FOUNDAMENTAL OF NURSING AND NUTRITION PRE-TEST

By: SIR JONASH

100 ITEM

1. The physician has ordered a minimal bacteria diet for a client with cancer. Which seasoning is

NOT permitted for this client?

A. Salt

B. Lemon juice

C. Pepper

D. Ketchup

RATIONALE AND ANSWER:

CORRECT ANSWER: C

Pepper is not processed and contains bacteria. Answer A is incorrect because fruits can be eaten; they
should be cooked or washed and peeled. Answers B and D are allowed. Ground pepper is an
unprocessed food and will not be allowed because of the possible bacteria. The nurse would also ensure
that this client receives no uncooked fruits and vegetables.

2. The cause of scurvy can come from a lack of _______ in patient diet.

A. Vitamin D

B. Fruits

C. Protein

D. Thiamine

RATIONALE AND ANSWER:

CORRECT ANSWER: B

Scurvy is a clinical syndrome that results from vitamin C deficiency. The key feature of scurvy is
hemorrhage which can occur in almost any organ. Further, bone formation is altered and become
brittle.This disease was first reported in 1550 BC when people accurately described the diagnosis and
treatment using onions and vegetables. Hippocrates officially termed the disease "ileos
ematitis" with the description, “the mouth feels bad; the gums are detached from the teeth; blood
runs from the nostrils…ulcerations on the legs. The best way to prevent vitamin C deficiency is to
consume fruits and vegetables regularly. Vitamin C is naturally found in fresh fruits and vegetables; for
example, grapefruits, oranges,lemons, limes, potatoes, spinach, broccoli, red peppers, and tomatoes. Up
to 90% of vitamin C is consumed in the form of vegetables and fruits.

3. Micronutrient supplementation is included in what program of the DOH?

A. Sentrong Sigla

B. Araw ng Sangkap Pinoy

C. Expanded program on immunization

D. Reproductive health Bill.

RATIONALE AND ANSWER:

CORRECT ANSWER: B

The Food Fortification Program locally known as Araw ng Sangkap Pinoy is the Philippine government’s
response to the growing micronutrient malnutrition. Republic Act 8976, “An Act Establishing the
Philippine Food Fortification Program and for other purposes” mandating fortification of flour, oil and
sugar with Vitamin A and flour and rice with iron. Food fortification is the addition of Sangkap Pinoy or
Micronutrient such as vitamin A, iron and iodine to food. Sentrong Sigla Movement is the joint effort of
the DOH and the LGU whose goal was quality health care. Sentrong sigla main strategy is certification of
health centers that are able to comply with standards set by the DOH.

4. You assess for a child's nutritional status using the mid-upper arm circumference
(MUAC).Measurement reads 120cm which falls under the orange color of a 4-colored tape. This indicate
that the child __________.

A. Well nourished

B. Is at risk for acute malnutrition

C. Should be immediately referred for supplementation

D. Should be immediately reffered for treatment

RATIONALE AND ANSWER:

C. Should be immediately referred for supplementation

5. Among which of the following foods has the highest amount of potassium?

A. White rice

B. Corn

C. Lima bean

D. Broccoli

RATIONALE AND ANSWER:

C. Lima bean

6. A client with COPD is instructed to follow what diet?

A. High protein, high calorie and low carbohydrate diet

B. High protein, high carbohydrate and high calorie diet

C. High carbohydrate, low protein and high calorie diet

D. High carbohydrate , high calorie and low carbohydrate diet

RATIONALE AND ANSWER:

A. High protein, high calorie and low carbohydrate diet

7. The patient with ulcerative colitis is in low residue diet. All are true except

A. roasted chicken

B. noodle

C. cooked broccoli

D. roast beef

RATIONALE AND ANSWER:

C. cooked broccoli

8. The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be
taught to avoid eating:
A. Fruits

B. Salt

C. Pepper

D. Ketchup

RATIONALE AND ANSWER:

ANSWER: C

pepper is not processed and contains bacteria. Answer A, B and D are incorrect because fruits should be
cooked or washed and peeled, and salt and ketchup are allowed.

9. A client has disabling attacks of vertigo. The nurse suspects that the client has Meniere's disease. The
nurse is aware that the diet of the client must be modified. Which of the following is the BEST diet for
the client?

A. High protein

B. Low Carbohydrates

C. Low Sodium

D. Low Fat

RATIONALE AND ANSWER:

ANSWER: C

The diet recommendations for Meniere’s disease include low-sodium, caffeine-free foods and fluids
distributed evenly throughout the day.

10. What nutritional instruction should you advise Alberto when taking Theophylline? He should

AVOID taking _______.

A. Milk and milk products

B. Fruit and vegetable juices

C. Soda and non-carbonated drinks

D. Hot tea or coffee

RATIONALE AND ANSWER:

ANSWER: D

Drinking alcohol or eating/drinking foods high in caffeine, like coffee, tea, cocoa, and chocolate, may
increase the side effects caused by theophylline.

Situation - Mrs. Cruz, 68 years old, 5'2 tall, weighs 80lbs came to the of General hospital because of
diarrhea and eating problems. Her BMI is <18.5 and has not eaten anything for almost 12 hours.

11. Which of the following is the APPROPRIATE initial questions to be asked to the patient upon
admission?

A. "Does stress give you problem with your eating habits?"

B. "Do you recall the food you have taken prior to your admission?"

C. "Do your family members allot enough budget for your nutritional needs?"

D. "What is your usual eating pattern?"

RATIONALE AND ANSWER:

D. "What is your usual eating pattern?"

12. Considering the clinical manifestation presented by the patient, how BEST should the nurse state her
nursing diagnosis?

