CJE READINESS II EXAM -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 acute care medical-surgical unit is preparing to administer morning
medications. Which action represents the most effective practice for ensuring client safety
during medication administration?
A. Relying on memory when preparing routine medications
B. Comparing the medication label against the MAR three times
C. Administering medications to two clients simultaneously to save time
D. Documenting administration prior to administering the medication
Rationale: Performing three checks of the medication label against the medication
administration record (MAR) is a foundational nursing safety standard that minimizes
medication administration errors and ensures verified client safety.
2. A charge nurse receives a client report regarding an elderly individual who was recently
admitted with dehydration and confusion. What is the priority nursing assessment?
A. Inspecting skin turgor over the back of the hand
B. Assessing neurological status and vital signs
C. Obtaining a detailed diet history for the past month
D. Ordering an immediate physical therapy evaluation
Rationale: Assessing neurological status and vital signs provides vital baseline data and
identifies immediate life-threatening physiological instability in a dehydrated, confused
client.
3. A nurse is caring for a client who underwent an abdominal hysterectomy 12 hours ago.
The client reports severe abdominal pain rating 8 out of 10. What is the initial nursing
action?
A. Instruct the client to perform deep breathing exercises
B. Assess the operative site and check vital signs
,C. Administer the prescribed PRN opioid analgesic immediately
D. Notify the surgeon regarding the client's complaint
Rationale: Assessment is the first step in the nursing process. Assessing the surgical site and
vital signs helps rule out complications such as internal hemorrhage prior to administering
pain medication.
4. A registered nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating a client's response to pain medication
B. Performing a sterile dressing change on a central line
C. Assisting a stable post-operative client with ambulation
D. Teaching a diabetic client how to administer insulin
Rationale: Assisting stable clients with activities of daily living and ambulation falls within the
scope of practice for a UAP, whereas assessment, teaching, and sterile procedures require
professional nursing judgment.
5. A nurse observes an adult client having a tonic-clonic seizure in bed. Which of the
following actions should the nurse take first?
A. Insert a padded tongue blade into the client's mouth
B. Restrain the client's arms and legs to prevent injury
C. Turn the client onto their side to maintain an open airway
D. Administer high-flow oxygen via a non-rebreather mask
Rationale: Positioning the client on their side prevents aspiration and maintains airway
patency during a seizure, which is the primary nursing priority.
6. A client admitted with acute heart failure is prescribed furosemide intravenously. Which
laboratory finding requires immediate follow-up by the nurse?
A. Serum sodium 138 mEq/L
B. Serum potassium 2.9 mEq/L
C. Blood urea nitrogen (BUN) 18 mg/dL
,D. Serum creatinine 1.0 mg/dL
Rationale: Loop diuretics like furosemide cause potassium wasting. A serum potassium of 2.9
mEq/L indicates significant hypokalemia, placing the client at severe risk for fatal cardiac
dysrhythmias.
7. A nurse is caring for a client with a deep vein thrombosis (DVT) in the left lower
extremity. Which action should be included in the plan of care?
A. Massaging the left calf to relieve discomfort
B. Elevating the left leg above the heart level
C. Encouraging vigorous leg exercises in bed
D. Applying cold compresses directly to the leg
Rationale: Elevating the affected extremity promotes venous return and reduces edema.
Massaging or vigorous exercise is contraindicated because it can dislodge the thrombus,
causing a pulmonary embolism.
8. A nurse receives report on four clients. Which client should the nurse assess first?
A. A client with pneumonia who has an oxygen saturation of 89% on room air
B. A client post-cholecystectomy reporting incisional pain of 5 out of 10
C. A client with diabetes mellitus whose fasting blood glucose is 150 mg/dL
D. A client with hypertension requesting a PRN dose of antihypertensive medication
Rationale: Airway and oxygenation are top priorities (ABC framework). An oxygen saturation
of 89% indicates hypoxia requiring immediate assessment and intervention.
