NUR 430 EXAM 1 NCLEX QUESTIONS | COMPREHENSIVE NURSING
PRACTICE QUESTIONS, ANSWERS & RATIONALES 2026/2027
Nutritional intervention in heart failure is aimed at a reduction in fluid retention and sodium limitation in
order to:
A) increase central venous pressure.
B) increase end-diastolic volume.
C) reduce afterload.
D) reduce preload. - ✔✔D) reduce preload
Interventions in heart failure are designed to reduce fluid retention, thereby reducing the preload.
Anorexia may interfere with oral intake. Patients who are unable to meet their caloric needs on their
own require nutritional intervention. Which of the following statements best describes the goal of
initiating a nutritional intervention for a patient with anorexia?
A) Diarrhea from concurrent administration of lactulose coincides with feeding intolerance.
B) Small, frequent feedings are usually tolerated less than are three regular meals daily.
C) Standard nasogastric feeding tubes can be used safely without increasing the risk of variceal bleeding.
D) Total parenteral nutrition (TPN) should be reserved for patients who are absolutely unable to tolerate
oral and enteral feeding. - ✔✔D) Total parenteral nutrition (TPN) should be reserved for patients who
are absolutely unable to tolerate oral and enteral feeding.
Small-bore nasoenteric feeding tubes can be used safely without increasing the risk of variceal bleeding.
TPN should be reserved for patients who are absolutely unable to tolerate enteral feeding. Diarrhea from
concurrent administration of lactulose should not be confused with feeding intolerance.
A patient with facial trauma is unable to eat after surgery. His albumin level is 1.5. He is probably in a:
A) Positive nitrogen balance
B) Negative nitrogen balance
C) Nitrogen equilibrium
D) Nitrogen disequilibrium - ✔✔B) Negative nitrogen balance
The patient is experiencing a high rate of gluconeogenesis and is burning up his protein stores. Muscle
mass will break down unless nutrition is given. A positive nitrogen balance means the patient is eating
more than he is excreting (healing). Nitrogen equilibrium occurs in normal, healthy adults. Nitrogen
disequilibrium is a nonexistent condition.
A patient has low albumin, prealbumin, and transferrin levels with a decreased total lymphocyte count.
The priority nursing diagnosis is:
A) Altered Nutrition, Less Than Body Requirement
B) Risk for Infection
C) Fluid Volume Overload
D) Altered Nutrition, More Than Body Requirement - ✔✔A) Altered Nutrition, Less Than Body
Requirement
,In this case, the patient is showing signs of malnutrition and protein deficiency that must be corrected.
There is a risk for infection, but an actual problem is more of a priority than a potential one. The patient
would have a fluid volume deficit, not an overload. Cognitive Level: Synthesis Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
The nurse is providing dietary education for the patient with hypertension. The patient asks what the
DASH diet is. Which of the following comments is appropriate for the nurse to make?
A) "DASH refers to the salt-free spices you should learn to cook with now."
B) "DASH stands for dietary approach to stop hypertension."
C) "It means you must eliminate all salt from your diet."
D) "The DASH diet eliminates fruits from the diet." - ✔✔B) "DASH stands for dietary approach to stop
hypertension."
Dietary Approach to Stop Hypertension is the correct definition for DASH. The object is to consume a
diet rich in fruits and vegetables, potassium, and calcium and low in saturated fat to help control
hypertension. The DASH diet does not refer to salt-free spices. One cannot eliminate all salt from the
diet, but lower salt is advisable for those sensitive to increased salt levels. The DASH diet is high in both
fruits and vegetables. Cognitive Level: Comprehension Nursing Process: Implementation Client Need:
Health Promotion and Maintenance
Nutritional intervention in heart failure is aimed at a reduction in fluid retention and sodium limitation in
order to:
A) reduce afterload.
B) reduce preload.
C) increase end-diastolic volume.
D) increase central venous pressure. - ✔✔B) reduce preload.
Interventions in heart failure are designed to reduce fluid retention, thereby reducing the preload.
A patient is receiving enteral nutritional feeding. Which intervention should be included to reduce the
risk of aspiration?
A) Maintain head of bed at less than 30 degrees.
B) Deflate the endotracheal tube cuff during feeding administration.
C) Feed into the small bowel rather than the stomach.
D) Hold feedings for gastric residual volume of 50 mL. - ✔✔C) Feed into the small bowel rather than the
stomach.
Pulmonary aspiration of enteral formulas and subsequent pneumonia is a serious complication of enteral
feeding in critically ill patients. To reduce the risk of pulmonary aspiration of formula during enteral
feeding, the nurse must keep the head of the bed elevated unless contraindicated; temporarily stop
feedings when the patient must be supine for prolonged periods; position the patient in the right lateral
decubitus position when possible to encourage gastric emptying; use postpyloric feeding methods; keep
the cuff of the endotracheal tube inflated as much as possible during enteral feeding, if applicable; and
be alert to any increase in abdominal distention. Except in selected high-risk patients, there is little
evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL.
When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely,
resulting in:
, A) acute myocardial infarction.
B) aortic valve failure.
C) cardiac murmur.
D) systemic venous congestion. - ✔✔C) cardiac murmur.