A. Imbalanced nutrition less than body requirements R/T poor absorption of food

B. Activity intolerance R/T inadequate caloric intake

C. Risk for infection R/T poor nutritional status

D. Self-care deficit R/T decreased strength

RATIONALE AND ANSWER:

A. Imbalanced nutrition less than body requirements R/T poor absorption of food
13. The doctor ordered a nasogastric tube (NGT) inserted before administering Osmolite tube feeding.
Which of the following nursing measures should the nurse do?

A. Assess the presence of bowel sounds

B. Evaluate if patient's residual is <50 ml

C. Warm the Osmolite to 98.8 F.

D. Flush theNGT with 10 ml of water

RATIONALE AND ANSWER:

B. Evaluate if patient's residual is <50 ml

14. Which of the following results will describe abnormal physical finding when performing gastro-
intestinal assessment?

A. Eversion of umbilicus upon inspection

B. Tympany on percussion of the abdomen

C. Gurgling abdominal sounds upon auscultation

D. Liver edge of 1-2 cm below the right costal margin on palpation

RATIONALE AND ANSWER:

A. Eversion of umbilicus upon inspection

15. Which of the following outcomes indicate the NGT feeding was effective? *

A. Vital signs remained stable

B. Patient gains 2 lbs. in a week

C. 24 hours urine output is equivalent to her intake

D. Blood sugar remains between 100-150 mg/dl

RATIONALE AND ANSWER:

A. Vital signs remained stable

16. The Dash Diet has been Prescribe to Mr. Co by his physician. Which of the following is NOT included
in the dietary Approach to stop Hypertension?

A Meats lean, poultry without skin and fish

B. Vegetables like squash, Spinach, carrot and potatoes.

C. Fruits like bananas, oranges, melons and mangoes.

D. Dairy Products, high in fats, non-skim mozzarella cheese

RATIONALE AND ANSWER:

D. Dairy Products, high in fats, non-skim mozzarella cheese

17. There were several diagnostic examinations done on patient Marina as she was also passing dark
and tarry stool. Colonoscopy was ordered and prior to this procedure, she was placed on ________.

A. Clear liquids twenty four (24) before the procedure

B. nothing per orem (NPO) overnight

C. Soft diet twelve hours (12) before the procedure

D. Sips of water an hour before the procedure

RATIONALE AND ANSWER:

A. Clear liquids twenty four (24) before the procedure

18. The nurse recalls that there are other known risk factors for breast cancer such as family history,
environmental and dietary factors. Which of the following is a BEST establish dietary risk factor for
breast cancer?

A. Fat-rich foods

B. Alcohol intake

C. Carbonated drink consumption

D. Caffeine consumption

RATIONALE AND ANSWER:

B. Alcohol intake
Situation – Jenalyn Abad, a 40 year old women , has a history of rheumatoid arthritis for the last ten
years. The following questions refers to this situation.

19. Jenalyn has been talking steroids for the last five years to control her arthritis .which of the following
is a common side effects of steroid therapy?

A. Hyponatremia

B. Hyperkalemia

C. Increased blood glucose

D. Protein anabolism

RATIONALE AND ANSWER:

ANSWER: C

Glucose levels will increase when patients are taking Corticosteroids, and insulin may be required to
control blood glucose. Corticosteroids can cause catabolic effects on protein metabolism,
hypernatremia, hypokalemia, and fluid retention.

20. Which of the following diets is the best suited to decrease the side effects of Jenalyn’s steroid
therapy?

A. Normal carbohydrate , high protein, high potassium

B. Low carbohydrate, high protein high potassium

C. Low carbohydrate , high protein, low potassium

D. High carbohydrate ,low protein, low sodium

RATIONALE AND ANSWER:

B. Low carbohydrate, high protein high potassium

21. Nurse Ashma explains ABC strategies to improve healthy nutrition. These ABC strategies are the
following, EXCEPT:
A. Build healthy nutrition-related practices.

B. Aim for ideal body weight.

C. Choose food wisely.

D. Access weight-reducing herbs.

RATIONALE AND ANSWER:

D. Access weight-reducing herbs.

22. The physician ordered bland diet to Mr. Red with PUD. What kind of food do you expect to find in his
meal tray?

A. Pork steak, fried fish, white rice

B. Fried chicken, French fries, spaghetti

C. Pureed squash, creamed soup, white rice

D. Ground beef, mashed potato, white rice

RATIONALE AND ANSWER:

ANSWER: C

Plain and simple, red meat is one of the hardest things for the stomach to digest properly.Meats that are
lower in fat (lean chicken, fish, turkey) create less acid and it is allowed. When an ulcer is actively
causing signs and symptoms, the patient should avoid acidic foods like tomatoes or citric fruits/juices,
chocolate, alcohol, fried foods and caffeine. These foods can irritate the ulcer site. Instead the patient
should consume alkalotic or bland foods like squash, white rice, bananas and creamed soup. Milk may
be included in the diet, but it is not recommended in excessive amounts.

Situation - Mrs. Abigail, 65 years old was admitted in the medical unit because of malnutrition. She has
been anorexic for the last 6 months due to family problems. She always feel fatigue with body weakness
and have lost weight ( 12 lbs in 2 months) due to poor appetite.

23. As the nurse-in-charge of this patient, if an individual has a caloric deficiency in the diet, what
specific manifestations do you expect to be present? EXCEPT ________

A. Loss of subcutaneous fat

B. Sparse hair

C. Muscle wasting

D. Listlessness

RATIONALE AND ANSWER:

ANSWER: B

One of the earliest signs that your body is low in calories will be a continuous feeling of weakness and
lethargy or listlessness. The hallmark of caloric deficiency is severe muscle wasting or the loss of
subcutaneous fat. Lack of protein can result in hair loss, and the growth of weak, thin, dry and sparse
brittle strands.

