Question 1

Which dietary recommendation is best for a client at risk for osteoporosis?

Accepted Answer

Answer reason: Calcium and vitamin D are essential for bone mineralization and maintaining bone density, making them the most appropriate dietary recommendation for osteoporosis risk reduction. Vitamin D improves intestinal absorption of calcium, supporting optimal bone health. Increasing sodium can increase urinary calcium loss, and limiting green leafy vegetables would reduce intake of bone-supportive nutrients (including calcium and vitamin K). Decreasing protein and fat intake is not a primary evidence-based strategy to prevent osteoporosis and may compromise overall nutrition if done excessively.
Category reason: This question asks for a nursing dietary recommendation to reduce risk of osteoporosis, focusing on appropriate nutrition counseling rather than detailed biomedical mechanisms, which fits NCLEX Nutrition and Oral Hydration.

Question 2

The client at risk for aspiration due to dysphagia asks the nurse for a snack. The nurse offers which of the following?

Accepted Answer

Answer reason: Clients with dysphagia are at higher risk of aspiration and generally tolerate thicker, cohesive foods/liquids better than thin liquids. Apple juice is a thin liquid and is more easily aspirated. Yogurt with fruit chunks and carrot sticks contain mixed/solid textures that can be difficult to control and increase choking/aspiration risk. A milkshake is a thicker liquid that is typically safer (assuming a thickened-liquid diet is indicated).
Category reason: This question tests a nursing intervention—selecting a safer snack consistency to reduce aspiration risk in a client with dysphagia—so it falls under Nutrition and Oral Hydration in Basic Care and Comfort.

Question 3

Nurse Lee is discussing meal planning with the mother of a 2-year-old toddler. Which of the mother's statements indicates a need for further instruction?

Accepted Answer

Answer reason: Hot dogs are a high-risk choking hazard for toddlers because their round, firm shape can occlude the airway. For a 2-year-old, foods like hot dogs should be avoided or modified by cutting lengthwise into small, irregular pieces and supervising closely while eating. This statement shows unsafe meal planning compared with the other options, which are generally acceptable (though juice and ice cream should be limited for nutrition).
Category reason: The question focuses on appropriate food choices and safety considerations in meal planning for a toddler, which falls under nursing guidance on nutrition and oral hydration.

Question 4

Nurse Lee is advising Ms. Davis, a patient who needs to follow a diet low in fat and cholesterol. Which of the following food choices is the lowest in saturated fats?

Accepted Answer

Answer reason: Turkey breast is a lean protein choice and, when compared with macaroni and cheese or many pasta dishes prepared with cheese, butter, or meat sauces, it typically contains less saturated fat. Macaroni and cheese is high in saturated fat due to cheese and often added butter/cream. Shrimp is relatively low in saturated fat, but “shrimp with rice” can vary widely depending on preparation (e.g., frying, butter/cream sauces), whereas turkey breast is more reliably low in saturated fat and fits a low-fat, low-cholesterol diet plan. Therefore, turkey breast is the best answer.
Category reason: This item tests dietary counseling and food selection to reduce saturated fat and cholesterol intake, which is a nursing nutrition intervention within Basic Care and Comfort (Nutrition and Oral Hydration).

Question 5

Nurse Ramirez is planning a meal for Mr. Clark, who has been hospitalized following a facial stroke. Which diet option would be most appropriate for him?

Accepted Answer

Answer reason: After a facial stroke, patients commonly have facial weakness and dysphagia, increasing aspiration risk and making chewing difficult. The safest, most appropriate meal is soft/pureed foods with thicker textures that are easier to control in the mouth and swallow safely. Option B provides mostly soft, cohesive foods (mashed potatoes, pudding) and a thicker soup, whereas sandwiches, chips, hamburger, beans, and toast are harder to chew and can increase choking/aspiration risk. Milk can be acceptable if the patient tolerates thin liquids; overall, B best matches a soft diet pattern for post-stroke oral motor impairment.
Category reason: The question focuses on selecting an appropriate meal for a hospitalized post-stroke patient, emphasizing safe feeding and texture modification to support swallowing and prevent complications, which is a nursing nutrition/oral hydration intervention.

Question 6

A patient with hypothyroidism asks about diet. What should the nurse recommend?

