CLINICAL JUDGMENT (CJE) BENCHMARK
FINAL EXAM #3 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES 100%
GUARANTEED PASS!!
<LATEST VERSION>
Question 1
An older adult patient on bed rest reports dizziness when standing for the first time
after surgery. What is the nurse’s priority intervention?
A. Encourage the patient to stand immediately
B. Assess vital signs for orthostatic hypotension
C. Apply restraints
D. Have the patient sit on the floor
Correct Answer: B
Rationale:
Orthostatic hypotension is common after immobility. Vital signs should be
assessed before ambulation to prevent falls and syncope.
,Question 2
Which nursing intervention best reduces venous stasis in a patient on prolonged
bed rest?
A. Encourage fluid restriction
B. Perform passive and active leg exercises
C. Keep the patient supine at all times
D. Elevate the head of the bed to 90°
Correct Answer: B
Rationale:
Movement promotes venous return and prevents DVT formation.
Question 3
A patient with osteoporosis is admitted with a hip fracture. Which intervention is
most important to prevent further injury?
A. Encourage weight-bearing without support
B. Use fall-prevention strategies and assistive devices
C. Limit analgesic medications
D. Restrict mobility entirely
Correct Answer: B
Rationale:
Fall prevention is crucial for patients with fragile bones to avoid additional
fractures.
Question 4
Which bed rest effect requires immediate nursing attention?
A. Mild constipation
B. Shortness of breath and decreased lung sounds
C. Mild fatigue
D. Slight appetite reduction
,Correct Answer: B
Rationale:
Immobilization can cause atelectasis and hypostatic pneumonia, which are life-
threatening if unaddressed.
Question 5
A patient develops a stage 2 pressure injury on the sacrum. Which intervention is
most important?
A. Keep the patient in a supine position
B. Reposition frequently and implement pressure-relieving devices
C. Encourage large meals
D. Limit oral fluids
Correct Answer: B
Rationale:
Pressure relief through repositioning and specialized devices prevents progression.
Question 6
Which assessment finding indicates deep vein thrombosis in a postoperative
patient?
A. Bilateral lower leg warmth and redness
B. Unilateral calf swelling, tenderness, and erythema
C. Cool, pale toes
D. Intermittent ankle pain on movement
Correct Answer: B
Rationale:
Classic DVT signs are unilateral, with swelling, warmth, and tenderness.
, Question 7
A patient with Parkinson’s disease chokes on thin liquids. Which intervention is
best?
A. Encourage rapid swallowing
B. Provide thickened liquids and monitor for aspiration
C. Offer supine feeding
D. Provide large mouthfuls
Correct Answer: B
Rationale:
Thickened liquids and observation reduce aspiration risk.
Question 8
Which action best addresses psychosocial needs of an older adult in isolation due
to TB?
A. Limit visits to reduce infection risk
B. Provide frequent therapeutic communication and social interaction within safety
guidelines
C. Avoid discussing feelings
D. Restrict patient activities to bed
Correct Answer: B
Rationale:
Isolation can cause anxiety, depression, and delirium; therapeutic communication
supports mental health.
Question 9
Which finding indicates a patient may have developed orthostatic hypotension?
A. Heart rate decreases by 10 bpm upon standing
B. Systolic BP drops 25 mmHg and patient feels dizzy
FINAL EXAM #3 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES 100%
GUARANTEED PASS!!
<LATEST VERSION>
Question 1
An older adult patient on bed rest reports dizziness when standing for the first time
after surgery. What is the nurse’s priority intervention?
A. Encourage the patient to stand immediately
B. Assess vital signs for orthostatic hypotension
C. Apply restraints
D. Have the patient sit on the floor
Correct Answer: B
Rationale:
Orthostatic hypotension is common after immobility. Vital signs should be
assessed before ambulation to prevent falls and syncope.
,Question 2
Which nursing intervention best reduces venous stasis in a patient on prolonged
bed rest?
A. Encourage fluid restriction
B. Perform passive and active leg exercises
C. Keep the patient supine at all times
D. Elevate the head of the bed to 90°
Correct Answer: B
Rationale:
Movement promotes venous return and prevents DVT formation.
Question 3
A patient with osteoporosis is admitted with a hip fracture. Which intervention is
most important to prevent further injury?
A. Encourage weight-bearing without support
B. Use fall-prevention strategies and assistive devices
C. Limit analgesic medications
D. Restrict mobility entirely
Correct Answer: B
Rationale:
Fall prevention is crucial for patients with fragile bones to avoid additional
fractures.
Question 4
Which bed rest effect requires immediate nursing attention?
A. Mild constipation
B. Shortness of breath and decreased lung sounds
C. Mild fatigue
D. Slight appetite reduction
,Correct Answer: B
Rationale:
Immobilization can cause atelectasis and hypostatic pneumonia, which are life-
threatening if unaddressed.
Question 5
A patient develops a stage 2 pressure injury on the sacrum. Which intervention is
most important?
A. Keep the patient in a supine position
B. Reposition frequently and implement pressure-relieving devices
C. Encourage large meals
D. Limit oral fluids
Correct Answer: B
Rationale:
Pressure relief through repositioning and specialized devices prevents progression.
Question 6
Which assessment finding indicates deep vein thrombosis in a postoperative
patient?
A. Bilateral lower leg warmth and redness
B. Unilateral calf swelling, tenderness, and erythema
C. Cool, pale toes
D. Intermittent ankle pain on movement
Correct Answer: B
Rationale:
Classic DVT signs are unilateral, with swelling, warmth, and tenderness.
, Question 7
A patient with Parkinson’s disease chokes on thin liquids. Which intervention is
best?
A. Encourage rapid swallowing
B. Provide thickened liquids and monitor for aspiration
C. Offer supine feeding
D. Provide large mouthfuls
Correct Answer: B
Rationale:
Thickened liquids and observation reduce aspiration risk.
Question 8
Which action best addresses psychosocial needs of an older adult in isolation due
to TB?
A. Limit visits to reduce infection risk
B. Provide frequent therapeutic communication and social interaction within safety
guidelines
C. Avoid discussing feelings
D. Restrict patient activities to bed
Correct Answer: B
Rationale:
Isolation can cause anxiety, depression, and delirium; therapeutic communication
supports mental health.
Question 9
Which finding indicates a patient may have developed orthostatic hypotension?
A. Heart rate decreases by 10 bpm upon standing
B. Systolic BP drops 25 mmHg and patient feels dizzy