24. In order to improve the nutritional needs of patient Abigail, the physician ordered insertion
nasogastric tube (NGT). What is the appropriate size of the feeding tube you should prepare for this
purpose?

A. Fr. 13 to 14

B. Fr. 15 to 16

C. Fr. 16 to 18

D. Fr. 8 to 12

RATIONALE AND ANSWER:

ANSWER: C

It is widely acceptable to use a size 16 or 18 French for adults

25. When inserting NGT to patient Abigail, the SAFETY ALERT and decision points you should implement
are the following:

I. Identify the patient using name birthday

II. Determine length of the tube to be inserted and mark location

III. Position her at 45 degrees head of bed elevation

IV. Let her breath and swallow during the procedure

V. Measure gastric residual volume during tube feeding *

A. I, II, III and IV

B. I, II, III, IV and V

C. II and III

D. I and II

RATIONALE AND ANSWER:

ANSWER: B

All of the above are SAFETY ALERT in placement of Nasogastric tube.

26. After inserting the NGT to patient Abigail, you would like to be sure the tube is in the stomach.
Which of the following PH VALUE of the gastric aspirate indicates it is in place?

A. 6

B. 7

C. 8

D. 5

RATIONALE AND ANSWER:

ANSWER: D

Confirm placement per your facility&#39;s policy. Ways to check placement include aspirating gastric
contents and testing it with pH paper (a pH of 5.5 or less indicates gastric acid), or obtaining a chest X-
ray. Special consideration: Average gastric pH is 1 to 3; with patients who are taking medication for acid
reduction, the pH can be higher than 4. Thecolor and pH of gastricacid is, Gastric: pH: &lt; 5.0;Color: dark
green; cloudy, dingy yellow; clear; and clear, dark brown. The Gold Standard for checking NG tube
placement is by X ray confirmation

27. While you were feeding patient Abigail, you observed that the tube is clogged. Which of the
following solutions is appropriate to use in flushing the NG?

A. 22 to 25 ml. Ice H20

B. 20 to 30 ml. Of NSS

C. 18 to 25 ml. Lukewarm H20

D. 15 to 20 ml of distilled H20

RATIONALE AND ANSWER:

B. 20 to 30 ml. Of NSS

28. Nurse Celestina noticed that the patient still has difficulty in swallowing. His son was told by Nurse
Celestina that the patient is still on clear liquids. Which of the following will Nurse Celestina exclude in
her health teachings as examples of clear liquids?

A. Clear juice

B. Broth

C. Milk

D. Tea

RATIONALE AND ANSWER:

ANSWER: C

A clear liquid diet is a specific dietary plan that consists solely of liquids/semi-liquids that are fully clear.
Some items that may be permitted include water, ice, fruit juices without pulp, sports drinks,
carbonated drinks, gelatin, tea, coffee, clear broths, and clear ice pops. Items can have color as long as
they are transparent. Items such as milk and orange juice are not considered clear liquids because they
are not fully transparent and may take more effort for the digestive system to break down, whereas
grape juice is allowed (it is pigmented, but fully transparent). Depending on individual patients' dietary
restrictions, selected food items may be allowed such as honey, and clear hard candies. The clear liquid
diet assists in maintaining hydration, it provides electrolytes and calories, and offers some level of
satiety when a full diet is not appropriate, but may struggle to provide adequate caloric needs if
employed for more than five days.

29. At early stage Mr. Joe’s liver cirrhosis disease process, the physician ordered this SPECIFIC diet for
Mr. Joe. You emphasized to the dietitian that he should be served foods that is _____________.

A. high carbohydrate and low sodium

B. high calorie and high carbohydrate

C. low protein and high fat

D. high protein and high fat

RATIONALE AND ANSWER:

B. high calorie and high carbohydrate

30. While in the hospital, the physician in coordination with the nurses, dietitian and other health
professional has to consider total patient care. What particular meal plan will be carried out by the
nurse for Ms. Belen diagnosed with Diabetic ketoacidosis? Food has to be ________.

1. 60 to 70% Caloric intake from CHO and monosaturated fats

2. Prepared from lower mono saturated oil like olive oil

3. Prepared from avocado oil and nuts

4. High in CHO, High in saturated fats and low protein

A. 1, 2, and 3

B. 2 and 3

C. 1, 2, 3 and 4

D. 1 and 2

RATIONALE AND ANSWER:

A. 1, 2, and 3

31.The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the
following snacks would be BEST for the client with mania?

A. Potato chips

B. Apple

C. Diet cola

D. Milkshake

RATIONALE AND ANSWER:

ANSWER: D

The milkshake will provide needed calories and nutrients for the client with mania. Milk is the only
beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.
ANSWERS A and B are incorrect because they are high in sodium, which causes the client to excrete the
lithium. ANSWER C has some nutrient value, but not as much as the milkshake.

32. One of your manic patients lacks food and fluid intake due to poor appetite. What foods would be
the BEST meet the patient’s nutritional needs?

A. Steak and spaghetti

B. Peanut butter, sandwich and milk

C. Carrots, celery, raisins, apple

D. Beef and non-diet soda

RATIONALE AND ANSWER:

ANSWER: B

Finger foods, or things clients can eat while moving around, are the best options to improve nutrition.
Such foods should be as high in calories and protein as possible.

33. Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol
withdrawal?