Accepted Answer

Answer reason: Hypothyroidism slows metabolic rate, which predisposes patients to weight gain, so a low-calorie diet helps prevent further weight increase. Constipation is also common due to decreased GI motility, making a higher-fiber intake appropriate. A high-calorie/high-protein diet is more consistent with hyperthyroidism (increased metabolism), and high-fat/high-sodium is not indicated and may worsen cardiovascular risk.
Category reason: The question asks for a nurse dietary recommendation for a patient condition, focusing on nutrition counseling as part of basic patient care rather than detailed endocrine pathophysiology, fitting Nutrition and Oral Hydration.

Question 7

Which nursing intervention is most appropriate for a patient experiencing hypoglycemia?

Accepted Answer

Answer reason: Hypoglycemia is an acute low blood glucose state that is treated first with fast-acting carbohydrate if the patient can safely swallow. Providing a carbohydrate-rich snack raises serum glucose and relieves symptoms, preventing progression to neuroglycopenia and seizures. Administering rapid-acting insulin or an IV insulin drip would worsen hypoglycemia. Monitoring potassium is not the immediate priority for symptomatic hypoglycemia compared with restoring blood glucose.
Category reason: The question asks for the most appropriate nursing intervention to correct hypoglycemia, which is a direct patient-care action focused on providing oral nutrition to address an immediate physiologic need.

Question 8

A nurse is providing diet teaching to a client with congestive heart failure (CHF). The nurse tells the client to avoid which of the following?

Accepted Answer

Answer reason: Clients with CHF are typically taught to limit sodium intake to reduce fluid retention, edema, and cardiac workload. Steak sauce is commonly high in sodium, making it a food item to avoid or strictly limit. Apple juice and leafy green vegetables are not inherently high in sodium, and sherbet is not the most sodium-relevant choice compared with a salty condiment. Therefore, steak sauce is the best answer.
Category reason: This is a patient teaching question about dietary modifications (sodium restriction) as part of nursing management of CHF, which fits NCLEX patient care under Nutrition and Oral Hydration.

Question 9

A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase her diet?

Accepted Answer

Answer reason: In late-stage CKD, phosphorus is typically restricted because impaired excretion causes hyperphosphatemia, which contributes to renal bone disease. High phosphate levels lower serum calcium and reduce active vitamin D, leading to secondary hyperparathyroidism; increasing calcium intake (often alongside phosphate binders as prescribed) helps support bone mineral balance. Potassium and sodium are usually limited in advanced CKD to reduce risk of hyperkalemia, hypertension, and fluid overload. Therefore, among the options given, calcium is the nutrient to increase.
Category reason: The item asks about client dietary teaching (what to increase in the diet) for a chronic condition, which is a nursing nutrition intervention and fits NCLEX Nutrition and Oral Hydration.

Question 10

The most common problem associated with tube feeding is ;?

Accepted Answer

Answer reason: Diarrhea is the most commonly reported complication of enteral (tube) feeding due to factors such as high osmolar formulas, rapid infusion rates, medication-related effects (e.g., sorbitol-containing liquids, antibiotics), and intolerance/malabsorption. While vomiting/aspiration and infection can occur, they are generally less frequent than diarrhea as day-to-day problems in tube-fed patients. Hyperglycemia may occur with high-calorie feeds, especially in diabetes or critical illness, but it is not the most common overall complication compared with gastrointestinal intolerance. Therefore, diarrhea is the best answer among the options.
Category reason: The item tests a common nursing-related complication of enteral nutrition and focuses on monitoring and managing feeding tolerance, which aligns with nutrition support in patient care (Nutrition and Oral Hydration).

Question 11

During a dietary assessment of a vegan client, which vitamin deficiency should the nurse recognize the client is at-risk for?

Accepted Answer

Answer reason: Vegans are at increased risk for vitamin B12 deficiency because reliable natural sources of B12 are primarily animal-derived (meat, dairy, eggs). While some plant foods are fortified, inadequate intake without supplementation can lead to deficiency. B12 deficiency can cause megaloblastic anemia and neurologic symptoms (e.g., paresthesias, gait changes) due to impaired myelin synthesis. Vitamins A, C, and E are readily available from plant-based foods, making deficiency less likely with a varied vegan diet.
Category reason: This item tests nursing nutritional assessment and identifying a diet-related deficiency risk for a client, which aligns with patient care needs under Nutrition and Oral Hydration.

Question 12

The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?

Accepted Answer

Answer reason: Children with cystic fibrosis have pancreatic enzyme insufficiency leading to fat malabsorption, poor weight gain, and increased energy expenditure from chronic lung disease. Therefore, nutrition goals emphasize a high-calorie, high-fat diet (often with pancreatic enzyme replacement) to support growth and maintain adequate BMI. Low-fat or low-calorie diets would worsen nutritional deficits, and low sodium/gluten-free is not the standard dietary recommendation for CF.
Category reason: This question tests a nursing education intervention about dietary management for a child with a chronic condition, which aligns with patient care needs related to nutrition and hydration rather than basic biomedical facts.

