KAPLAN CLINICAL JUDAMENT C PRACTICE TEST 100 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains
Clinical Judgment Measurement Model (CJMM) Application
Cue Recognition and Data Analysis
Hypothesis Prioritization and Diagnostic Reasoning
Solution Generation and Intervention Planning
Action Implementation and Safety Protocols
Outcome Evaluation and Care Adjustment
Patient Safety and Risk Reduction
Pharmacological Therapies and Medication Safety
Ethics, Legal Compliance, and Professional Standards
Critical Thinking and Decision-Making in Clinical Scenarios
Introduction
This assessment is designed to evaluate core clinical judgment knowledge, nursing reasoning, and bedside decision-making across common
clinical scenarios. The exam measures skills in recognizing relevant cues, analyzing patient data, prioritizing hypotheses, generating evidence-
based solutions, implementing appropriate actions, and evaluating outcomes. The multiple-choice and scenario-based structure emphasizes real-
world application, critical thinking, and professional decision-making required for safe, effective nursing practice. Questions cover foundational
theory, applied professional knowledge, regulatory compliance, ethics, and critical clinical situations that test candidates' ability to make sound
judgments under pressure.
Section One: Questions 1–100
Question 1
,A nurse is assessing a patient with diabetes mellitus who reports feeling shaky, sweaty, and confused. The patient's blood glucose reading is 48
mg/dL. What is the nurse's FIRST action?
A. Administer 15 grams of rapid-acting carbohydrate
B. Administer 1 unit of regular insulin subcutaneously
C. Give 4 ounces of orange juice immediately
D. Call the physician to report the blood glucose level
🟢 C. Give 4 ounces of orange juice immediately
🔴 RATIONALE: The patient is experiencing hypoglycemia (blood glucose <70 mg/dL) with symptoms of shakiness, sweating, and confusion. The
first action for a conscious patient with hypoglycemia is to provide rapid-acting carbohydrates immediately. Orange juice contains approximately 15
grams of carbs and is rapidly absorbed. Administering insulin would worsen hypoglycemia, and calling the physician delays immediate treatment
needed.
Question 2
Which of the following best demonstrates the "Recognize Cues" step of the Clinical Judgment Measurement Model?
A. Cluster vital signs showing tachycardia and hypotension
B. Document that the patient's blood pressure is 88/52 mmHg
C. Determine that the patient may be experiencing hemorrhage
D. Administer IV fluids to treat suspected hypovolemia
🟢 B. Document that the patient's blood pressure is 88/52 mmHg
🔴 RATIONALE: "Recognize Cues" involves identifying and collecting relevant information from different sources (vital signs, labs, patient
statements). Simply documenting the blood pressure reading is cue recognition. Clustering data (A) is "Analyze Cues," determining hemorrhage (C)
is "Prioritize Hypotheses," and administering fluids (D) is "Take Action."
Question 3
A postoperative patient develops sudden shortness of breath, chest pain, and tachycardia 24 hours after knee surgery. The nurse suspects pulmonary
embolism. Which hypothesis should be prioritized FIRST?
,A. Pneumonia requiring antibiotics
B. Pulmonary embolism requiring anticoagulation
C. Myocardial infarction requiring cardiac evaluation
D. Anxiety requiring reassurance and breathing exercises
🟢 B. Pulmonary embolism requiring anticoagulation
🔴 RATIONALE: The patient's risk factors (postoperative, orthopedic surgery) and symptoms (sudden shortness of breath, chest pain, tachycardia)
are classic for pulmonary embolism. This is the most serious and likely explanation requiring immediate anticoagulation. Pneumonia typically
presents with fever and productive cough. MI would show different cardiac symptoms. Anxiety is least likely given the acute physical presentation.
Question 4
When generating solutions for a patient with acute kidney injury and fluid overload, which intervention should be included in the plan?