A. Milk

B. Orange Juice

C. Soda

D. Regular Coffee

RATIONALE AND ANSWER:

ANSWER: D

Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety
and agitation. Serving coffee top the client may add to tremors or wakefulness

34. You are planning to teach the patient with spinal cord injury and intermittent nasogastric suctioning
about interventions to maintain the patient’s integumentary system. You should instruct the patient to
__________.
A. Stay in a warm environment to prevent chilling

B. Stay in a cool environment to prevent sweating

C. Eat low-sodium food to prevent edema

D. Eat enough calories to maintain desired weight

RATIONALE AND ANSWER:

ANSWER: D

To decrease the rate of muscle atrophy and prevent skin breakdown and infection. The client with SCI
does not have poikilothermy, the ability to adjust body temperature to the environment. The client
should add additional clothes ore coverage below the level of transection in cool environments.The
client does not sweat below the level of transection and should be sensitive to the possibility of
overheating in hot climates. The client with intermittent NG suctioning is at risk for development of
metabolic alkalosis and an electrolyte imbalance that leads to decreased tissue perfusion; therefore, the
clients needs to increase Na and K, not decrease Na.

35. The nurse includes in the care plan dietary instructions. Which of the food items should the nurse
instruct the client with SLE to AVOID?

A. Steak

B. Legumes

C. Broccoli

D. Fish

RATIONALE AND ANSWER:

ANSWER: A

The client with SLE is at risk for cardiovascular disorders such as coronary artery disease and
hypertension. The client is advised of lifestyle changes to reduce these risk, which include smoking
cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat and
cholesterol intake.

Situation- Ms. Alvarez is a newly registered nurse. She upgrades her nursing competencies by attending
seminars and workshopson advanced nursing procedures. A workshop she recently participated is on
physical assessment. She applies her skills in the female medical unit where she is assigned.
36. Ms. Alvarez inspect the abdomen of a patient. Which of the following sequences represent the order
in assessing a patient`s abdomen?

A. Palpate, percuss, auscultation, observe

B. Observe, auscultation, percuss, palpate

C. Percuss, palate, auscultate, observe

D. Auscultate, observe, percuss, palpate

RATIONALE AND ANSWER:

ANSWER: B

In order to prevent stimulation of gastrointestinal activity, the correct sequence or order of the
abdominal assessment is changed to Inspection, Auscultation, Percussion, and Palpation.

37. Ms. Alvarez auscultates for breath sounds. What type of data should auscultation produce?

A. Secondary

B. Subjective

C. Primary

D. Objective

RATIONALE AND ANSWER:

ANSWER: D

Auscultation provides OBJECTIVE type of data. Objective data is what the nurse observes by inspecting,
percussing, palpating, and auscultating during the physical examination. Subjective data is what the
person says about him or herself during history taking. The terms primary and secondary are sources
ofdata and are not used to describe type of data.

38. Ms. Alvarez proceeds to palpate a patient`s body to detect warmth. What part of her hand should
she use?

A. Finger tips

B. Back or dorsal surface

C. Ulnar surface

D. Finger pads

RATIONALE AND ANSWER:

ANSWER: B

The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is
thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination, not
for assessing skin temperature. The ulnar and palmar surfaces of the hands are not useful for palpation.

39. Ms. Alvarez assesses a patient for gag reflex. Which part of the tongue should she place the tongue
blade?

A. On the middle of the tongue and ask the patient to cough

B. On the ovula

C. Lightly on the posterior aspect of the tongue

D. On the front of the tongue and ask the patient to say "ahh"

RATIONALE AND ANSWER:

C. Lightly on the posterior aspect of the tongue

40. Ms. Alvarez takes and records the body temperature of a patient. The temperature registers a
reading of 38. Which of the following conditions will the patient MOST likely demonstrate?

A. Increased pulse rate

B. Precordial pain

C. Dyspnea

D. Elevated blood pressure

RATIONALE AND ANSWER:

A. Increased pulse rate

41. The nurse on duty is preparing for discharge plan for Ms. Chuchay, what dietary restriction should
she emphasize so that recurrence of gallstone formation (cholelithiasis) will be prevented

A. Calamansi juice, white bread and chicken breast salad

B. Whole milk, butter, cheese and fried meat

C. Steamed fish, broiled vegetable and lean meat

D. Broiled banana, vegetable salad and white meat of chicken

RATIONALE AND ANSWER:

ANSWER: B

Fat-Restricted Diet is used for pts with gallbladder and liver disease, obesity, and certain heart diseases
avoid cream, whole milk, butter cheese, fats, fatty meats, rich desserts, chocolate, fried foods, salad
dressings, nuts, and coconut oil.

42. The patient asks you about goiter. You describe this disorder as ___________-.

A. A condition produced by excessive endogenous or exogenous thyroid hormone

B. The enlargement of the thyroid gland and usually caused by an iodine-deficient diet

C. None of the choices

D. Inflammation of the thyroid gland that may lead to chronic hypothyroidism

RATIONALE AND ANSWER:

ANSWER: B

Goiter is the enlargement of the thyroid gland; usually caused by an iodine-deficient diet. Thyrotoxicosis
is a condition produced by excessive endogenous or exogenous thyroid hormone. Thyroiditis is the
inflammation of the thyroid gland most often is a result of a viral infection of the thyroid gland this is an
acute disorder that may become chronic resulting in a hypothyroid state as repeated infections destroy
gland tissue.

43. An interdependent function of nurse is when the nurse_____________:

A. Irrigates a feeding tube that appears obstructed.

B. Gives ice chips to a client who has an order of NPO.

C. Applies a dry sterile dressing to an abdominal incision.

D. Helps a client choose foods rich in protein from an ordered diet.

RATIONALE AND ANSWER:

D. Helps a client choose foods rich in protein from an ordered diet.

44. A nurse decides to give partial bath to a client instead of a complete bath. The nurse is
working.___________

A. Independently

B. Dependently

C. Interdependently

D. Collaboratively

RATIONALE AND ANSWER:

ANSWER: A

Independent nursing interventions are activities that do not need an order from another healthcare
professional. Teaching the patient about deep breathing exercises, assisting the patient with a bed bath,
and repositioning the patient can be performed independently by the nurse.