Question 13

A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following dietary recommendations is appropriate for this patient?

Accepted Answer

Answer reason:  Low phosphorus intake In CKD, the kidneys cannot excrete phosphorus effectively, leading to hyperphosphatemia and contributing to renal osteodystrophy and secondary hyperparathyroidism. Therefore, restricting dietary phosphorus (and often using phosphate binders) is a common recommendation. High sodium intake worsens fluid retention and hypertension, and high protein intake can increase nitrogenous waste burden (protein is typically moderated, not increased). A blanket “low calcium intake” is not an appropriate general recommendation in CKD because calcium balance is managed carefully and may need supplementation depending on labs and therapy.
Category reason: This is a nursing care question focused on appropriate diet teaching/interventions for a patient with CKD, which fits NCLEX patient-care content under Nutrition and Oral Hydration.

Question 14

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Accepted Answer

Answer reason: Butter. Milk is a major dietary source of calcium, and leafy greens like spinach and collard greens also contain calcium. Butter is primarily fat and contains minimal calcium compared with milk and many vegetables. Therefore, butter is least likely to contribute meaningful calcium intake.
Category reason: This question tests dietary teaching (which foods contain or do not contain calcium) as part of nursing client education about nutrition, fitting NCLEX Basic Care and Comfort: Nutrition and Oral Hydration.

Question 15

A nursing intervention to reduce symptoms of dumping syndrome is?

Accepted Answer

Answer reason: Lie down for 30 minutes after meals Dumping syndrome occurs when gastric contents empty too rapidly into the small intestine, causing fluid shifts and vasomotor/GI symptoms. Lying down after meals slows gastric emptying and helps reduce postprandial hypotension and abdominal symptoms. In contrast, fluids with meals and high-carbohydrate meals can worsen dumping by increasing rapid osmotic load; walking after meals may also promote faster transit and symptoms in some patients.
Category reason: This item tests a nursing intervention/teaching strategy to manage a postoperative GI complication (dumping syndrome), which is patient-care focused and fits NCLEX nursing management under nutrition and oral hydration.

Question 16

A nurse is teaching a client with chronic kidney disease about dietary restrictions. Which food should the client avoid?

Accepted Answer

Answer reason: Bananas Clients with chronic kidney disease commonly need to limit dietary potassium because impaired renal excretion increases the risk of hyperkalemia and life-threatening dysrhythmias. Bananas are a high-potassium food and are therefore a typical item to avoid or strictly limit. Apples and white rice are generally lower in potassium, and grilled chicken is primarily a protein restriction issue that depends on the prescribed renal diet stage and labs.
Category reason: This question tests nursing dietary teaching for a client condition (CKD) and which food to avoid, which aligns with patient care education about nutrition and hydration needs rather than basic science alone.

Question 17

The nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse should make which response to the mother?

Accepted Answer

Answer reason: In 3 weeks. After tonsillectomy, the tonsillar fossae develop a protective eschar that typically sloughs around days 5–10, and the risk of secondary hemorrhage is increased during this period. Rough, crunchy, spicy, or sharp foods (such as a taco shell) can traumatize healing tissue and precipitate bleeding, so they are avoided until the throat is well healed. Many postoperative teaching guidelines recommend avoiding such foods for about 2 weeks or longer; among the options given, 3 weeks is the safest specific timeframe. Options of 2 days or 1 week are too soon, and deferring to the provider is not appropriate when standard postoperative nursing teaching can be provided.
Category reason: This is a postoperative nursing teaching question focused on when a child can resume certain foods after tonsillectomy, which is best categorized under Nutrition and Oral Hydration in Basic Care and Comfort.

Question 18

A nursing diagnosis for a patient with poor nutrition would be?

Accepted Answer

Answer reason: Imbalanced nutrition: Less than body requirements Poor nutrition most directly indicates an actual nutrition problem, making this NANDA-I diagnosis the best match. It describes intake insufficient to meet metabolic needs and guides nursing interventions such as dietary assessment, monitoring weight/labs, and optimizing caloric/protein intake. The other options are either potential complications (risk for infection) or unrelated primary problems (breathing pattern, acute pain) unless additional assessment data support them.
Category reason: This item asks for the most appropriate nursing diagnosis related to inadequate intake, which falls under patient care needs for nutrition and hydration.