9. A nurse is providing discharge education to a client prescribed warfarin. Which
statement by the client demonstrates a correct understanding of the teaching?
A. "I will increase my intake of dark green leafy vegetables."
B. "I should use a soft-bristled toothbrush to prevent gum bleeding."
C. "I can take aspirin whenever I get a headache."
D. "I do not need to have my blood tested once I feel better."
, Rationale: Warfarin increases bleeding risk; using a soft-bristled toothbrush prevents trauma
to the gums. Dietary vitamin K should remain consistent, aspirin should be avoided, and
routine INR monitoring is required.
10. A client with a history of asthma arrives at the emergency department experiencing
acute shortness of breath and wheezing. Which medication should the nurse anticipate
administering first?
A. Intravenous methylprednisolone
B. Inhaled albuterol
C. Oral montelukast
D. Inhaled fluticasone
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that acts rapidly as a rescue
bronchodilator to relieve acute bronchospasm.
11. A nurse is reviewing a client's arterial blood gas (ABG) results: pH 7.28, PaCO2 52
mmHg, HCO3- 24 mEq/L. How should the nurse interpret these findings?
A. Uncompensated metabolic acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Partially compensated respiratory alkalosis
Rationale: The pH is acidic (< 7.35) and the PaCO2 is elevated (> 45 mmHg), while the HCO3- is
within normal limits (22–26 mEq/L), indicating uncompensated respiratory acidosis.
12. A nurse is providing care to a client who has a chest tube connected to a suction
drainage system. The nurse notes continuous bubbling in the water seal chamber. What
does this observation indicate?
A. Normal expected functioning of the chest drain
B. The system is functioning on low suction
C. An air leak in the chest drainage system or client's pleural space
D. The lung has completely re-expanded
ALL QUESTIONS AND ANSWERS (CORRECT ANSWERS) PLUS
DETAILED RATIONALES | COMPLETE STUDYGUIDE|
GUARANTEED PASS | DOWNLOAD INSTANT PDF 2027-2028
1. A nurse in an acute care medical-surgical unit is preparing to administer morning
medications. Which action represents the most effective practice for ensuring client safety
during medication administration?
A. Relying on memory when preparing routine medications
B. Comparing the medication label against the MAR three times
C. Administering medications to two clients simultaneously to save time
D. Documenting administration prior to administering the medication
Rationale: Performing three checks of the medication label against the medication
administration record (MAR) is a foundational nursing safety standard that minimizes
medication administration errors and ensures verified client safety.
2. A charge nurse receives a client report regarding an elderly individual who was recently
admitted with dehydration and confusion. What is the priority nursing assessment?
A. Inspecting skin turgor over the back of the hand
B. Assessing neurological status and vital signs
C. Obtaining a detailed diet history for the past month
D. Ordering an immediate physical therapy evaluation
Rationale: Assessing neurological status and vital signs provides vital baseline data and
identifies immediate life-threatening physiological instability in a dehydrated, confused
client.
3. A nurse is caring for a client who underwent an abdominal hysterectomy 12 hours ago.
The client reports severe abdominal pain rating 8 out of 10. What is the initial nursing
action?
A. Instruct the client to perform deep breathing exercises
B. Assess the operative site and check vital signs
,C. Administer the prescribed PRN opioid analgesic immediately
D. Notify the surgeon regarding the client's complaint
Rationale: Assessment is the first step in the nursing process. Assessing the surgical site and
vital signs helps rule out complications such as internal hemorrhage prior to administering
pain medication.
4. A registered nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Evaluating a client's response to pain medication
B. Performing a sterile dressing change on a central line
C. Assisting a stable post-operative client with ambulation
D. Teaching a diabetic client how to administer insulin
Rationale: Assisting stable clients with activities of daily living and ambulation falls within the
scope of practice for a UAP, whereas assessment, teaching, and sterile procedures require
professional nursing judgment.
