Question 1

Scenario: A patient with right-sided weakness after a stroke is unable to feed himself. Q. What is the nurse’s priority?

Accepted Answer

Answer reason: Maintaining adequate nutrition and hydration is an immediate nursing responsibility, and the patient can often safely eat with assistance and adaptive strategies when one side is weak. Encouraging use of the unaffected side supports independence and functional recovery while meeting a basic physiologic need. An NG tube or NPO status would be inappropriate without evidence of impaired swallowing/aspiration risk. Occupational therapy referral is helpful but is not the most immediate priority compared with ensuring the patient can eat now with safe assistance.
Category reason: This question focuses on a direct nursing intervention to meet a basic physiologic need (feeding assistance) in a post-stroke patient, which aligns with Nutrition and Oral Hydration under Basic Care and Comfort.

Question 2

A breastfeeding mother develops a red, painful, swollen area on her breast with flu-like symptoms. What should the nurse advise?

Accepted Answer

Answer reason: This presentation is consistent with lactational mastitis, where effective and frequent milk removal is a key part of treatment to relieve ductal obstruction and reduce bacterial load. Continuing breastfeeding (or pumping if too painful) helps prevent milk stasis and can speed symptom improvement, while breastfeeding is generally safe for the infant. Stopping breastfeeding or waiting can worsen engorgement and increase risk of abscess. Supportive measures like analgesics/warm compresses and medical evaluation for antibiotics if systemic symptoms persist are also indicated.
Category reason: This question tests nursing advice/interventions for a breastfeeding complication (mastitis) and focuses on patient-care management to promote effective feeding and symptom relief, which fits NCLEX patient care under nutrition-related comfort care.

Question 3

A client on a sodium-restricted diet asks, “Can I use salt substitutes?” What is the best response?

Accepted Answer

Answer reason: C. "They may be high in potassium; consult your provider." Many salt substitutes replace sodium chloride with potassium chloride, which can raise serum potassium. This is especially risky for clients with kidney disease or those taking ACE inhibitors, ARBs, or potassium-sparing diuretics, where hyperkalemia can cause dangerous dysrhythmias. The safest nursing response is to caution the client and advise coordination with the healthcare provider before using these products. Other options give unsafe blanket reassurance or promote “sea/Himalayan” salts, which still contain significant sodium.
Category reason: This question tests patient dietary teaching and safe nutrition choices in the context of a sodium-restricted diet, which aligns with nursing care guidance under Nutrition and Oral Hydration.

Question 4

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will?

Accepted Answer

Answer reason: Infants with a ventricular septal defect often develop increased pulmonary blood flow and, when significant, congestive heart failure, which raises metabolic demand and work of breathing. Feeding becomes an energy-expensive activity, so intake may be inadequate despite higher energy expenditure, leading to poor weight gain unless caloric density is increased. Providing higher-calorie feeds supports growth while limiting fatigue from prolonged feeding sessions. A common distractor is normal growth, which is less likely when the shunt is moderate-to-large and causes heart failure symptoms.

Question 5

Your patient ate an 8 ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

Accepted Answer

Answer reason: All oral liquids and foods that are liquid at room temperature (including ice-based items like Italian ice) are counted as fluid intake for I&O. The volume is converted from ounces to milliliters using 1 oz ≈ 30 mL. Therefore 8 oz × 30 mL/oz ≈ 240 mL (cc). Documenting 120 cc would reflect only 4 oz, and recording 0 would incorrectly exclude a measurable fluid source.

Question 6

You are getting the patient ready to eat. The patient is on complete bed rest. You will put the head of the bed up at ____ degrees or more.?

Accepted Answer

Answer reason: Safe oral intake requires positioning that promotes swallowing and reduces aspiration risk. Elevating the head of bed at least 30 degrees improves airway protection and helps keep gastric contents from refluxing into the pharynx, especially in a patient who cannot sit independently due to bed rest. Lower angles such as 10–20 degrees keep the patient too supine, increasing the chance of choking or aspiration during meals. This is a basic nursing intervention to support nutrition while preventing respiratory complications.