A. Encourage oral fluid intake of 2-3 liters daily
B. Implement strict fluid restriction and monitor daily weights
C. Administer potassium supplements to prevent hypokalemia
D. Increase dietary sodium to improve fluid balance
🟢 B. Implement strict fluid restriction and monitor daily weights
🔴 RATIONALE: Patients with acute kidney injury and fluid overload require fluid restriction to prevent worsening overload. Daily weights monitor
fluid status accurately. Encouraging fluids (A) would worsen overload. AKI often causes hyperkalemia, not hypokalemia, so potassium supplements
(C) are contraindicated. Increased sodium (D) worsens fluid retention.
Question 5
A nurse is administering IV morphine to a patient with pain. Which action demonstrates proper "Take Action" clinical judgment?
A. Document the pain score before administration
B. Check the patient's respiratory rate before and after administration
C. Tell the patient the medication will make them feel better
D. Compare the current pain score to the previous score
, 🟢 B. Check the patient's respiratory rate before and after administration
🔴 RATIONALE: "Take Action" involves implementing the safest intervention. Monitoring respiratory rate is critical before and after opioid
administration due to the risk of respiratory depression. Documentation (A) and comparing scores (D) are part of evaluation. Reassurance (C) is
communication but not the primary safety action.
Question 6
Which ethical principle is most violated when a nurse administers medication without verifying the patient's identity?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Beneficence
🟢 C. Nonmaleficence
🔴 RATIONALE: Nonmaleficence means "do no harm." Administering medication without identity verification risks giving medication to the wrong
patient, potentially causing harm. Autonomy relates to patient decision-making. Justice involves fair distribution of resources. Beneficence means
acting for the patient's benefit, but the primary violation here is the risk of harm.
Question 7
A patient with a chest tube has 300 mL of bright red drainage in the first hour postoperatively. What should the nurse do FIRST?
A. Clamp the chest tube to assess for air leak
B. Document the finding as expected postoperative drainage
C. Notify the physician immediately
D. Increase the suction pressure on the chest tube
🟢 C. Notify the physician immediately
🔴 RATIONALE: Bright red drainage >100 mL/hour in the first hour indicates active hemorrhage and requires immediate physician notification.
Clamping (A) is contraindicated and can cause tension pneumothorax. Documenting as expected (B) is incorrect—this is abnormal. Increasing
suction (D) could worsen bleeding.
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF
Core Domains
Clinical Judgment Measurement Model (CJMM) Application
Cue Recognition and Data Analysis
Hypothesis Prioritization and Diagnostic Reasoning
Solution Generation and Intervention Planning
Action Implementation and Safety Protocols
Outcome Evaluation and Care Adjustment
Patient Safety and Risk Reduction
Pharmacological Therapies and Medication Safety
Ethics, Legal Compliance, and Professional Standards
Critical Thinking and Decision-Making in Clinical Scenarios
Introduction
This assessment is designed to evaluate core clinical judgment knowledge, nursing reasoning, and bedside decision-making across common
clinical scenarios. The exam measures skills in recognizing relevant cues, analyzing patient data, prioritizing hypotheses, generating evidence-
based solutions, implementing appropriate actions, and evaluating outcomes. The multiple-choice and scenario-based structure emphasizes real-
world application, critical thinking, and professional decision-making required for safe, effective nursing practice. Questions cover foundational
theory, applied professional knowledge, regulatory compliance, ethics, and critical clinical situations that test candidates' ability to make sound
judgments under pressure.
Section One: Questions 1–100
Question 1
,A nurse is assessing a patient with diabetes mellitus who reports feeling shaky, sweaty, and confused. The patient's blood glucose reading is 48
mg/dL. What is the nurse's FIRST action?
A. Administer 15 grams of rapid-acting carbohydrate
B. Administer 1 unit of regular insulin subcutaneously
C. Give 4 ounces of orange juice immediately
D. Call the physician to report the blood glucose level
🟢 C. Give 4 ounces of orange juice immediately
🔴 RATIONALE: The patient is experiencing hypoglycemia (blood glucose <70 mg/dL) with symptoms of shakiness, sweating, and confusion. The
first action for a conscious patient with hypoglycemia is to provide rapid-acting carbohydrates immediately. Orange juice contains approximately 15
grams of carbs and is rapidly absorbed. Administering insulin would worsen hypoglycemia, and calling the physician delays immediate treatment
needed.