Question 19

True or False: A patient with heart failure should limit sodium intake.?

Accepted Answer

Answer reason: True Limiting sodium helps reduce fluid retention by decreasing water following sodium, which lowers preload and edema in heart failure. High sodium intake can worsen congestion, weight gain, and symptoms such as dyspnea and peripheral swelling. Sodium restriction is a standard nonpharmacologic management strategy used alongside diuretics and other HF therapies.
Category reason: This is a patient-care teaching/intervention question about dietary management (sodium restriction) to prevent worsening symptoms in heart failure, fitting NCLEX nutrition and hydration care.

Question 20

True or False: A patient with a colostomy should avoid carbonated beverages.?

Accepted Answer

Answer reason: True Carbonated beverages can increase gas production and abdominal distention, which may lead to increased flatus and pouch ballooning in patients with a colostomy. Many ostomy diet recommendations advise limiting carbonated drinks, especially early after surgery, to reduce gas and discomfort. Individual tolerance varies, but as a general teaching point, avoiding carbonated beverages is appropriate.
Category reason: This is a nursing patient-education question about dietary choices to minimize ostomy-related gas and discomfort, which fits Nutrition and Oral Hydration under Basic Care and Comfort.

Question 21

Which diet should the nurse recommend for a client with Cushing's syndrome?

Accepted Answer

Answer reason: B. Low sodium, high protein Hypercortisolism causes sodium and water retention leading to edema and hypertension, so sodium restriction helps reduce fluid overload and blood pressure. It also increases protein catabolism, producing muscle wasting and impaired wound healing, so higher protein intake supports tissue repair and preserves lean body mass. Cushing’s is also associated with hypokalemia risk, so a low-potassium diet would be unsafe, and high sodium would worsen cardiovascular and fluid complications.
Category reason: This item asks for a nursing dietary recommendation to manage a client’s condition, which is a patient-care intervention best categorized under Nutrition and Oral Hydration.

Question 22

A person who has had a renal transplant should regulate the intake of ______?

Accepted Answer

Answer reason: Following a kidney transplant, dietary counseling often emphasizes avoiding excessive protein intake to reduce the kidney’s workload from nitrogenous waste production, while still providing enough for healing and maintaining lean body mass. Overly high protein can contribute to hyperfiltration stress on the transplanted kidney, especially in the early post-transplant period. Nutrition plans are individualized based on graft function, labs, and medications (e.g., steroids), but protein regulation is a core concept compared with the other macronutrients listed.
Category reason: This is a patient-care nutrition teaching question about diet management after a renal transplant, which fits nursing care under Nutrition and Oral Hydration.

Question 23

True or False: A low-residue diet is recommended for patients with inflammatory bowel disease during flare-ups.?

Accepted Answer

Answer reason: During acute IBD flares, reducing insoluble fiber and residue can help decrease stool volume and bowel stimulation, which may lessen diarrhea and cramping. A low-residue (often low-fiber) diet is commonly used short-term to improve symptoms and reduce mechanical irritation of inflamed mucosa. Nutrition should still be individualized based on severity, obstruction/stricture risk, and tolerance, with attention to hydration and electrolyte replacement.
Category reason: This item tests diet/nutrition teaching for symptom control in a gastrointestinal flare, which is a nursing care intervention under Nutrition and Oral Hydration.

Question 24

A malnourished elderly patient with a pressure ulcer is admitted. Which meal should the nurse encourage?

Accepted Answer

Answer reason: Adequate wound healing in a malnourished patient requires increased protein and sufficient calories, along with key micronutrients. This meal provides high-quality protein to support tissue repair and collagen synthesis, plus additional nutrients from leafy greens and dairy that support overall nutritional repletion. The other options are comparatively low in protein and energy density and would not best support pressure ulcer healing.
Category reason: This question asks the nurse to choose an appropriate meal to support healing and nutrition in a patient, which is a direct patient-care nutrition intervention under basic care.

Question 25

A client was taught about the low-fat diet. The nurse informed the client that it is acceptable to eat which food item(s)?

Accepted Answer

Answer reason: A low-fat diet prioritizes foods with minimal fat grams per serving, emphasizing legumes, fruits, and many non-cream-based soups. Lentil-based soups are typically low in fat compared with cream-based soups, which often contain higher amounts of cream/butter/oil. Watermelon and tomato soup can also be low-fat choices, but if a single best option is required, the clearly appropriate low-fat protein/legume choice is selected. Cream of mushroom soup is commonly higher in fat due to dairy/cream content.
Category reason: This item tests client teaching about appropriate food choices to meet a prescribed low-fat diet, which is a nursing nutrition intervention under Basic Care and Comfort.