Question 7

A nurse is caring for an infant who has heart failure and is formula-fed. Which of the following nursing interventions is appropriate to meet the infant's nutritional needs?

Accepted Answer

Answer reason: Infants with heart failure fatigue easily and may not tolerate large-volume feeds, so supporting adequate intake often means offering smaller, more frequent feedings based on early hunger cues. Responding promptly helps the infant feed before becoming exhausted, improving caloric intake without increasing work of breathing. Diluting formula decreases caloric density and can worsen growth failure and potentially contribute to electrolyte imbalance. Thickening feeds or changing nipple firmness primarily targets swallowing/aspiration mechanics and may increase effort or alter intake, but it does not directly address the typical fatigue-and-low-intake problem seen in heart failure.

Question 8

When teaching a client with coronary artery disease about nutrition, the nurse should emphasize?

Accepted Answer

Answer reason: Teaching the client to avoid very heavy meals helps reduce episodes of angina and cardiac stress, especially in coronary artery disease where perfusion is limited. The other options are either too nonspecific for CAD symptom prevention or contain incorrect guidance (e.g., 7 g/day sodium is not a cardiac-protective restriction and is generally higher than recommended). This advice also aligns with practical lifestyle modification strategies that reduce symptom triggers in daily life.

Question 9

Which of the following food enhances the absorption of an iron supplement?

Accepted Answer

Answer reason: Taking an oral iron supplement with a vitamin C–rich drink improves bioavailability and helps raise iron stores more effectively. In contrast, calcium-containing foods and drinks can inhibit iron absorption by competing for absorption and forming insoluble complexes. This makes a citrus juice a practical, evidence-based pairing when teaching patients how to take iron.

Question 10

A nurse provides dietary instructions to a client with iron deficiency anemia. The nurse should tell the client to increase the intake of which food item?

Accepted Answer

Answer reason: Legumes such as beans provide a meaningful amount of iron and are commonly recommended for clients who need to boost iron consumption. Egg whites are primarily protein and contain little iron compared with iron-rich foods. Fruits like plums and red apples are not significant iron sources and would not address the underlying dietary deficiency as effectively.

Question 11

A nurse is providing discharge instructions to a client diagnosed with dumping syndrome. Which of the following client statements indicates the teaching has been effective?

Accepted Answer

Answer reason: g., weakness, dizziness) and/or reactive hypoglycemia after meals. Resting in a recumbent position after eating can slow gastric emptying and reduce postprandial symptoms by decreasing gravitational transit into the small intestine. In contrast, increasing fluids with meals can worsen rapid transit, and patients are typically taught to separate fluids from meals. Patients are also taught to eat small, frequent meals and limit simple carbohydrates rather than increasing carbohydrate intake.

Question 12

A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Accepted Answer

Answer reason: Postoperative clients with large wounds need adequate vitamin C to support tissue repair and reduce risk of delayed healing. Citrus fruits are among the richest common dietary sources of vitamin C, making this choice the most direct way to increase intake. Milk and chicken are better sources of protein than vitamin C, and bananas provide some micronutrients but are not a high vitamin C food compared with citrus.

Question 13

As a part of a 9 pound full-term newborn's assessment, the nurse performs a distressful "tug test" butt lift. The ensuing acute reading is 65 mg/dl. What action by the nurse is appropriate at this time?

Accepted Answer

Answer reason: Neonatal glucose of 65 mg/dL in a term newborn is generally within acceptable range and does not indicate symptomatic hypoglycemia requiring emergent IV therapy. The most appropriate nursing action is to support physiologic glucose maintenance by ensuring adequate caloric intake with regular feeds. Oral glucose water is not preferred because it provides transient carbohydrate without adequate nutrition and may interfere with successful feeding. Notifying the provider or starting IV dextrose would be more appropriate for persistently low values (commonly

Question 14

A client with AIDS is admitted for treatment of wasting syndrome. Which of the following dietary absorptive capability of the intestinal tract?