45. A nurse works with a skin care team. The nurse is functioning______________:

A. Dependently

B. Collaboratively

C. Interdependently

D. Independently

RATIONALE AND ANSWER:

ANSWER: C

A collaborative or interdependent intervention is one that is carried out in collaboration with other
health team member. Collaborative interventions require the combined knowledge, skills, and expertise
of multiple healthcare professionals.
46. A nurse initiates a visit from member of the clergy for a terminally ill client. The nurse is
functioning______________:

A. Interdependently

B. Independently

C. Collegially

D. Dependently

RATIONALE AND ANSWER:

ANSWER: B

The nurse is initiating the referral to the member of the clergy and is therefore working independently.
Nurses are legally permitted to diagnose and treat human responses to actual or potential health
problems.

47. When a nurse uses a straight catheter to obtain a urine specimen for laboratory test, the nurse is
functioning______________:

A. Dependently

B. Independently

C. Interdependently

D. Collegially

RATIONALE AND ANSWER:

ANSWER: A

Executing physician's orders, such as catheterization and medication administration, are examples of
dependent nursing interventions.

48. Pancytopenia occurs when a person has a decrease in__________

A. red blood cells, white blood cells and platelets

B. red blood cells and white blood cells

C. white blood cells and platelets

D. white blood cells

RATIONALE AND ANSWER:

ANSWER: A

Pancytopenia is the simultaneous presence of anemia, leucopenia and thrombocytopenia. Pancytopenia

is a condition that occurs when a person has low counts for all three types of blood cells: red blood cells,
white blood cells, and platelets. Pancytopenia is usually due to a problem with the bone marrow that
produces the blood cells.

49. The nurse is instructing the parents of a child with iron deficiency anemia regarding the
administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?

A. Administer the iron at mealtimes

B. Administer the iron through a straw

C. Mix the iron with cereal to administer

D. Add the iron to formula milk for easy administration

RATIONALE AND ANSWER:

ANSWER: B

In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the
manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through
a straw or medicine dropper placed at the back of the mouth because iron stains the teeth. The parents
should be instructed to brush the teeth after administration. Iron is administered between meals
because absorption is decreased if there is food in the stomach. Iron requires an acid environment to
facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other
food items.
50. What CHIEF ingredient of prenatal vitamin for pregnancy nutrition that the patient should look for?

A. Vitamin B12

B. Potassium

C. Vitamin C

D. Folic acid

RATIONALE AND ANSWER:

ANSWER: D

Because folic acid is important during pregnancy to reduce the incidence of spinal cord lesions, prevent
abortion, and prevent megaloblastic anemia, it is added at greater strengths to prenatal vitamins. Folic
acid is added to maternal prenatal vitamins because of the threat of developing anemia.The pregnant
patient should take a prenatal vitamin that contains a folic acid supplement of 0.4 to 0.6 mg, which may
or may not be a part of an over-the-counter vitamin supplement. Vitamin C, potassium, and vitamin B12
are important; however, do not have the same risk of developing a health problem if not present in a
prenatal vitamin supplement.

51. Which food below is NOT a good source of iron?

A. Milk

B. Grains

C. Legumes

D. Beef

RATIONALE AND ANSWER:

ANSWER: A

The foods richest in iron include organ meats; eggs; green, leafy vegetables; whole grains; enriched
breads; or dried fruits. Milk is not a good source of iron.
52. The population in a poor community has risen including the increasing trend of pregnant women
who are undernourished. You coordinate with the local social welfare department to provide foods that
are nutritionally adequate. This is considered:_________

A. prevention Health promotion

B. Tertiary

C. Primary prevention

D. Secondary prevention

RATIONALE AND ANSWER:

D. Secondary prevention

53. The nurse is educating the family regarding general need for adequate nutrition, rest, and

physical activity. Which level of prevention does this describe?

A. Tertiary prevention

B. Secondary prevention

C. Health maintenance

D. Primary prevention

RATIONALE AND ANSWER:

ANSWER: D

Primary preventions involve immunizations, health education programs, nutrition, rest and physical
activities. Secondary prevention involves early diagnosis and prompt treatment. Tertiary prevention
involves minimizing the effects of long-term illness or disability, including rehabilitation.

54. A child with phenylketonuria must be referred to____________

A. geneticist

B. nutritionist

C. dietician

D. cardiologist
RATIONALE AND ANSWER:

C. dietician

55. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight
every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this
newborn receive at each feeding to meet nutritional needs?

A. 2 ounces

B. 3 ounces

C. 4 ounces

D. 6 ounces

RATIONALE AND ANSWER:

ANSWER: B

To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120
cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60
calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the
calculation. 2, 4 or 6 ounces are incorrect.

56. When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs,
which of the following types of diet would the nurse discuss?

A. High-residue diet

B. Low-sodium diet

C. Regular diet

D. High protein diet

RATIONALE AND ANSWER:

ANSWER: C

For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the
client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and
vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia.
Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.
57. The nurse is planning a meal that would provide IRON for a child with hemophilia bleeding
disorders. Which dinner menu would be the BEST?

A. Chicken nuggets, macaroni, peas, cantaloupe, milk

B. Fish sticks, French fries, banana, cookies, milk

C. Ground beef patty, lima beans, wheat roll, raisins, milk

D. Peanut butter and jelly sandwich, apple slices, milk

RATIONALE AND ANSWER:

ANSWER: C

A rich source of iron is needed in the diet, and ground beef pattyare high in iron. Iron rich foods include
red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins.
This dinner is the best choice: It is high in iron and is appropriate for a toddler.

