CJE BENCHMARK EXAM #3 QUESTIONS &
ANSWERS | 300 VERIFIED QUESTIONS WITH
COMPLETE SOLUTIONS | NCLEX-STYLE
NURSING PRACTICE | UPDATED 2026/2027
1. The nurse is caring for a client with an indwelling urinary catheter. Which
action is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A) Irrigate the catheter with normal saline daily
B) Maintain a closed drainage system
C) Change the catheter every 48 hours
D) Position the drainage bag above the bladder
Answer B: Maintain a closed drainage system
Rationale: Maintaining a closed system is the most important intervention to
prevent CAUTI by preventing bacterial entry.
2. The nurse is preparing to insert a nasogastric tube. Which measurement is
used to determine the correct insertion length?
A) Tip of nose to earlobe to xiphoid process
B) Tip of nose to earlobe to xiphoid process (NEX)
C) Corner of mouth to earlobe to xiphoid process
D) Midline of nose to earlobe to umbilicus
,Answer B: Tip of nose to earlobe to xiphoid process
Rationale: NEX measurement is the standard method for estimating NG tube
insertion length.
3. The nurse is assessing a client's skin integrity. Which finding requires
immediate intervention?
A) Stage 1 pressure injury on the heel
B) Stage 3 pressure injury on the sacrum with visible bone
C) Stage 2 pressure injury on the coccyx
D) Moisture-associated skin damage in the perineal area
Answer B: Stage 3 pressure injury on the sacrum with visible bone
Rationale: Visible bone indicates a stage 4 pressure injury, which is the most
severe and requires immediate intervention.
4. The nurse is calculating a client's intake and output. Which item should be
included in the intake calculation?
A) Moisture from the client's skin
B) Intravenous fluids administered
C) Insensible water loss
D) Sweat output
Answer B: Intravenous fluids administered
Rationale: Intake includes all fluids taken by mouth, IV fluids, and tube feedings.
Insensible losses are not measured.
,5. The nurse is preparing to administer a patient-controlled analgesia (PCA)
pump. Which statement by the client indicates understanding of the PCA
pump?
A) "My family can press the button when I am asleep."
B) "I will press the button when I feel pain."
C) "The pump will give me a continuous dose regardless of pain."
D) "I cannot use the PCA if I have a history of addiction."
Answer B: "I will press the button when I feel pain."
Rationale: Only the patient should activate PCA. Family activation is unsafe and
may be considered battery.
6. The nurse is assessing a client's level of consciousness using the Glasgow
Coma Scale. The client opens eyes to pain, makes incomprehensible sounds,
and localizes pain. What is the total score?
A) 8
B) 9
C) 10
D) 11
Answer B: 9
Rationale: GCS scores: eye to pain = 2, sounds incomprehensible = 2, localizes
pain = 5 → total 9.
, 7. The nurse is caring for a client with a nasogastric tube to low intermittent
suction. Which finding indicates the tube is functioning properly?
A) The client reports nausea
B) Drainage is present in the collection chamber
C) Abdominal distention increases
D) The tube is not secured to the client's gown
Answer B: Drainage is present in the collection chamber
Rationale: Presence of gastric drainage indicates patency. Nausea and distention
suggest obstruction.
8. The nurse is assessing a client's vital signs. Which technique is correct for
measuring blood pressure?
A) Place the client's arm above the heart level
B) Use a cuff that covers 80% of the arm circumference
C) Deflate the cuff rapidly
D) Use a cuff that covers 40% of the arm circumference
Answer B: Use a cuff that covers 80% of the arm circumference
Rationale: Bladder width should be 40% of arm circumference, length 80%. Arm
at heart level; deflate slowly.
9. The nurse is preparing to administer a subcutaneous injection. Which site
is appropriate for injection?
ANSWERS | 300 VERIFIED QUESTIONS WITH
COMPLETE SOLUTIONS | NCLEX-STYLE
NURSING PRACTICE | UPDATED 2026/2027
1. The nurse is caring for a client with an indwelling urinary catheter. Which
action is most important to prevent catheter-associated urinary tract
infection (CAUTI)?
A) Irrigate the catheter with normal saline daily
B) Maintain a closed drainage system
C) Change the catheter every 48 hours
D) Position the drainage bag above the bladder
Answer B: Maintain a closed drainage system
Rationale: Maintaining a closed system is the most important intervention to
prevent CAUTI by preventing bacterial entry.
2. The nurse is preparing to insert a nasogastric tube. Which measurement is
used to determine the correct insertion length?
A) Tip of nose to earlobe to xiphoid process
B) Tip of nose to earlobe to xiphoid process (NEX)
C) Corner of mouth to earlobe to xiphoid process
D) Midline of nose to earlobe to umbilicus
,Answer B: Tip of nose to earlobe to xiphoid process
Rationale: NEX measurement is the standard method for estimating NG tube
insertion length.
3. The nurse is assessing a client's skin integrity. Which finding requires
immediate intervention?
A) Stage 1 pressure injury on the heel
B) Stage 3 pressure injury on the sacrum with visible bone
C) Stage 2 pressure injury on the coccyx
D) Moisture-associated skin damage in the perineal area
Answer B: Stage 3 pressure injury on the sacrum with visible bone
Rationale: Visible bone indicates a stage 4 pressure injury, which is the most
severe and requires immediate intervention.
4. The nurse is calculating a client's intake and output. Which item should be
included in the intake calculation?
A) Moisture from the client's skin
B) Intravenous fluids administered
C) Insensible water loss
D) Sweat output
Answer B: Intravenous fluids administered
Rationale: Intake includes all fluids taken by mouth, IV fluids, and tube feedings.
Insensible losses are not measured.
,5. The nurse is preparing to administer a patient-controlled analgesia (PCA)
pump. Which statement by the client indicates understanding of the PCA
pump?
A) "My family can press the button when I am asleep."
B) "I will press the button when I feel pain."
C) "The pump will give me a continuous dose regardless of pain."
D) "I cannot use the PCA if I have a history of addiction."
Answer B: "I will press the button when I feel pain."
Rationale: Only the patient should activate PCA. Family activation is unsafe and
may be considered battery.
6. The nurse is assessing a client's level of consciousness using the Glasgow
Coma Scale. The client opens eyes to pain, makes incomprehensible sounds,
and localizes pain. What is the total score?
A) 8
B) 9
C) 10
D) 11
Answer B: 9
Rationale: GCS scores: eye to pain = 2, sounds incomprehensible = 2, localizes
pain = 5 → total 9.
, 7. The nurse is caring for a client with a nasogastric tube to low intermittent
suction. Which finding indicates the tube is functioning properly?
A) The client reports nausea
B) Drainage is present in the collection chamber
C) Abdominal distention increases
D) The tube is not secured to the client's gown
Answer B: Drainage is present in the collection chamber
Rationale: Presence of gastric drainage indicates patency. Nausea and distention
suggest obstruction.
8. The nurse is assessing a client's vital signs. Which technique is correct for
measuring blood pressure?
A) Place the client's arm above the heart level
B) Use a cuff that covers 80% of the arm circumference
C) Deflate the cuff rapidly
D) Use a cuff that covers 40% of the arm circumference
Answer B: Use a cuff that covers 80% of the arm circumference
Rationale: Bladder width should be 40% of arm circumference, length 80%. Arm
at heart level; deflate slowly.
9. The nurse is preparing to administer a subcutaneous injection. Which site
is appropriate for injection?