Question 2
Which of the following best demonstrates the "Recognize Cues" step of the Clinical Judgment Measurement Model?
A. Cluster vital signs showing tachycardia and hypotension
B. Document that the patient's blood pressure is 88/52 mmHg
C. Determine that the patient may be experiencing hemorrhage
D. Administer IV fluids to treat suspected hypovolemia
🟢 B. Document that the patient's blood pressure is 88/52 mmHg
🔴 RATIONALE: "Recognize Cues" involves identifying and collecting relevant information from different sources (vital signs, labs, patient
statements). Simply documenting the blood pressure reading is cue recognition. Clustering data (A) is "Analyze Cues," determining hemorrhage (C)
is "Prioritize Hypotheses," and administering fluids (D) is "Take Action."
Question 3
A postoperative patient develops sudden shortness of breath, chest pain, and tachycardia 24 hours after knee surgery. The nurse suspects pulmonary
embolism. Which hypothesis should be prioritized FIRST?
,A. Pneumonia requiring antibiotics
B. Pulmonary embolism requiring anticoagulation
C. Myocardial infarction requiring cardiac evaluation
D. Anxiety requiring reassurance and breathing exercises
🟢 B. Pulmonary embolism requiring anticoagulation
🔴 RATIONALE: The patient's risk factors (postoperative, orthopedic surgery) and symptoms (sudden shortness of breath, chest pain, tachycardia)
are classic for pulmonary embolism. This is the most serious and likely explanation requiring immediate anticoagulation. Pneumonia typically
presents with fever and productive cough. MI would show different cardiac symptoms. Anxiety is least likely given the acute physical presentation.
Question 4
When generating solutions for a patient with acute kidney injury and fluid overload, which intervention should be included in the plan?
A. Encourage oral fluid intake of 2-3 liters daily
B. Implement strict fluid restriction and monitor daily weights
C. Administer potassium supplements to prevent hypokalemia
D. Increase dietary sodium to improve fluid balance
🟢 B. Implement strict fluid restriction and monitor daily weights
🔴 RATIONALE: Patients with acute kidney injury and fluid overload require fluid restriction to prevent worsening overload. Daily weights monitor
fluid status accurately. Encouraging fluids (A) would worsen overload. AKI often causes hyperkalemia, not hypokalemia, so potassium supplements
(C) are contraindicated. Increased sodium (D) worsens fluid retention.
Question 5
A nurse is administering IV morphine to a patient with pain. Which action demonstrates proper "Take Action" clinical judgment?
A. Document the pain score before administration
B. Check the patient's respiratory rate before and after administration
C. Tell the patient the medication will make them feel better
D. Compare the current pain score to the previous score
, 🟢 B. Check the patient's respiratory rate before and after administration
🔴 RATIONALE: "Take Action" involves implementing the safest intervention. Monitoring respiratory rate is critical before and after opioid
administration due to the risk of respiratory depression. Documentation (A) and comparing scores (D) are part of evaluation. Reassurance (C) is
communication but not the primary safety action.
Question 6
Which ethical principle is most violated when a nurse administers medication without verifying the patient's identity?
A. Autonomy
B. Justice
C. Nonmaleficence
D. Beneficence
🟢 C. Nonmaleficence
🔴 RATIONALE: Nonmaleficence means "do no harm." Administering medication without identity verification risks giving medication to the wrong
patient, potentially causing harm. Autonomy relates to patient decision-making. Justice involves fair distribution of resources. Beneficence means
acting for the patient's benefit, but the primary violation here is the risk of harm.
Question 7
A patient with a chest tube has 300 mL of bright red drainage in the first hour postoperatively. What should the nurse do FIRST?
A. Clamp the chest tube to assess for air leak
B. Document the finding as expected postoperative drainage
C. Notify the physician immediately
D. Increase the suction pressure on the chest tube
🟢 C. Notify the physician immediately
🔴 RATIONALE: Bright red drainage >100 mL/hour in the first hour indicates active hemorrhage and requires immediate physician notification.
Clamping (A) is contraindicated and can cause tension pneumothorax. Documenting as expected (B) is incorrect—this is abnormal. Increasing
suction (D) could worsen bleeding.