Accepted Answer

Answer reason: Smaller, more frequent feedings reduce gastric distention and nausea and are less likely to trigger diarrhea, helping the gut handle nutrients more effectively across the day. This approach also supports meeting higher calorie and protein needs without overwhelming compromised intestinal function. A common distractor is focusing on special foods like yogurt; while probiotics may help some diarrhea patterns, they do not reliably address the broader issue of limited intake and tolerance driving wasting.

Question 15

The nurse is providing diet teaching to the parents of a child with end-stage renal disease. The nurse will educate the parents on maintaining which of the following diets?

Accepted Answer

Answer reason: Higher carbohydrate intake helps meet energy needs and prevents the body from breaking down its own protein stores, which would increase nitrogenous waste. High sodium is avoided because it promotes hypertension and fluid retention, and high protein generally increases urea burden in advanced renal failure. A common teaching point is that calories are supported with carbohydrates/fats while sodium (and often potassium/phosphorus) are restricted and protein is individualized by stage and dialysis status.

Question 16

When teaching about the dietary control of gout, the nurse is aware that the dietary teaching is understood when the client states; "I will avoid eating:"?

Accepted Answer

Answer reason: Shellfish are classically high in purines and are associated with increased urate levels and higher risk of acute gout attacks. Eggs and most dairy products (including cottage cheese) are low in purines and are generally acceptable or even helpful as protein choices for patients with gout. Fried poultry is not a classic high-purine trigger compared with organ meats and certain seafood, so it is a less direct target for avoidance in gout education.

Question 17

Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do?

Accepted Answer

Answer reason: A prescribed thickened-liquid consistency is a dysphagia safety intervention to slow bolus flow and reduce aspiration risk. Since plain water is thinner than honey-thick and does not meet the ordered consistency, it should be modified to match the prescribed thickness before being given. Refusing fluids outright can contribute to dehydration and does not address the request within the provider’s order. Substituting an unrelated food or declaring NPO adds restrictions not ordered and may delay safe hydration without clinical justification.

Question 18

You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

Accepted Answer

Answer reason: g., 25%, 50%, 100%) to support monitoring of nutrition status, hydration, and response to diet orders. This option provides standardized percentage-based descriptors that are commonly used in nursing charting and are meaningful for trending intake over time. Recording intake in “cc” is generally used for measurable fluids, not solid meal portions, and can be misleading for mixed foods. Clear, consistent percentage estimates improve communication among staff and help identify patients at risk for inadequate intake.

Question 19

A nurse is calculating a client's intake and output. During the last shift, the client has had ¾ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client has urinated 250 cc and has had 2 bowel movements. What is this client's intake and output for this shift?

Accepted Answer

Answer reason: Water intake is 300 cc, and gelatin is counted as fluid (¾ cup = 6 oz ≈ 180 cc), giving a total intake of 480 cc; however, using common nursing I&O approximations where 1 cup = 240 cc and ¾ cup = 180 cc, some test keys treat gelatin as 120 cc, yielding 420 cc total intake (300 + 120). Output includes measurable urine; routine bowel movements are not counted unless liquid/measureable (e.g., diarrhea, ostomy). Therefore, output is 250 cc from urine, and the best matching option is the one pairing that output with the counted fluid intake for the shift.

Question 20

A nurse is educating a client who was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?

Accepted Answer

Answer reason: A whole-grain cereal is a classic fiber-rich choice that supports these goals. In contrast, foods like fish and cottage cheese are low in fiber and do not address the primary dietary need. Adequate fluid intake is also typically encouraged alongside fiber to prevent constipation and bloating.

Question 21

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Accepted Answer

Answer reason: A cold, easy-to-tolerate item supports oral fluid intake even when pain, nausea, or poor appetite are present. Compared with high-protein solid foods, it requires minimal chewing and is less likely to worsen nausea or fatigue during an acute episode. Encouraging frequent small amounts of fluid-like foods aligns with supportive care alongside analgesia and oxygen as ordered.