Question 26

Which dietary instruction is appropriate for a patient with heart failure?

Accepted Answer

Answer reason: Excess sodium promotes water retention, increasing intravascular volume and worsening edema and pulmonary congestion in heart failure. Many patients also require fluid restriction to reduce preload and prevent decompensation, especially if hyponatremic or symptomatic with volume overload. Increasing water intake or sodium intake would counteract diuretic and volume-management goals, and avoiding fruits/vegetables is not indicated for heart failure nutrition.
Category reason: This item tests patient-care teaching about diet and hydration to prevent fluid overload in a clinical condition (heart failure), which is a nursing intervention/education focus under Nutrition and Oral Hydration.

Question 27

A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?

Accepted Answer

Answer reason: e." Caffeine can increase gastric acid secretion and worsen epigastric pain, so avoiding it is an appropriate self-management strategy for peptic ulcer disease. Sucralfate is typically administered on an empty stomach (e.g., 1 hour before meals and at bedtime), not taken with meals. A severe protein restriction is not indicated for peptic ulcer disease and could impair healing. NSAIDs such as ibuprofen can exacerbate mucosal injury and increase the risk of bleeding, so they should be avoided unless specifically prescribed.
Category reason: This item tests dietary/medication teaching to reduce ulcer irritation and symptoms, which is a patient-care education intervention focused on nutrition and oral intake management.

Question 28

Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:

Accepted Answer

Answer reason: B. Mashed potatoes and broiled chicken A 500-mg sodium diet requires choosing foods that are naturally low in sodium and avoiding processed, cured, canned, and packaged items. Plain broiled chicken is low in sodium if not seasoned with salt, and mashed potatoes can be prepared without added salt using unsalted butter/milk. The other options contain high-sodium ingredients such as ham and cheese, olives, and bouillon, which would exceed the sodium restriction quickly.
Category reason: This question tests nursing dietary teaching and food selection for a prescribed low-sodium diet, which fits patient nutrition management within Basic Care and Comfort.

Question 29

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?

Accepted Answer

Answer reason: These items can decrease lower esophageal sphincter tone and/or increase gastric acid secretion, which worsens reflux symptoms and esophageal irritation. Avoiding common dietary triggers is a core nonpharmacologic strategy for GERD management alongside lifestyle changes. In contrast, elevating the foot of the bed is incorrect (the head of the bed should be elevated), and a low-carbohydrate diet is not a standard GERD recommendation. While avoiding late meals can help, the broad trigger-avoidance guidance here is the most directly therapeutic option provided.
Category reason: This is a patient-teaching question about lifestyle and dietary measures to reduce GERD symptoms, which is a nursing care intervention focused on nutrition-related comfort and symptom control rather than testing underlying basic science.

Question 30

Client receiving full strength tube feedings most commonly develop diarrhea because of?

Accepted Answer

Answer reason: Hyperosmolar formulas (especially when given full-strength or advanced too quickly) draw water into the intestine, causing an osmotic diarrhea. This is the most common cause of diarrhea associated with enteral nutrition compared with infection or positioning issues. Reducing the infusion rate, using isotonic formulas, or gradual titration can decrease symptoms. Infection can cause diarrhea but is less common than osmotic effects when feeds are initiated or concentrated.
Category reason: This question tests a common patient-care complication of enteral (tube) feeding and the nursing-related nutrition management concept behind it, which fits Nutrition and Oral Hydration.

Question 31

Dietary instructions are provided by the nurse to an immobile client who is experiencing frequent episodes of constipation. The client also complained that constipation is uncomfortable. Which food item should the nurse tell the client would be most helpful to include in the diet?

Accepted Answer

Answer reason: In immobility-related constipation, increasing dietary fiber helps add bulk and promote peristalsis, which improves stool frequency and ease of passage. Whole grains are a reliable high-fiber choice compared with refined grains such as white bread and many pasta products. While vegetables like cabbage contain some fiber, the best single option listed for consistent fiber support is the whole-grain product. Adequate fluid intake should also accompany fiber to prevent worsening constipation.
Category reason: This item tests a nursing dietary intervention to relieve constipation in an immobile client, which is a basic comfort need addressed through nutrition and hydration teaching.

Question 32

A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client?