58. The nurse is providing dietary teaching for a client with elevated cholesterol levels. Which cooking
oil is NOT suggested for the client on a low-cholesterol diet?

A. Safflower oil

B. Sunflower oil

C. Coconut oil

D. Canola oil

RATIONALE AND ANSWER:

Answer C

Coconut oil is high in saturated fat and is not appropriate for the client on a low- cholesterol diet.
Answers A, B, and D are incorrect because they are suggested for the client with elevated cholesterol
levels.

59. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse
should instruct the patient to AVOID which of the following for breakfast?
A. Puffed wheat

B. Banana

C. Puffed rice

D. Cornflakes

RATIONALE AND ANSWER:

Answer A

Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include
wheat, barley, oats, and rye. The other foods are allowed.

60. Which of the following post-operative diets is most appropriate for the client who has had a
hemorrhoidectomy?

A. High-fiber

B. Low-residue

C. Bland

D. Clear-liquid

RATIONALE AND ANSWER:

D. Clear-liquid

61. The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a
low-roughage diet. Which food would have to be eliminated from this client's diet?

A. Roasted chicken

B. Noodles

C. Cooked broccoli

D. Custard

RATIONALE AND ANSWER:

Answer C
The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal
discomfort, such as cooked broccoli. Foods such as those listed in Answers A, B, and D are allowed.

62. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be
avoided?

A. Bran flakes

B. Peaches

C. Cucumber and tomato salad

D. Whole wheat bread

RATIONALE AND ANSWER:

Answer C

The client with diverticulosis should avoid foods with seeds. The foods in Answers A, B, and D will help
prevent constipation that increases the likelihood of diverticulitis. Rinehart, Wilda. NCLEX-RN Exam
Cram: NCLEXRN Exam Cram_5 (Kindle Locations). Pearson Education. Kindle Edition.

63. The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse
should instruct the patient to avoid which of the following for breakfast?

A. Cream of wheat

B. Banana

C. Puffed rice

D. Cornflakes

No correct answers

65. A nurse is teaching a client who has celiac disease about gluten free foods. Which of the following
foods should the nurse recommend? EXCEPT

A. Tapioca
B. Cold cuts

C. Flavor chips

D. Barley

RATIONALE AND ANSWER:

D. Barley

66. The parents of a 6-year-old child with celiac disease tell the school nurse that their child becomes
dejected because she is not able to eat snack foods like the rest of her class and friends. What snack can
the nurse recommend that is safe for the child to eat

A. tortilla chips

B. Pretzels

C. oatmeal cookies

D. peanut butter crackers

RATIONALE AND ANSWER:

AMSWER: A

Products composed of corn, rice, and millet do not contain gluten and are permitted on a low-gluten
diet; tortilla chips are made from corn flour. Pretzels contain wheat flour, which is not permitted on a
low-gluten diet; products containing rye, oats, and barley are also restricted. Oatmeal cookies contain
oats, which are not permitted on a low-gluten diet. Peanut butter crackers contain wheat flour, which is
not permitted on a low-gluten diet.

67. The FIRST solid food(s) usually added to the infant's diet is (are)

A. cow's milk.

B. iron-fortified cereals.

C. pureed fruits.

D. pureed vegetables.

RATIONALE AND ANSWER:

ANSWER: B
The first semi-solid food offered to infants is usually a rice cereal. Start with rice, then veggie, fruits and
meat.

68. An infant triples his or her birth weight by about __________ of age.

A. 4 months

B. 8 months

C. 6 months

D. 12 months

RATIONALE AND ANSWER:

D. 12 months

69. Kakai learned that newborn infants should ONLY be given, which of the following?

A. Fruit juice

B. Breastmilk

C. water

D. cows milk

RATIONALE AND ANSWER:

ANSWER: B

Exclusive breastfeeding for six months has many benefits for the infant and mother. Nurses should
strongly recommend breastfeeding exclusively (no formula, juice, or water) for 6 months. Baby starts to
receive the immunological effects of colostrum (the first breastmilk, which provides protection against
infection and disease).

70. Weight loss and Malnutrition are commonly observed among patients with COPD. They should be
taught to avoid ______.

A. have full stomach even when in dyspneic condition

B. keeping body mass between 21-25 kg./m»

C. a high caloric and high protein diet

D. exercise one hour before and after eating

RATIONALE AND ANSWER:

A. have full stomach even when in dyspneic condition.

71. Which of the statements of Patient Benito will convince Nurse Virgo that his instructions for the
prevention of pancreatitis were understood by the patient? I will _______.

A. “Increase my intake of high protein products"

B. "try to stop drinking alcohol”

C. "follow a high fat diet faithfully"

D. "be careful of exposing myself to infection"

RATIONALE AND ANSWER:

B. "try to stop drinking alcohol”

72. Nurse Myrna is taking care of a family chose there young children are sick with malnutrition
particularly protein deficiency, which of the following behaviors is indicative of the family's positive
coping index

A. Observing erratic mealtime due to work schedule of parents

B. Bringing children to health enter for consult only when needed.

C. Serving foods that children like but with high in carbohydrates

D. Cooking foods in variety that include meat, dairy products and beans.

RATIONALE AND ANSWER:

D. Cooking foods in variety that include meat, dairy products and beans.

Situation: Evelyn a multigravida, in her 20th weeks of gestation visited the community clinic with
complaints of dizziness, vertigo, and heartburns. After the physical assessment, Nurse Harpar finds the
patient as malnourished.
73. Iron supplementation was prescribed because of her low hemoglobin level. which statement, if
made by Evelyn, would indicate an understanding of health instructions?