Question 22

A nurse is caring for a client who has a new prescription for a low-sodium diet. The client’s family has requested to bring in some of the client’s favorite foods. Which of the following food items should the nurse recommend the family members to omit?

Accepted Answer

Answer reason: Pickling commonly uses brine (salt and/or sodium-containing preservatives), making many pickled vegetables a high-sodium choice. The other options are typically low in sodium when prepared without added salt and are not inherently preserved with salt. Choosing low-sodium protein and plain grains supports sodium restriction while still meeting calorie and protein needs.

Question 23

A 3-year old child was brought by his mother to the health center because of fever of 4-day duration. The child had a positive tourniquet test result. In the absence of other signs, which is the most appropriate measure that the PHN may carry out to prevent Dengue shock syndrome?

Accepted Answer

Answer reason: The key preventive measure for progression to dengue shock in a stable child without warning signs is maintaining adequate hydration to support intravascular volume. Oral rehydration solution is appropriate because it provides both water and electrolytes and can be safely administered at home while monitoring intake and urine output. IV fluids are reserved for patients who have warning signs, cannot tolerate oral intake, or show evidence of shock, so starting them “STAT” would be excessive based on the stem. NGT feeding and immediate physician referral are not the most appropriate first measures when the child can be managed with oral hydration and observation at the community level.

Question 24

Which meal best promotes healing for a patient recovering from a burn injury?

Accepted Answer

Answer reason: This meal provides high-quality complete protein from chicken and milk to replace nitrogen losses and promote tissue repair. Strawberries add vitamin C, a key cofactor for collagen formation and capillary integrity, supporting wound healing. The other options are comparatively lower in protein and micronutrients important for repair, and caffeinated beverages can be less ideal when optimizing hydration and nutrient density.

Question 25

A client with diarrhea should avoid which of the following?

Accepted Answer

Answer reason: Citrus juices are acidic and can increase intestinal motility and irritation, and many commercial juices are hyperosmolar, which can draw water into the bowel and aggravate diarrhea. In contrast, bland, low-fiber starches such as macaroni are typically better tolerated and can help firm stools. Protein foods like tuna or eggs are not inherently stool-loosening unless they are high-fat, spoiled, or poorly tolerated by the individual, making them less clearly contraindicated than acidic juice.

Question 26

When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula?

Accepted Answer

Answer reason: Delivering formula continuously at a controlled rate reduces dumping-like intolerance, cramping, diarrhea, and aspiration risk compared with intermittent or bolus delivery. Bolus and widely spaced intermittent schedules (e.g., every 4–6 hours) are more appropriate for gastric tubes where the stomach can accommodate volume and regulate emptying. A continuous pump regimen also allows titration based on tolerance and minimizes rapid osmotic fluid shifts into the intestine.

Question 27

A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?

Accepted Answer

Answer reason: Plain potato chips are typically made from potatoes, oil, and salt and do not inherently contain gluten, making them a safer snack choice in a daycare setting. In contrast, crackers, sandwiches made with regular bread, and most cookies are commonly wheat-based and therefore likely to contain gluten. A key nursing consideration is choosing simple, minimally processed foods to reduce hidden gluten exposure from flours or shared manufacturing lines.

Question 28

An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice?

Accepted Answer

Answer reason: This meal is the lowest-sodium choice among the options because it avoids processed meats and cheeses, which are typically very high in salt. It still provides protein from poultry without the heavy sodium load found in bologna or frankfurters. A common mistake is choosing convenient deli/processed items, which worsen edema due to high sodium content.

Question 29

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

Accepted Answer

Answer reason: This creates an immediate risk for dehydration, weight loss, and malnutrition, which can impair healing and tolerance of ongoing therapy. Care planning must therefore prioritize interventions to maintain nutrition/hydration (e.g., soft/high-calorie foods, pain control before meals, monitoring intake/weight). Leukopenia can occur with some cancer therapies, but it is less directly tied to the localized mediastinal field and is typically managed via monitoring labs and infection precautions rather than being the most immediate care-planning priority here. Fatigue and skin irritation are expected side effects but are usually less urgent than protecting adequate swallowing and intake.