Accepted Answer

Answer reason: Physiologic needs take priority over psychosocial concerns in nursing prioritization frameworks (e.g., ABCs/Maslow). Depression can significantly reduce appetite and motivation, placing the client at risk for dehydration, malnutrition, weight loss, and related complications. Addressing intake supports physiologic stability and can improve energy needed to participate in activity and therapeutic engagement. The other problems are important but are less immediately life-sustaining than meeting basic nutrition and hydration needs.
Category reason: This question asks the nurse to prioritize a patient problem focusing on meeting essential physiologic needs (food and fluids), which falls under Basic Care and Comfort—Nutrition and Oral Hydration.

Question 33

When teaching a client at discharge with a permanent colostomy, the nurse will discuss about-?

Accepted Answer

Answer reason: Immediately after colostomy formation and at discharge teaching, dietary guidance helps manage stool consistency, decrease excessive gas/odor, and reduce risk of obstruction while the bowel adapts. A bland, low-residue pattern is commonly recommended initially, then foods are gradually reintroduced based on tolerance and stoma output. Routine activity restriction and special clothing are not typically required long term, and stoma dilation is not standard colostomy care (more relevant to certain stenosing ostomies or other procedures).
Category reason: This question tests discharge teaching focused on diet management for a client with a colostomy, which is a nursing care intervention under Nutrition and Oral Hydration.

Question 34

A nurse is teaching a patient with chronic kidney disease about dietary restrictions. Which of the following statements by the patient indicates a need for further teaching?

Accepted Answer

Answer reason: C. I can eat as much protein as I want to maintain my strength. In chronic kidney disease, excessive protein intake increases nitrogenous waste (uremia) and can accelerate decline in kidney function, so protein is typically moderated/individualized rather than unlimited. Sodium restriction helps reduce hypertension and fluid retention. Potassium restriction is often needed due to impaired excretion and risk of hyperkalemia, and fluid monitoring helps prevent volume overload and edema.
Category reason: This item tests client education about diet and fluid restrictions for a chronic condition, focusing on nursing teaching related to nutrition and hydration management.

Question 35

A client with pneumonia has a temperature of 101.5°F. What intervention is most appropriate?

Accepted Answer

Answer reason: Fever increases insensible water loss through sweating and tachypnea, raising dehydration risk and thickening respiratory secretions. Encouraging oral fluids helps maintain hydration, supports mucociliary clearance, and can improve comfort during febrile illness. A cooling blanket is usually reserved for very high or refractory hyperthermia, not a mild fever. Antibiotics and oxygen may be indicated based on orders and clinical status, but the safest immediate supportive intervention for a stable client with this temperature is to promote hydration.
Category reason: This question asks for the most appropriate nursing intervention to support a client with fever from pneumonia, focusing on comfort measures and hydration rather than disease mechanisms, so it fits NCLEX Basic Care and Comfort (Nutrition and Oral Hydration).

Question 36

A client with chronic kidney disease is experiencing hyperkalemia. Which food should the nurse instruct the client to avoid?

Accepted Answer

Answer reason: With hyperkalemia in chronic kidney disease, dietary potassium restriction is important because impaired renal excretion can allow potassium to accumulate and trigger dysrhythmias. Bananas are a well-known high-potassium fruit and are commonly restricted on low-potassium diets. Apples are relatively low in potassium compared with many fruits, making them a safer choice. Carrots and broccoli contain potassium, but bananas are typically higher per common serving and are a classic food to avoid when potassium is elevated.
Category reason: This item tests nursing dietary teaching to manage a physiologic problem (hyperkalemia) in a client with chronic kidney disease, which fits NCLEX patient-care guidance under Nutrition and Oral Hydration.

Question 37

In developing a nursing care plan for a 9-month-old infant with cystic fibrosis, because the nurse is concerned about adequate nutrition, which intervention would best meet this child's needs?

Accepted Answer

Answer reason: Cystic fibrosis commonly causes pancreatic insufficiency, leading to fat and protein malabsorption and poor weight gain. Pancreatic enzyme replacement given with meals improves digestion and absorption, directly supporting adequate caloric intake and growth. Mixing the contents with an acidic soft food (like applesauce) is an age-appropriate way to administer without destroying the enteric coating by chewing. The other options do not address the primary cause of malnutrition in cystic fibrosis and may introduce unnecessary risks or side effects.
Category reason: The primary intent is selecting an appropriate nursing intervention to improve an infant’s nutrition in a clinical condition (cystic fibrosis), which aligns with patient care planning under Nutrition and Oral Hydration.

Question 38

Which of the following strategies can help maintain a patient's nutritional status?

