than 90 degrees when sitting up.
D. Elevate the foot of the bed while keeping knees bent.
NURSING 2026-2027 | ALL QUESTIONS AND ANSWERS
(CORRECT ANSWERS) PLUS DETAILED RATIONALES |
COMPLETE STUDYGUIDE| GUARANTEED PASS | DOWNLOAD
INSTANT PDF 2027-2028
1. A nurse in an outpatient clinic is preparing to administer an intramuscular injection to
an adult client. Which site is the safest and preferred location for administering this
medication?
A. Dorsogluteal site
B. Ventrogluteal site
C. Deltoid site
D. Vastus lateralis site
The ventrogluteal site is the safest and preferred site for intramuscular injections in adults
because it is located away from major blood vessels and nerves, reducing the risk of
accidental neurovascular injury.
2. A nurse is caring for a client who is 2 hours postoperative following abdominal surgery.
The nurse notes a heart rate of 120 bpm, blood pressure of 88/52 mmHg, and pale, cool
skin. What is the priority nursing action?
A. Administer the prescribed oral pain medication.
B. Elevate the head of the bed to 90 degrees.
C. Place the client in a modified Trendelenburg position and notify the surgeon.
D. Document the findings as an expected post-surgical recovery baseline.
The client is exhibiting classical signs of hypovolemic shock. Placing the client in a position
that optimizes blood flow to vital organs and immediately notifying the surgical team is the
priority intervention to prevent systemic collapse.
3. A staff nurse observes a nursing assistive personnel (NAP) using alcohol-based hand rub
after caring for a client with confirmed Clostridioides difficile infection. Which response by
the nurse is most appropriate?
A. Commend the NAP for adhering to routine hand hygiene guidelines.
B. Instruct the NAP to rewash their hands thoroughly using soap and warm water.
C. Instruct the NAP to apply sterile gloves before entering the room next time.
D. Advise the NAP to use an chlorhexidine gluconate scrub for at least 3 minutes.
,Clostridioides difficile spores are resistant to alcohol-based hand rubs. Proper handwashing
with soap and water is mechanically required to flush the bacterial spores from the hands.
4. A nurse receives a critical laboratory value for a client showing a serum potassium level
of 6.8 mEq/L. Which electrocardiogram (ECG) change should the nurse monitor for most
closely?
A. Prominent U waves
B. Tall, peaked T waves
C. ST-segment elevation
D. Prolonged QT interval
Hyperkalemia alters cardiac cellular repolarization, directly resulting in tall, peaked T waves
on an ECG. Unmanaged hyperkalemia can quickly transition into lethal dysrhythmias like
ventricular fibrillation.
5. A nurse is teaching a client diagnosed with type 1 diabetes mellitus about foot care.
Which instruction should the nurse include in the educational plan?
A. Soak feet in warm water daily for 30 minutes to soften skin.
B. Apply moisturizing lotion between the toes after drying.
C. Inspect the bottoms of the feet daily using a mirror.
D. Cut toenails in a curved shape following the nail bed.
Daily inspection using a mirror allows early detection of unnoticed lesions, ulcers, or
breakdown due to peripheral neuropathy. Soaking causes maceration, lotion between toes
promotes fungal growth, and nails should be cut straight across.
6. A client admitted with heart failure is prescribed furosemide 40 mg intravenous push
once daily. Which assessment finding indicates that the medication is producing its
intended therapeutic effect?
A. Increase in blood pressure from 110/70 to 138/84 mmHg
B. Decrease in bilateral lower extremity edema from 3+ to 1+
C. Decrease in urine output over 24 hours
D. Weight gain of 2 kg over 24 hours
Furosemide is a loop diuretic that promotes fluid excretion. A decrease in peripheral edema,
along with weight loss and increased urine output, indicates successful management of fluid
volume overload.
7. A nurse is reviewing arterial blood gas (ABG) results for a client with acute respiratory
distress: pH 7.28, PaCO2 54 mmHg, HCO3- 24 mEq/L. How should the nurse interpret
these results?
