# CJE Readiness II Exam Study Questions and Answers
**1. A client who has had abdominal surgery complains of feeling as though "something gave way" in
the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel
protruding through the incision. Which nursing interventions should the nurse take? (Select all that
apply)**
A) Contact the surgeon
B) Instruct the client to remain quiet
C) Prepare the client for wound closure
D) Document the findings and actions taken
**Answer: A, B, C, D**
**Rationale:** This is a surgical wound evisceration, an emergency. The nurse should cover the
protruding bowel with sterile saline-moistened gauze, keep the patient quiet, prepare for surgery,
notify the surgeon, and document findings. All of the listed actions are appropriate .
**2. After surgery, your patient is semicomatose with vital signs within normal limits. What position
would be best for this patient?**
A) Supine position
B) Side-lying position (preferably the left side)
C) High Fowler's position
D) Trendelenburg position
**Answer: B**
**Rationale:** The side-lying (lateral) position is best for a semicomatose patient to maintain a
patent airway and prevent aspiration. The left side is often preferred to facilitate gastric emptying .
**3. After surgery, your patient starts to shivering uncontrollably. What nursing intervention should
you do FIRST?**
A) Increase the room temperature
B) Apply warm blankets and continue oxygen as prescribed
C) Administer a PRN sedative
D) Notify the healthcare provider
,**Answer: B**
**Rationale:** Postoperative shivering increases oxygen demand and can lead to hypothermia. The
priority is to warm the patient with blankets while maintaining oxygen administration .
**4. The nurse would be alerted to the occurrence of malignant hyperthermia when the patient
demonstrates which manifestation?**
A) Hypotension
B) Muscle rigidity
C) Bradycardia
D) Hypothermia
**Answer: B**
**Rationale:** Malignant hyperthermia is a life-threatening emergency triggered by anesthetic
agents. It presents with muscle rigidity, hyperthermia, tachycardia, and acidosis. Muscle rigidity is a
key early sign .
**5. The client returns to the nursing unit following an open reduction with internal fixation of the
right hip. Nursing assessment findings include temperature 100.8°F, heart rate 112, respiratory rate
28, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse
interprets these findings as indicating which complication?**
A) Malignant hyperthermia
B) Pulmonary embolism
C) Infection
D) Hypovolemic shock
**Answer: D**
**Rationale:** Tachycardia, hypotension, tachypnea, and oliguria (no urine output) are classic signs
of hypovolemic shock. Postoperative bleeding or third-spacing of fluids can cause this. A low-grade
fever may also be present .
**6. The nurse is monitoring a patient who is 24 hours post-op from surgery. Which finding requires
immediate intervention?**
A) 24-hour urine output of 800 mL
B) 24-hour urine output of 300 mL
, C) Temperature of 99.0°F
D) Pain level of 4 on a 0-10 scale
**Answer: B**
**Rationale:** Minimum urine output should be at least 30 mL/hour or 720 mL in 24 hours. An
output of 300 mL in 24 hours indicates acute kidney injury or hypovolemia and requires immediate
intervention .
**7. What is a potential postoperative concern regarding a patient who has already resumed a solid
diet?**
A) Constipation
B) Failure to pass stool within 48 hours of eating solid foods
C) Nausea and vomiting
D) Diarrhea
**Answer: B**
**Rationale:** After resuming a solid diet, the patient should have a bowel movement within 48
hours. Failure to do so may indicate an ileus or obstruction .
**8. A nurse is developing a care plan for a patient at risk for developing pneumonia after surgery.
Which of the following is NOT an appropriate nursing intervention?**
A) Repositioning every 2 hours
B) Repositioning every 3-4 hours
C) Encouraging deep breathing and coughing
D) Using an incentive spirometer
**Answer: B**
**Rationale:** To prevent postoperative pneumonia, patients should be repositioned every 2 hours,
not every 3-4 hours. More frequent repositioning helps prevent atelectasis and promote lung
expansion. Deep breathing, coughing, and incentive spirometry are also appropriate interventions .