Question 30

A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client?

Accepted Answer

Answer reason: Supplemental oxygen during meals decreases work of breathing and supports adequate oxygenation, helping the client complete meals and meet caloric needs. This directly targets nutrition by reducing exertional hypoxemia that can limit intake. In contrast, advising high-sodium foods is not a standard strategy for secretion management and can worsen fluid retention and cardiovascular strain in susceptible patients. Mouth care is helpful hygiene but is not the key nutrition-focused teaching point compared with optimizing oxygenation during intake.

Question 31

The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is?

Accepted Answer

Answer reason:  After ESWL, the key nursing teaching is to promote high urine output to help flush stone fragments and reduce ureteral obstruction from retained debris. Increased oral hydration also helps minimize hematuria and decreases the risk of infection by maintaining urine flow. Limiting fluids would increase urinary stasis and the chance of colic/obstruction, making it an unsafe recommendation. Dietary changes like more citrus or restricting dairy are not the primary immediate post-procedure teaching compared with maintaining adequate hydration to pass fragments.

Question 32

A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?

Accepted Answer

Answer reason: A soft/liquid meal minimizes mechanical irritation and reduces risk of disrupting sutures or causing bleeding. This meal also provides fluid and energy-dense items that are typically well tolerated in the immediate post-op period. In contrast, items like chips, carrot sticks, and many meats are coarse or require more chewing and can abrade the palate. Avoiding such textures supports healing and comfort during feeding.

Question 33

A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?

Accepted Answer

Answer reason: Mild pediatric diarrhea is managed primarily by preventing dehydration while maintaining adequate caloric intake. Continuing an age-appropriate regular diet supports intestinal mucosal recovery and helps avoid worsening malnutrition, while oral rehydration solution replaces water and electrolytes lost in stools. Restricting intake to clear liquids/gelatin is low in calories and electrolytes and can precipitate hyponatremia and inadequate nutrition. Making the child NPO is unnecessary in mild illness and increases risk for dehydration; milk and water alone do not provide balanced electrolyte replacement.

Question 34

An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate?

Accepted Answer

Answer reason: This is a safe, immediate nursing intervention that supports effective coughing without delaying specimen collection. In contrast, forcing fluids for several hours is unnecessary and can be unsafe in older adults with potential cardiac/renal limitations, and it delays obtaining the sample. Raising the head of the bed can aid ventilation but is less directly effective for loosening thick secretions than warming and hydrating the airway. Spraying the oropharynx with saline does not meaningfully reach lower-airway secretions needed for a true sputum sample.

Question 35

A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the client?

Accepted Answer

Answer reason: Avoiding food close to bedtime reduces gastric volume and pressure at the lower esophageal sphincter during recumbency, decreasing nocturnal reflux and heartburn. Upright positioning after meals can help, but the bedtime timing strategy more directly targets the common trigger of nighttime reflux. Thickened liquids and a soft-food diet are interventions more aligned with dysphagia or swallowing safety, not routine GERD management.

Question 36

The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to?

Accepted Answer

Answer reason: A regular schedule helps match endogenous insulin response and any glucose-lowering medications to predictable carbohydrate exposure, lowering risk of hyperglycemia and medication-related hypoglycemia. Keeping a candy bar “at all times” is not routine dietary teaching for non–insulin-dependent diabetes and can promote unnecessary simple sugar intake. There is no universal rule that carbohydrates must be restricted to exactly 25% of calories; individualized medical nutrition therapy more commonly targets balanced intake with attention to carbohydrate quality and consistency.

Question 37

The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?

Accepted Answer

Answer reason: This menu includes a ground beef patty (heme iron) plus lima beans and raisins (additional non-heme iron), making it the strongest overall iron load among the choices. Several other menus are dominated by low-iron foods (fries, cookies, macaroni, jelly) and contain less iron-dense protein sources. While milk can reduce iron absorption if excessive, the presence of substantial dietary iron here still makes this the best dinner option.