5. A nurse observes an adult client having a tonic-clonic seizure in bed. Which of the
following actions should the nurse take first?
A. Insert a padded tongue blade into the client's mouth
B. Restrain the client's arms and legs to prevent injury
C. Turn the client onto their side to maintain an open airway
D. Administer high-flow oxygen via a non-rebreather mask
Rationale: Positioning the client on their side prevents aspiration and maintains airway
patency during a seizure, which is the primary nursing priority.
6. A client admitted with acute heart failure is prescribed furosemide intravenously. Which
laboratory finding requires immediate follow-up by the nurse?
A. Serum sodium 138 mEq/L
B. Serum potassium 2.9 mEq/L
C. Blood urea nitrogen (BUN) 18 mg/dL
,D. Serum creatinine 1.0 mg/dL
Rationale: Loop diuretics like furosemide cause potassium wasting. A serum potassium of 2.9
mEq/L indicates significant hypokalemia, placing the client at severe risk for fatal cardiac
dysrhythmias.
7. A nurse is caring for a client with a deep vein thrombosis (DVT) in the left lower
extremity. Which action should be included in the plan of care?
A. Massaging the left calf to relieve discomfort
B. Elevating the left leg above the heart level
C. Encouraging vigorous leg exercises in bed
D. Applying cold compresses directly to the leg
Rationale: Elevating the affected extremity promotes venous return and reduces edema.
Massaging or vigorous exercise is contraindicated because it can dislodge the thrombus,
causing a pulmonary embolism.
8. A nurse receives report on four clients. Which client should the nurse assess first?
A. A client with pneumonia who has an oxygen saturation of 89% on room air
B. A client post-cholecystectomy reporting incisional pain of 5 out of 10
C. A client with diabetes mellitus whose fasting blood glucose is 150 mg/dL
D. A client with hypertension requesting a PRN dose of antihypertensive medication
Rationale: Airway and oxygenation are top priorities (ABC framework). An oxygen saturation
of 89% indicates hypoxia requiring immediate assessment and intervention.
9. A nurse is providing discharge education to a client prescribed warfarin. Which
statement by the client demonstrates a correct understanding of the teaching?
A. "I will increase my intake of dark green leafy vegetables."
B. "I should use a soft-bristled toothbrush to prevent gum bleeding."
C. "I can take aspirin whenever I get a headache."
D. "I do not need to have my blood tested once I feel better."
, Rationale: Warfarin increases bleeding risk; using a soft-bristled toothbrush prevents trauma
to the gums. Dietary vitamin K should remain consistent, aspirin should be avoided, and
routine INR monitoring is required.
10. A client with a history of asthma arrives at the emergency department experiencing
acute shortness of breath and wheezing. Which medication should the nurse anticipate
administering first?
A. Intravenous methylprednisolone
B. Inhaled albuterol
C. Oral montelukast
D. Inhaled fluticasone
Rationale: Albuterol is a short-acting beta-2 agonist (SABA) that acts rapidly as a rescue
bronchodilator to relieve acute bronchospasm.
11. A nurse is reviewing a client's arterial blood gas (ABG) results: pH 7.28, PaCO2 52
mmHg, HCO3- 24 mEq/L. How should the nurse interpret these findings?
A. Uncompensated metabolic acidosis
B. Uncompensated respiratory acidosis
C. Fully compensated metabolic alkalosis
D. Partially compensated respiratory alkalosis
Rationale: The pH is acidic (< 7.35) and the PaCO2 is elevated (> 45 mmHg), while the HCO3- is
within normal limits (22–26 mEq/L), indicating uncompensated respiratory acidosis.
12. A nurse is providing care to a client who has a chest tube connected to a suction
drainage system. The nurse notes continuous bubbling in the water seal chamber. What
does this observation indicate?
A. Normal expected functioning of the chest drain
B. The system is functioning on low suction
C. An air leak in the chest drainage system or client's pleural space
D. The lung has completely re-expanded