Accepted Answer

Answer reason: This best supports adequate macro- and micronutrient intake while accommodating preferences, appetite changes, and potential dietary restrictions. Nutrient-dense choices provide more vitamins, minerals, and protein per bite, which is especially important if total intake is limited. The other options can worsen hydration status, create imbalanced nutrition, or reduce overall caloric and protein intake by decreasing meal opportunities.
Category reason: This question tests a nursing nutrition intervention to maintain nutritional status, fitting patient care under Nutrition and Oral Hydration.

Question 39

Which of the following is an appropriate nursing intervention for a patient who has difficulty feeding themselves?

Accepted Answer

Answer reason: This promotes independence and dignity while ensuring adequate nutritional intake. Adaptive devices (e.g., built-up handles, angled utensils, plate guards) compensate for weakness, limited grasp, tremor, or impaired coordination and reduce fatigue. The other options either remove the opportunity for self-care or create unnecessary nutritional risk rather than addressing the functional limitation safely.
Category reason: This item tests a nursing intervention to support a patient’s ability to eat safely and effectively, which is a basic care function under Nutrition and Oral Hydration.

Question 40

The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to?

Accepted Answer

Answer reason: Separating fluids from meals helps reduce rapid gastric emptying by avoiding increased gastric volume and osmotic load entering the small intestine at once. This decreases the fluid shift into the bowel lumen that triggers cramping, diarrhea, and vasomotor symptoms after eating. Typical teaching also includes small frequent meals, higher protein/fat with reduced simple carbohydrates, and resting after meals.
Category reason: This question tests nursing dietary teaching to manage a post-gastrectomy complication, which is a patient-care intervention focused on oral intake management.

Question 41

The nurse is reinforcing teaching with the parents of a 10-year-old client with a seizure disorder about ketogenic diet therapy. The nurse should reinforce that a ketogenic diet includes foods that are?

Accepted Answer

Answer reason: Ketogenic therapy aims to shift the body’s primary fuel source from glucose to ketone bodies by significantly restricting carbohydrate intake while providing high fat as the main energy source. Protein is included in adequate (not excessive) amounts to support growth and prevent muscle catabolism, especially in children. This metabolic state can reduce seizure frequency in some pediatric patients, so diet composition is central to therapy adherence and effectiveness.
Category reason: This question tests nursing teaching about a therapeutic diet pattern and nutrient composition, which aligns with patient nutrition education under Nutrition and Oral Hydration.

Question 42

A nurse is planning care to improve self-feeding for a client who has vision loss. which of the following interventions should the nurse include in the plan of care?

Accepted Answer

Answer reason: This strategy supports independence by giving a consistent spatial map of where items are located, allowing the client to self-feed safely without relying on vision. It reduces frustration and promotes autonomy because the client can locate each food item using a standardized reference. The other options either promote dependence, do not address vision-related orientation, or apply to dysphagia rather than visual impairment.
Category reason: This question tests a nursing intervention to support safe, independent eating for a client with a functional limitation, which fits Basic Care and Comfort focused on nutrition-related assistance.

Question 43

A new mother is having trouble breast-feeding her newborn son. He's making frantic rooting motions and will not grasp the nipple. Which intervention should the practical nurse implement?

Accepted Answer

Answer reason: C) encourage the mother to stop feeding for a few minutes and comfort the infant A frantic, rooting newborn who cannot latch is often overly distressed; pausing to calm the infant helps coordinate suck-swallow-breathe and improves latch success. Comforting measures (skin-to-skin, soothing voice, gentle rocking) reduce agitation so the infant can open wide and attach effectively. Forcing the head against the breast can worsen distress and interfere with airway alignment, and routine pacifier use may contribute to ineffective latch early on. Supplementing with formula is not first-line for a latch problem and can undermine breastfeeding establishment unless medically indicated.
Category reason: This question asks the nurse to choose an appropriate intervention to support breastfeeding and infant feeding behavior, which is a patient-care action within nutrition and oral hydration.

Question 44

In which of the following ways can the nurse promote the sense of taste for an older adult?

Accepted Answer

Answer reason: Chewing increases the exposure of food to saliva, which dissolves flavor molecules so they can contact taste receptors more effectively. Older adults commonly have reduced salivary flow and diminished taste sensitivity, so maximizing oral mixing time can improve taste perception and enjoyment of meals. Mixing foods together can reduce distinct flavors, and discouraging seasonings may further blunt taste and reduce intake. Odor control relates more to smell than taste and is not the most direct strategy for enhancing taste.
Category reason: This asks for a nursing intervention to improve eating enjoyment and intake in an older adult, which fits patient-care strategies for nutrition and hydration.

