CJE Readiness II — Practice Exam
120 Questions | Nursing Certification Readiness Review
1. A nurse is caring for a client who has a new prescription for a Foley catheter.
Which action is most important for the nurse to take to prevent
catheter-associated urinary tract infection (CAUTI)?
A. Irrigate the catheter every shift with normal saline.
B. Keep the drainage bag below the level of the bladder at all times.
C. Clamp the tubing for two hours every four hours to train the bladder.
D. Change the catheter every 48 hours regardless of function.
Correct Answer: B. Keep the drainage bag below the level of the bladder at all
times.
Rationale: Keeping the drainage bag below the bladder prevents backflow of urine,
which is a major source of ascending infection. Routine irrigation, clamping, and
scheduled catheter changes are not recommended practices and can increase
infection risk or cause unnecessary trauma.
2. A client on bedrest for 5 days reports calf pain and swelling in the left leg.
What is the nurse's priority action?
A. Apply a warm compress to the calf and reassess in 30 minutes.
B. Ambulate the client to assess for worsening pain.
C. Notify the provider and avoid massaging or manipulating the leg.
D. Elevate the leg and apply firm compression wraps.
Correct Answer: C. Notify the provider and avoid massaging or manipulating the
leg.
Rationale: Unilateral calf pain and swelling after prolonged immobility suggests deep
vein thrombosis. The leg should not be massaged or manipulated because this could
dislodge a clot and cause a pulmonary embolism. The provider should be notified
promptly for further evaluation (e.g., Doppler ultrasound).
,3. Which laboratory value should the nurse monitor most closely in a client
receiving furosemide (Lasix)?
A. Serum calcium
B. Serum potassium
C. Serum glucose
D. Serum albumin
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes significant potassium wasting,
increasing the risk for hypokalemia, which can lead to dangerous cardiac
dysrhythmias. Potassium levels should be monitored closely during therapy.
4. A nurse is teaching a client about a low-sodium diet. Which statement by the
client indicates a need for further teaching?
A. "I will read food labels to check the sodium content."
B. "I can use garlic powder and lemon juice to season my food."
C. "I will use a salt substitute freely since it is not regular salt."
D. "I should avoid canned soups and processed lunch meats."
Correct Answer: C. "I will use a salt substitute freely since it is not regular salt."
Rationale: Salt substitutes are typically potassium-based and should be used
cautiously, especially in clients with renal impairment or those on potassium-sparing
medications, as excessive use can cause hyperkalemia. The other statements reflect
correct understanding of a low-sodium diet.
5. A nurse is assessing a client 2 hours after abdominal surgery. Which finding
requires immediate intervention?
A. Blood pressure of 118/76 mmHg
B. Small amount of serosanguineous drainage on the dressing
C. Increasing abdominal distention with rigid, board-like abdomen
D. Client reports incisional pain rated 4/10
Correct Answer: C. Increasing abdominal distention with rigid, board-like
abdomen
Rationale: A rigid, board-like abdomen with increasing distention may indicate internal
hemorrhage or peritonitis, both surgical emergencies requiring immediate provider
notification. The other findings are expected postoperative findings.
,6. The nurse is caring for a client with a chest tube. The water seal chamber
shows continuous bubbling. What does this finding indicate?
A. The chest tube system is functioning correctly.
B. There is an air leak in the system.
C. The lung has fully re-expanded.
D. Suction needs to be increased.
Correct Answer: B. There is an air leak in the system.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak
somewhere in the system (connections, insertion site, or chest tube itself), and the
source should be identified and corrected. Intermittent bubbling that fluctuates with
respiration (tidaling) is normal.
7. A nurse is preparing to administer digoxin to a client. Which assessment
finding would cause the nurse to withhold the medication and notify the
provider?
A. Apical heart rate of 58 beats/min
B. Blood pressure of 128/80 mmHg
C. Serum potassium of 4.0 mEq/L
D. Respiratory rate of 18 breaths/min
Correct Answer: A. Apical heart rate of 58 beats/min
Rationale: Digoxin should be withheld if the apical pulse is below 60 beats/min in
adults, as it can cause or worsen bradycardia and increase the risk for toxicity. The
other values are within normal limits.
, 8. A client with a history of asthma is prescribed albuterol via metered-dose
inhaler. Which client teaching is appropriate?
A. "Take this medication only during an acute asthma attack, not daily."
B. "Rinse your mouth after each use to prevent fungal infection."
C. "Shake the inhaler and wait 5 minutes between each puff."
D. "Expect drowsiness as a common side effect."
Correct Answer: A. "Take this medication only during an acute asthma attack,
not daily."
Rationale: Albuterol is a short-acting beta-agonist (rescue inhaler) used for acute
bronchospasm relief, not for daily maintenance therapy. Mouth rinsing after use is
specifically important for inhaled corticosteroids, not albuterol, to prevent oral thrush.
A common side effect of albuterol is tachycardia/tremors, not drowsiness.
9. A nurse is caring for a client immediately following a thyroidectomy. Which
assessment finding is most concerning?
A. Mild hoarseness of voice
B. Tingling around the mouth and fingers
C. Incisional pain rated 3/10
D. Slight swelling at the incision site
Correct Answer: B. Tingling around the mouth and fingers
Rationale: Tingling around the mouth and fingers may indicate hypocalcemia from
accidental parathyroid gland removal or damage during thyroidectomy, which can
progress to tetany and laryngospasm. This requires immediate assessment and
intervention (calcium level, calcium gluconate available).