**9. Which client is at most risk for the development of an anorectal abscess?**
A) Client with diabetes
B) Client with Crohn's disease
C) Client with hypertension
**1. A client who has had abdominal surgery complains of feeling as though "something gave way" in
the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel
protruding through the incision. Which nursing interventions should the nurse take? (Select all that
apply)**
A) Contact the surgeon
B) Instruct the client to remain quiet
C) Prepare the client for wound closure
D) Document the findings and actions taken
**Answer: A, B, C, D**
**Rationale:** This is a surgical wound evisceration, an emergency. The nurse should cover the
protruding bowel with sterile saline-moistened gauze, keep the patient quiet, prepare for surgery,
notify the surgeon, and document findings. All of the listed actions are appropriate .
**2. After surgery, your patient is semicomatose with vital signs within normal limits. What position
would be best for this patient?**
A) Supine position
B) Side-lying position (preferably the left side)
C) High Fowler's position
D) Trendelenburg position
**Answer: B**
**Rationale:** The side-lying (lateral) position is best for a semicomatose patient to maintain a
patent airway and prevent aspiration. The left side is often preferred to facilitate gastric emptying .
**3. After surgery, your patient starts to shivering uncontrollably. What nursing intervention should
you do FIRST?**
A) Increase the room temperature
B) Apply warm blankets and continue oxygen as prescribed
C) Administer a PRN sedative
D) Notify the healthcare provider
,**Answer: B**
**Rationale:** Postoperative shivering increases oxygen demand and can lead to hypothermia. The
priority is to warm the patient with blankets while maintaining oxygen administration .
**4. The nurse would be alerted to the occurrence of malignant hyperthermia when the patient
demonstrates which manifestation?**
A) Hypotension
B) Muscle rigidity
C) Bradycardia
D) Hypothermia
**Answer: B**
**Rationale:** Malignant hyperthermia is a life-threatening emergency triggered by anesthetic
agents. It presents with muscle rigidity, hyperthermia, tachycardia, and acidosis. Muscle rigidity is a
key early sign .
**5. The client returns to the nursing unit following an open reduction with internal fixation of the
right hip. Nursing assessment findings include temperature 100.8°F, heart rate 112, respiratory rate
28, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse
interprets these findings as indicating which complication?**
A) Malignant hyperthermia
B) Pulmonary embolism
C) Infection
D) Hypovolemic shock
**Answer: D**
**Rationale:** Tachycardia, hypotension, tachypnea, and oliguria (no urine output) are classic signs
of hypovolemic shock. Postoperative bleeding or third-spacing of fluids can cause this. A low-grade
fever may also be present .
**6. The nurse is monitoring a patient who is 24 hours post-op from surgery. Which finding requires
immediate intervention?**
A) 24-hour urine output of 800 mL
B) 24-hour urine output of 300 mL
, C) Temperature of 99.0°F
D) Pain level of 4 on a 0-10 scale
**Answer: B**
**Rationale:** Minimum urine output should be at least 30 mL/hour or 720 mL in 24 hours. An
output of 300 mL in 24 hours indicates acute kidney injury or hypovolemia and requires immediate
intervention .
**7. What is a potential postoperative concern regarding a patient who has already resumed a solid
diet?**
A) Constipation
B) Failure to pass stool within 48 hours of eating solid foods
C) Nausea and vomiting
D) Diarrhea
**Answer: B**
**Rationale:** After resuming a solid diet, the patient should have a bowel movement within 48
hours. Failure to do so may indicate an ileus or obstruction .
**8. A nurse is developing a care plan for a patient at risk for developing pneumonia after surgery.
Which of the following is NOT an appropriate nursing intervention?**
A) Repositioning every 2 hours
B) Repositioning every 3-4 hours
C) Encouraging deep breathing and coughing
D) Using an incentive spirometer
**Answer: B**
**Rationale:** To prevent postoperative pneumonia, patients should be repositioned every 2 hours,
not every 3-4 hours. More frequent repositioning helps prevent atelectasis and promote lung
expansion. Deep breathing, coughing, and incentive spirometry are also appropriate interventions .
**9. Which client is at most risk for the development of an anorectal abscess?**
A) Client with diabetes
B) Client with Crohn's disease
C) Client with hypertension