,A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
The pH is acidic (less than 7.35) and the PaCO2 is elevated (greater than 45 mmHg) with a
normal bicarbonate level, indicating an uncompensated respiratory acidosis caused by carbon
dioxide retention.
8. An older adult client receiving continuous enteral tube feeding via a nasogastric tube
reports sudden dyspnea and coughing. The nurse observes coughing up feeding formula.
What immediate action must the nurse take?
A. Slow the rate of the enteral feeding infusion pump.
B. Stop the tube feeding immediately and position the client upright.
C. Auscultate lung sounds and administer oxygen at 2 L/min.
D. Flush the feeding tube with 30 mL of warm water.
Coughing up formula suggests tube displacement and pulmonary aspiration. Stopping the
feeding immediately prevents further aspiration into the lungs, protecting the airway.
9. A nurse is providing discharge instructions to a client prescribed warfarine. Which
dietary recommendation is essential for the nurse to emphasize?
A. Eliminate all green leafy vegetables from the daily diet completely.
B. Maintain a consistent daily intake of foods rich in Vitamin K.
C. Double the intake of citrus fruits to enhance drug absorption.
D. Take a daily over-the-counter vitamin E supplement.
Vitamin K antagonizes the anticoagulant effect of warfarin. Consistent dietary intake allows
stable dosing and therapeutic INR target levels, whereas drastic increases or decreases
disrupt anticoagulation therapy.
10. A nurse is assessing a client presenting with signs of appendicitis. Which specific
diagnostic assessment finding supports this clinical diagnosis?
A. Pain relieved by palpation in the left lower quadrant
B. Rebound tenderness at McBurney's point
C. Positive Murphy's sign
D. Absent bowel sounds in all four quadrants
McBurney's point (located halfway between the umbilicus and the right anterior superior iliac
spine) exhibits rebound tenderness in acute appendicitis due to localized peritoneal
inflammation.
, 11. A client diagnosed with severe major depressive disorder is initiated on phenelzine.
Which food selection from the client's dietary tray indicates a need for further teaching?
A. Fresh grilled chicken breast with steamed broccoli
B. Aged cheddar cheese and salami platter
C. White rice with baked salmon
D. Sliced apples with peanut butter
Phenelzine is a Monoamine Oxidase Inhibitor (MAOI). Consuming foods rich in tyramine, such
as aged cheeses and cured meats, can trigger a dangerous hypertensive crisis.
12. A newly admitted client presents with generalized edema, dark cola-colored urine, and
hypertension following a recent streptococcal pharyngitis infection. Which condition
should the nurse suspect?
A. Acute pyelonephritis
B. Acute glomerulonephritis
C. Nephrotic syndrome
D. Urolithiasis
Acute glomerulonephritis typically develops 1 to 2 weeks following a group A beta-hemolytic
streptococcal infection. It manifests as hematuria (cola-colored urine), hypertension,
proteinuria, and edema.
13. A charge nurse is assigning tasks to an experienced licensed practical nurse (LPN).
Which client care activity is within the legal scope of practice for the LPN?
A. Developing the initial nursing care plan for a client admitted with stroke.
B. Administering an intravenous push dose of cardiac resuscitation medication.
C. Administering subcutaneous insulin to a stable client with diabetes.
D. Completing the comprehensive physical assessment of a newly admitted client.
LPN scope of practice includes administering routine subcutaneous medications to stable
clients. Initial assessments, comprehensive plans of care, and IV push critical medications are
strictly reserved for Registered Nurses (RNs).
14. A nurse is caring for a postoperative total hip arthroplasty client. Which action is
essential to prevent joint dislocation during the immediate postoperative period?
A. Adduct the affected leg past the midline when turning.
B. Place an abduction pillow between the client's legs when turning.
C. Flex the affected hip greater than 90 degrees when sitting up.
D. Elevate the foot of the bed while keeping knees bent.