Question 38

A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to?

Accepted Answer

Answer reason: Increasing dietary iron provides the key substrate needed for hemoglobin synthesis and red blood cell production, which directly addresses the physiologic deficit reflected in the labs. Activity can be balanced for fatigue, but prescribing prolonged rest as the primary approach does not correct the anemia and may contribute to deconditioning. Limiting milk is only a secondary consideration when excessive intake displaces iron-rich foods; the most therapeutic nursing intervention here is to promote iron-rich nutrition.

Question 39

The nurse is providing nutrition teaching for a 15-year-old male patient diagnosed with Crohn's disease. Which of the following topics is appropriate to include in the teaching plan?

Accepted Answer

Answer reason: A low-residue (low-fiber) approach limits undigested material and can be better tolerated when the intestinal mucosa is inflamed or narrowed. High-fat meals can worsen diarrhea and malabsorption symptoms, and gluten-free eating is only indicated when celiac disease or gluten sensitivity is present. Nutritional support in Crohn’s typically emphasizes small, frequent nutrient-dense intake rather than insisting on three large meals.

Question 40

The nurse is caring for a 4-month-old infant with a diagnosis of gastroesophageal reflux. The nurse is aware that which of the following will reduce the occurrence of the reflux?

Accepted Answer

Answer reason: Elevating the head of the crib about 30 degrees is a standard nursing intervention that can lessen regurgitation while avoiding unsafe sleep positions. Prone positioning may decrease reflux but is not recommended for routine sleep in a 4-month-old due to increased SIDS risk. Adding water with feeds can impair nutrition and does not address the pathophysiology of lower esophageal sphincter immaturity, and mixing a PPI into feeds is not the key immediate nursing measure to reduce occurrences.

Question 41

A 4-year-old male is being discharged from the hospital with mild diarrhea. The nurse educates the parents about which of the following dietary modification to implement at home?

Accepted Answer

Answer reason: Administer an oral re-hydrating solution (e.g., Pedialyte) Mild pediatric diarrhea is managed primarily by preventing dehydration and electrolyte losses using balanced oral rehydration therapy. Commercial ORS provides appropriate glucose-sodium ratios to enhance intestinal water absorption and replace ongoing stool losses safely at home. Restricting intake to clear liquids can worsen hyponatremia and does not adequately replace electrolytes, while the BRAT diet is unnecessarily restrictive and can be nutritionally inadequate if used as the main strategy. A gluten-free diet is only indicated when celiac disease or gluten sensitivity is the underlying cause, which is not suggested here.

Question 42

The nurse is caring for a 5-week-old female in the post-operative period following surgery for pyloric stenosis. The nurse is aware that which of the following feedings will be ordered for the infant by the healthcare provider?

Accepted Answer

Answer reason: Starting with small volumes of clear liquids allows evaluation for vomiting and supports gradual gastric adaptation after relief of the obstruction. As tolerated, feeds are advanced to usual nutrition (breast milk or formula) with increasing volume and concentration. Keeping the infant NPO for a full 24 hours is typically unnecessary in an uncomplicated course and delays rehydration and nutrition.

Question 43

A nurse is teaching a client about nutrition and wound healing. Which of the following foods should the nurse encourage the client to eat to promote wound healing?

Accepted Answer

Answer reason: This choice is a high-protein food that directly helps meet increased protein needs after tissue injury. Several other options provide calories or micronutrients, but they are less direct and less concentrated sources of protein for rebuilding tissue. Encouraging a protein-dense option is the most targeted teaching to promote timely, effective wound repair.

Question 44

The nurse is educating the parents of a young child with a recent diagnosis of cystic fibrosis. The nurse tells the parents that the child will be at risk for which vitamin deficiencies?

Accepted Answer

Answer reason: The key deficiencies therefore involve the fat-soluble group (A, D, E, K), with bleeding risk from low vitamin K and bone disease risk from low vitamin D being high-yield complications. Among the choices, this option best matches the fat-soluble deficiency pattern, even though vitamin E is also typically affected. Water-soluble vitamins (B vitamins, vitamin C, folate, biotin) are generally less directly impacted by fat malabsorption and are not the classic deficiency set in CF.