A. "My body has all the iron it needs and I don&#39;t need to take supplements."

B. "Meat does not provide iron and should be avoided."

C. "The iron is best absorbed if taken on an empty stomach."

D. "Iron supplements will give green color to my stool."

RATIONALE AND ANSWER:

C. "The iron is best absorbed if taken on an empty stomach."

74. Evelyn was given iron as supplemental vitamin to prevent maternal anemia. She asks if Cat will not
be affected because she is regularly taking vitamin C. Which of the following would be the best response
of the nurse?

A. "Take two other vitamins separately."

B . "Take the iron after a full meal."

C. Absorption of iron is enhanced with Vit C.

D. "Drink milk when taking the iron supplement."

RATIONALE AND ANSWER:

B . "Take the iron after a full meal."

C. Absorption of iron is enhanced with Vit C.

75. Evelyn was also advised to take calcium supplements on the 2nd and 3rd trimester of pregnancy.
Which of the following would ENHANCE her intestinal absorption of calcium?

A. Fat-soluble vitamins

B. Proteins

C. Minerals

D. Water soluble vitamins

RATIONALE AND ANSWER:

A. Fat-soluble vitamins

76. Nurse Harper observes Evelyn has knowledge deficit regarding fetal nutrition. Nurse Harper has to
explain that the MAIN SOURCE of nutrition for the baby is which of the following?

A. Amniotic fluid

B. Uterus

C. Placenta

D. Chorionic villi

CORRECT ANSWER:

C. Placenta

77. While Ms. Evelyn is being prepared physically and psychologically for possible thyroid surgery, her
nutritional needs was also being met with a diet that is?

A. high fibrous, low protein, high CHO

B. high caloric, high CHO, low protein

C. high caloric, high CHO, and protein

D. high protein, low Vitamin A &amp; C

CORRECT ANSWER:

C. high caloric, high CHO, and protein

78. What mode of transmission is due to contaminated food and water being consumed?

A. Inoculation

B. Direct/ indirect contact

C. Ingestion

D. Airborne
CORRECT ANSWER:

C. Ingestion

79. The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients
with heart failure are?

A. Pleural rub

B. Stridor

C. Wheezes

D. Fine crackles

RATIONALE AND ANSWER:

Answer: D

Fine crackles are brief, discontinuous, popping lung sounds that are high-pitched. Crackles, previously
termed rales, can be heard in both phases of respiration. Early inspiratory and expiratory crackles are
the hallmark of chronic bronchitis. Late inspiratory crackles may mean pneumonia, CHF, or atelectasis.
Pleural rubs are discontinuous or continuous, creaking or grating sounds. Because these sounds occur
whenever the patient&#39;s chest wall moves, they appear on inspiration and expiration. Stridor is a
loud, high-pitched crowing breath sound heard during inspiration but may also occur throughout the
respiratory cycle most notably as a patient worsens. Stridor is caused by upper airway narrowing or
obstruction. Causes of stridor are pertussis, croup, epiglottis, aspirations. Wheezes are adventitious lung
sounds that are continuous with a musical quality. The proportion of the respiratory cycle occupied by
the wheeze roughly corresponds to the degree of airway obstruction. Wheezes are caused by narrowing
of the airways.

80. Which physical examination method should a nurse use when assessing for borborygmi?

A. Palpation

B. Percussion

C. Inspection

D. Auscultation

RATIONALE AND ANSWER:

ANSWER D
Auscultation is the process of listening to sounds produced in the body. It is performed directly by just
listening with the ears or indirectly by using a stethoscope that amplifies the sounds and conveys them
to the nurse's ears. Active intestinal peristalsis causes rumbling, gurgling, and tinkling abdominal sounds
known as bowel sounds (borborygmi). Which of the following pulse sites is used during CPR? a. aorta b.
radial c. brachial d. carotid.

81. The nurse is palpating a female patient's breasts during an examination. Which of these position is
most likely to make significant lumps more distinct during breast palpation?

A. Supine with the arms raised over her head

B. Sitting with the arms relaxed at her sides

C. Supine with the arms relaxed at her sides

D. Sitting with the arms flexed and fingertips touching her shoulders

RATIONALE AND ANSWER:

ANSWER: A

The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated,
and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and
medially displace it. Any significant lumps will then feel more distinct.

82. The BEST approach in assessing the EARLY sign of Mitral valve prolapse is through_______.

A. Percussion

B. Palpation

C. Inspection

D. Auscultation

RATIONALE AND ANSWER:

ANSWER: D
Cardiac auscultation is an essential physical exam tool for Mitral valve prolapse diagnosis. Upon
auscultation of an individual with mitral valve prolapse, a mid-systolic click, followed by a late systolic
murmur heard best at the apex, is common.

Situation - You are the nurse-on-duty (NOD) in the OPD on a Wednesday which is a day dedicated to
patients with Gastro-intestinal problems.

83. Ms. Marina, 55 year old cook consulted your unit because of on and off pain over the right upper of
the abdomen. While performing your health history, the patient asked you, what particular organs are
found in this particular affected area? The BEST response is ______.

1. Duodenum

2. Pylorus

3. Liver

4. Spleen

A. 1 & 2

B. 1 & 4

C. 2 & 3

D. 3 & 4

RATIONALE AND ANSWER:

C. 2 & 3

84. In performing physical assessment of the abdomen, auscultation has to be done FIRST than
palpation because ______.

A. it is less painful than performing palpation

B. more reliable means of evaluating the abdominal structure

C. it is easier to perform than palpation

D. palpation will alter the placement of the organ

RATIONALE AND ANSWER:

ANSWER: B

Auscultation is done before percussion and palpation.