Question 45

A client with chronic kidney disease (CKD) is prescribed a low-protein diet. Which food should the nurse recommend?

Accepted Answer

Answer reason: In CKD, a low-protein diet helps reduce nitrogenous waste (urea) and may lessen uremic symptoms and slow progression in some patients when not on dialysis. Among the options, a refined grain like rice provides primarily carbohydrates with minimal protein load. The other choices are protein-dense foods (fish, legumes, and dairy) and would contribute more dietary protein than desired for a low-protein plan.
Category reason: This item asks the nurse to recommend an appropriate food choice based on a prescribed therapeutic diet for a patient condition, which is a patient-care nutrition intervention under Nutrition and Oral Hydration.

Question 46

The child with no dehydration needs home treatment. Which of the following is not included in the rules for home treatment in this case?

Accepted Answer

Answer reason: Home management of a child with no dehydration (e.g., diarrhea without signs of dehydration) focuses on oral rehydration with increased fluids, continued/extra feeding, and clear counseling on danger signs and when to return for care. Vitamin A supplementation is not a routine component of immediate home treatment rules for “no dehydration”; it is given according to age-based public health schedules or specific indications (e.g., measles, documented deficiency risk programs). Therefore it does not belong to the standard home-treatment instructions for this specific classification.
Category reason: This item tests nursing home-care counseling for a child without dehydration, emphasizing oral hydration, feeding guidance, and return precautions, which aligns with basic supportive care and hydration education.

Question 47

Nina's treatment should include the following EXCEPT?

Accepted Answer

Answer reason: During diarrhea/dehydration management, continuing age-appropriate feeding is recommended to prevent malnutrition and support gut recovery. ORS replaces fluid and electrolytes, but it does not provide adequate calories and nutrients, so withholding foods can worsen nutritional status. Standard guidance is to continue breastfeeding and resume normal diet as soon as tolerated while giving ORS and monitoring hydration status.
Category reason: This item tests nursing management of dehydration/diarrhea with appropriate oral rehydration and feeding instructions, which fits patient-care guidance under Nutrition and Oral Hydration.

Question 48

To prevent aspiration after tube feeding via NG tube, the client should be in?

Accepted Answer

Answer reason: C. High Fowler's An upright position uses gravity to keep formula in the stomach and reduces gastroesophageal reflux, which lowers the risk of regurgitation into the airway. Elevating the head of bed also supports better airway protection and ventilation, especially in clients with decreased gag/cough reflexes. Supine or prone positions increase aspiration risk, and left lateral is not the standard safest position for post–NG tube feeding compared with maintaining head elevation.
Category reason: This item tests a nursing intervention (safe positioning) to prevent aspiration during/after enteral feeding, which is a patient-care safety measure within nutrition support.

Question 49

A nurse is teaching a client with heart failure about fluid restrictions. Which statement by the client shows understanding?

Accepted Answer

Answer reason: B. "I will measure all fluids including soup and ice." Clients with heart failure on fluid restriction must count all sources of free water intake, including liquids like soup and items that melt at room/body temperature such as ice. This prevents excess intravascular volume that can worsen pulmonary congestion, edema, and dyspnea. The other statements reflect common misconceptions: thirst is not a reliable guide, diuretics do not permit unrestricted intake, and many non-water items still contribute to total fluid volume.
Category reason: This item tests patient teaching about limiting and accurately tracking oral fluid intake to manage heart failure, which aligns with nursing care related to hydration and nutrition rather than foundational biomedical science.

Question 50

A newborn of a diabetic mother is jittery and has a glucose level of 38 mg/dL. What is the priority action?

Accepted Answer

Answer reason: A symptomatic newborn with low glucose should receive an immediate, rapidly available source of calories to correct hypoglycemia and prevent neurologic injury. For mild-to-moderate neonatal hypoglycemia, the first-line intervention is prompt feeding (breastmilk or formula) followed by reassessment of blood glucose. IV dextrose is typically reserved for severe hypoglycemia, inability to feed, or persistent symptoms/low values despite feeding. Warming can reduce energy expenditure but does not correct the acute low glucose, and delaying action to recheck risks ongoing hypoglycemia.
Category reason: This is a nursing priority/intervention question focused on immediate management of neonatal hypoglycemia through feeding and reassessment, which aligns with NCLEX patient-care decision-making under Nutrition and Oral Hydration.

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