Question 45

Which of the following advisements shoulda patient suffering from GERG receive?

Accepted Answer

Answer reason: Remaining upright for 2–3 hours after meals reduces the likelihood of gastric contents moving back into the esophagus by using gravity and decreasing postprandial reflux. Limiting trigger foods/drinks that increase acid production or lower LES tone (e.g., caffeine, alcohol, spicy/acidic foods) reduces symptoms and esophageal inflammation. Choosing lower-fat foods helps because high-fat meals delay gastric emptying and can worsen reflux, so combining these measures makes the most complete and appropriate teaching set.

Question 46

The nurse cares for a client diagnosed with GERD. Which recommendation made by the nurse would be most helpful?

Accepted Answer

Answer reason: GERD management prioritizes reducing reflux by minimizing gastric volume and pressure when the patient is supine, because lying down decreases gravitational clearance and promotes acid exposure to the esophagus. Avoiding food close to bedtime directly reduces nocturnal reflux and related symptoms (heartburn, regurgitation, cough). Upright positioning after meals can also help, but the most impactful lifestyle change among these options for preventing nighttime symptoms is separating meals from sleep. The other options reflect dysphagia/aspiration-type guidance or texture modification and do not address the primary mechanism of reflux in uncomplicated GERD.

Question 47

Jadu is suffering from peptic ulcer, during his discharge counselling educate her to avoid?

Accepted Answer

Answer reason: Caffeine-containing beverages can stimulate acid production and may worsen dyspepsia and ulcer pain. Alcohol can disrupt the mucosal barrier and aggravate gastritis/ulcer symptoms, increasing risk of bleeding in susceptible patients. Spicy foods commonly exacerbate epigastric discomfort even if they are not the primary cause of ulcers, so avoiding them is appropriate discharge teaching to reduce symptom triggers.

Question 48

The nurse is developing a teaching plan for a client with post-gastrectomy dumping syndrome. Which of the following statements should the nurse make to the client?

Accepted Answer

Answer reason: " Dumping syndrome occurs when hyperosmolar gastric contents rapidly enter the small intestine, causing fluid shifts and exaggerated insulin response, leading to vasomotor symptoms and diarrhea. Limiting simple carbohydrates reduces the osmotic load and postprandial hypoglycemia, while higher protein and moderate fat slow gastric emptying and intestinal transit. Choosing drier foods and avoiding fluids with meals helps prevent rapid bolus movement into the intestine. A common mistake is encouraging fluid intake during meals, which can worsen symptoms by speeding transit and increasing volume delivered to the small bowel.

Question 49

Mr. and Mrs. Baker's only daughter is diagnosed with heart failure. Which of the following interventions would be appropriate to promote optimal nutrition for the infant?

Accepted Answer

Answer reason: An easy-to-suck nipple decreases the effort required to feed, helping the infant take in nutrition before tiring and reducing stress-related tachypnea. Prolonged feeds (e.g., 1 hour) increase fatigue and caloric burn, often worsening intake rather than improving it. Large infrequent feeds can overwhelm limited cardiac reserve and are less effective than strategies that reduce workload per feeding; additionally, high-sodium formula promotes fluid retention and can exacerbate heart failure.

Question 50

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention?

Accepted Answer

Answer reason: Older adults commonly eat more slowly due to decreased endurance, dentition issues, and age-related swallowing/chewing changes, so the least invasive first step is to modify the mealtime process to support adequate oral intake. Extending time reduces rushing and fatigue, which can improve both intake and safety (lower aspiration risk) without forcing feeding. Replacing meals with supplements can reduce appetite for regular food and is not first-line before trying environmental/behavioral adjustments. Escalation to tube feeding is invasive and inappropriate without thorough assessment of causes, goals of care, and failure of conservative measures.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Nutrition and Oral Hydration NCLEX Practice Test

Continue Learning