85. When conducting a physical assessment of patients with endocrine disorders, the nurse is guided
that the only endocrine organ that can be done by palpation is the _____

A. Parathyroid gland

B. Adrenal gland

C. Pituitary gland

D. Thyroid gland

RATIONALE AND ANSWER:

ANSWER: D

Apart from the testes, the thyroid glands are the only that may be accessible for physical examination.
Standing behind the patient, attempt to locate the thyroid isthmus by palpating between the cricoid
cartilage and the suprasternal notch.

86. An appropriate technique to use during physical assessment of the thyroid gland is to

A. asking the patient to hyperextend the neck during palpation

B. percussing the neck for dullness to define the size of the thyroid

C. having the patient swallow water during inspection and palpation of the gland

D. using deep palpation to determine the extent of a visibly enlarged thyroid gland

RATIONALE AND ANSWER:

ANSWER: C
Having the patient swallow water during inspection and palpation of the gland. Water should always be
available for the patient to swallow as part of inspection and palpation of the thyroid gland.

87. The nurse had informed the mother why her weight is taken every visit. She said sudden weight gain
predisposes her to pre-eclampsia. Which among the following is the ideal weight gain?

A. 25-30 lbs

B. 15-30 lbs

C. 20-25 lbs

D. 18-24 lbs

RATIONALE AND ANSWER:

A. 25-30 lbs

88. When obtaining subjective data from a patient during assessment of the endocrine system, the
nurse asks specifically about_________

A. energy level.

B. intake of vitamin C.

C. employment history.

D. frequency of sexual intercourse.

CORRECT ANSWER:

A. energy level.

89. The nurse has difficulty eliciting some DTRs in Mr. Johnson. To facilitate reflex testing of the arms,
the nurse should give him which instruction?

A. "Clench your teeth"

B. "Flex your arms"

C. "Clasp your hands together"

D. "Make a fist"

CORRECT ANSWER:

A. "Clench your teeth"

90. When assessing a clients abdomen which finding should the nurse report as abnormal?

A. dullness over the liver

B. bowel sounds occurring every 10 seconds

C. shifting dullness over the abdomen

D. vascular sound over the renal arteries

RATIONALE AND ANSWER:

ANSWER C

shifting dullness over the abdomen would indicate ascites which is abnormal dullness over the liver,
bowel sounds every 10 seconds and vascular sounds over the renal arteries are all normal sounds in the
abdomen.

91. When percussing a clients chest, the nurse should expect to hear:

A. Hyperresonance

B. Resonance

C. tympany

D. dullness

CORRECT ANSWER:

B. Resonance

92. A nurse is assessing tactile fremitus in a client with pneumonia. For this examination the nurse
should use:

A. fingertips

B. ulnar surface of hand

C. dorsal surface of her hand

D. finger pads

RATIONALE AND ANSWER:

ANSWER B

ulnar surface ulnar for tactile fremitus, thrills, and vocal vibrations dorsal for temperature finger tips and
finger pads for texture and shape.

93. When examining a client who has abdominal pain, a nurse should assess

A. any quadrant first

B. the symptomatic quadrant first

C. the symptomatic quadrant last

D. the symptomatic quadrant second or third

CORRECT ANSWER:

C. the symptomatic quadrant last

94. a nurse is caring for a client who has suffered a severe stroke. During routine assessment the nurse
notices cheyne - strokes respirations which are:

A. progressively deeper breaths followed by shallower breaths with apneic sounds

B. rapid deep breaths with abrupt pauses between breaths

C. rapid deep breaths and irregular breathing without pauses

D. shallow breaths with an increased respiratory rate

CORRECT ANSWER:

A. progressively deeper breaths followed by shallower breaths with apneic sounds

95. A nurse is assessing a clients abdomen. Which examination technique should the nurse use first

A. auscultation

B. percussion

C. inspection
D. palpation

CORRECT ANSWER:

D. palpation

96. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that
percussion over an area of atelectasis in the lungs would reveal:

A. Dullness

B. Resonance

C. Tympany

D. Hyperresonance

CORRECT ANSWER:

A. Dullness

97. A 21-year-old college football player has been in the hospital 24 hours for observation following a
concussion. His blood pressure (BP) has been stable at 118/62 mm Hg, but suddenly he complains of a
severe headache and his BP is 170/94 mm Hg. The nurse orders vital sign monitoring with what
frequency?

A. every 4 hrs

B. every 8 hrs

C. every 5 minutes

D. once per shift

CORRECT ANSWER:

C. every 5 minutes

98. Standard vital sign measurement times is _________

A. Every hour

B. Every 2 hours
C. Every 8 hours

D. Every 4 hours

CORRECT ANSWER:

D. Every 4 hours

99. Considering the patient’s rights, the physician explained to the patient that classification of blood
pressure (BP) for adults an its category. Since Mr. Co’s BP range from 145/159 (systolic) 92/98 (diastolic)
an was consistent for almost 3 months he was classified to be in______.

A. Stage 2 HPN

B. Stage 3 HPN

C. Stage 1 HPN

D. Prehypertension

RATIONALE AND ANSWER:

ANSWER: A

Normal. between, less than 120 mmHg and less than 80 mmHg.Elevated. Elevated stage starts from 120
mmHg to 129 mmHg for systolic blood pressure and less than 80 mmHg for diastolic pressure.Stage 1
hypertension. Stage 1 starts when the patient has a systolic pressure of 130 to 139 mmHg and a diastolic
pressure of 80 to 89 mmHg.Stage 2 hypertension. Stage 2 starts when the systolic pressure is already
more than or equal than 140 mmHg and the diastolic is more than or equal than 90 mmHg.

100. The nurse auscultates the abdominal area of the patient with AAA. Which of the following sounds
can be DISTINCTLY heard over the area?

A. Dullness

B. Friction rubs

C. Bruit

D. Crackles

CORRECT ANSWER:

C. Bruit