120 Questions | Nursing Certification Readiness Review
1. A nurse is caring for a client who has a new prescription for a Foley catheter.
Which action is most important for the nurse to take to prevent
catheter-associated urinary tract infection (CAUTI)?
A. Irrigate the catheter every shift with normal saline.
B. Keep the drainage bag below the level of the bladder at all times.
C. Clamp the tubing for two hours every four hours to train the bladder.
D. Change the catheter every 48 hours regardless of function.
Correct Answer: B. Keep the drainage bag below the level of the bladder at all
times.
Rationale: Keeping the drainage bag below the bladder prevents backflow of urine,
which is a major source of ascending infection. Routine irrigation, clamping, and
scheduled catheter changes are not recommended practices and can increase
infection risk or cause unnecessary trauma.
2. A client on bedrest for 5 days reports calf pain and swelling in the left leg.
What is the nurse's priority action?
A. Apply a warm compress to the calf and reassess in 30 minutes.
B. Ambulate the client to assess for worsening pain.
C. Notify the provider and avoid massaging or manipulating the leg.
D. Elevate the leg and apply firm compression wraps.
Correct Answer: C. Notify the provider and avoid massaging or manipulating the
leg.
Rationale: Unilateral calf pain and swelling after prolonged immobility suggests deep
vein thrombosis. The leg should not be massaged or manipulated because this could
dislodge a clot and cause a pulmonary embolism. The provider should be notified
promptly for further evaluation (e.g., Doppler ultrasound).
,3. Which laboratory value should the nurse monitor most closely in a client
receiving furosemide (Lasix)?
A. Serum calcium
B. Serum potassium
C. Serum glucose
D. Serum albumin
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes significant potassium wasting,
increasing the risk for hypokalemia, which can lead to dangerous cardiac
dysrhythmias. Potassium levels should be monitored closely during therapy.
4. A nurse is teaching a client about a low-sodium diet. Which statement by the
client indicates a need for further teaching?
A. "I will read food labels to check the sodium content."
B. "I can use garlic powder and lemon juice to season my food."
C. "I will use a salt substitute freely since it is not regular salt."
D. "I should avoid canned soups and processed lunch meats."
Correct Answer: C. "I will use a salt substitute freely since it is not regular salt."
Rationale: Salt substitutes are typically potassium-based and should be used
cautiously, especially in clients with renal impairment or those on potassium-sparing
medications, as excessive use can cause hyperkalemia. The other statements reflect
correct understanding of a low-sodium diet.
5. A nurse is assessing a client 2 hours after abdominal surgery. Which finding
requires immediate intervention?
A. Blood pressure of 118/76 mmHg
B. Small amount of serosanguineous drainage on the dressing
C. Increasing abdominal distention with rigid, board-like abdomen
D. Client reports incisional pain rated 4/10
Correct Answer: C. Increasing abdominal distention with rigid, board-like
abdomen
Rationale: A rigid, board-like abdomen with increasing distention may indicate internal
hemorrhage or peritonitis, both surgical emergencies requiring immediate provider
notification. The other findings are expected postoperative findings.
,6. The nurse is caring for a client with a chest tube. The water seal chamber
shows continuous bubbling. What does this finding indicate?
A. The chest tube system is functioning correctly.
B. There is an air leak in the system.
C. The lung has fully re-expanded.
D. Suction needs to be increased.
Correct Answer: B. There is an air leak in the system.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak
somewhere in the system (connections, insertion site, or chest tube itself), and the
source should be identified and corrected. Intermittent bubbling that fluctuates with
respiration (tidaling) is normal.
7. A nurse is preparing to administer digoxin to a client. Which assessment
finding would cause the nurse to withhold the medication and notify the
provider?
A. Apical heart rate of 58 beats/min
B. Blood pressure of 128/80 mmHg
C. Serum potassium of 4.0 mEq/L
D. Respiratory rate of 18 breaths/min
Correct Answer: A. Apical heart rate of 58 beats/min
Rationale: Digoxin should be withheld if the apical pulse is below 60 beats/min in
adults, as it can cause or worsen bradycardia and increase the risk for toxicity. The
other values are within normal limits.
, 8. A client with a history of asthma is prescribed albuterol via metered-dose
inhaler. Which client teaching is appropriate?
A. "Take this medication only during an acute asthma attack, not daily."
B. "Rinse your mouth after each use to prevent fungal infection."
C. "Shake the inhaler and wait 5 minutes between each puff."
D. "Expect drowsiness as a common side effect."
Correct Answer: A. "Take this medication only during an acute asthma attack,
not daily."
Rationale: Albuterol is a short-acting beta-agonist (rescue inhaler) used for acute
bronchospasm relief, not for daily maintenance therapy. Mouth rinsing after use is
specifically important for inhaled corticosteroids, not albuterol, to prevent oral thrush.
A common side effect of albuterol is tachycardia/tremors, not drowsiness.
9. A nurse is caring for a client immediately following a thyroidectomy. Which
assessment finding is most concerning?
A. Mild hoarseness of voice
B. Tingling around the mouth and fingers
C. Incisional pain rated 3/10
D. Slight swelling at the incision site
Correct Answer: B. Tingling around the mouth and fingers
Rationale: Tingling around the mouth and fingers may indicate hypocalcemia from
accidental parathyroid gland removal or damage during thyroidectomy, which can
progress to tetany and laryngospasm. This requires immediate assessment and
intervention (calcium level, calcium gluconate available).