A dysfunction of the chordae tendineae or of a papillary muscle can cause incomplete closure of an
atrioventricular valve, which results in backflow of blood into the atrium and produces a murmur. If a
papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely. Clinically,
this causes acute mitral regurgitation and an audible murmur that can be auscultated with a
stethoscope.
Aortic valve dysfunction pathologically alters the:
A) left atrium.
B) left ventricle.
C) right ventricle.
D) mitral valve. - ✔✔B) left ventricle.
Aortic valve dysfunction from any cause not only affects the valve leaflets but also pathologically alters
the shape of the left ventricle.
A physiologic cardiac shunt occurs when there is mixing of deoxygenated blood (usually venous blood
with reduced oxygen content) with arterial oxygenated blood. In the heart, this is demonstrated by:
A) atrial septal defect.
B) patent foramen ovale.
C) thebesian veins.
D) ventricular septal defect. - ✔✔C) thebesian veins.
The thebesian veins are small vessels that connect capillary beds directly with the cardiac chambers via
irregular endothelium-lined sinuses within the myocardium. The thebesian veins add a small quantity of
deoxygenated blood to the oxygenated blood in the left ventricle.
An important intracellular structure, essential for cardiac contraction, that stores calcium ions for release
and use after depolarization is the:
A) sarcoplasmic reticulum.
B) sarcomere.
C) sarcolemma.
D) transverse tubules. - ✔✔A) sarcoplasmic reticulum.
An extremely important intracellular structure that is necessary for successful contraction is the
sarcoplasmic reticulum. Calcium ions are stored in the sarcoplasmic reticulum and released for use after
depolarization.
The time from the beginning of the cardiac action potential (AP) until the time when the fiber can accept
another AP is called the:
A) excitability period.
B) depolarization period.
C) relative refractory period.
D) absolute refractory period. - ✔✔D) absolute refractory period.
PRACTICE QUESTIONS, ANSWERS & RATIONALES 2026/2027
Nutritional intervention in heart failure is aimed at a reduction in fluid retention and sodium limitation in
order to:
A) increase central venous pressure.
B) increase end-diastolic volume.
C) reduce afterload.
D) reduce preload. - ✔✔D) reduce preload
Interventions in heart failure are designed to reduce fluid retention, thereby reducing the preload.
Anorexia may interfere with oral intake. Patients who are unable to meet their caloric needs on their
own require nutritional intervention. Which of the following statements best describes the goal of
initiating a nutritional intervention for a patient with anorexia?
A) Diarrhea from concurrent administration of lactulose coincides with feeding intolerance.
B) Small, frequent feedings are usually tolerated less than are three regular meals daily.
C) Standard nasogastric feeding tubes can be used safely without increasing the risk of variceal bleeding.
D) Total parenteral nutrition (TPN) should be reserved for patients who are absolutely unable to tolerate
oral and enteral feeding. - ✔✔D) Total parenteral nutrition (TPN) should be reserved for patients who
are absolutely unable to tolerate oral and enteral feeding.
Small-bore nasoenteric feeding tubes can be used safely without increasing the risk of variceal bleeding.
TPN should be reserved for patients who are absolutely unable to tolerate enteral feeding. Diarrhea from
concurrent administration of lactulose should not be confused with feeding intolerance.
A patient with facial trauma is unable to eat after surgery. His albumin level is 1.5. He is probably in a:
A) Positive nitrogen balance
B) Negative nitrogen balance
C) Nitrogen equilibrium
D) Nitrogen disequilibrium - ✔✔B) Negative nitrogen balance
The patient is experiencing a high rate of gluconeogenesis and is burning up his protein stores. Muscle
mass will break down unless nutrition is given. A positive nitrogen balance means the patient is eating
more than he is excreting (healing). Nitrogen equilibrium occurs in normal, healthy adults. Nitrogen
disequilibrium is a nonexistent condition.
A patient has low albumin, prealbumin, and transferrin levels with a decreased total lymphocyte count.
The priority nursing diagnosis is:
A) Altered Nutrition, Less Than Body Requirement
B) Risk for Infection
C) Fluid Volume Overload
D) Altered Nutrition, More Than Body Requirement - ✔✔A) Altered Nutrition, Less Than Body
Requirement
,In this case, the patient is showing signs of malnutrition and protein deficiency that must be corrected.
There is a risk for infection, but an actual problem is more of a priority than a potential one. The patient
would have a fluid volume deficit, not an overload. Cognitive Level: Synthesis Nursing Process: Planning
Client Need: Physiological Integrity: Physiological Adaptation
The nurse is providing dietary education for the patient with hypertension. The patient asks what the
DASH diet is. Which of the following comments is appropriate for the nurse to make?
A) "DASH refers to the salt-free spices you should learn to cook with now."
B) "DASH stands for dietary approach to stop hypertension."
C) "It means you must eliminate all salt from your diet."
D) "The DASH diet eliminates fruits from the diet." - ✔✔B) "DASH stands for dietary approach to stop
hypertension."
Dietary Approach to Stop Hypertension is the correct definition for DASH. The object is to consume a
diet rich in fruits and vegetables, potassium, and calcium and low in saturated fat to help control
hypertension. The DASH diet does not refer to salt-free spices. One cannot eliminate all salt from the
diet, but lower salt is advisable for those sensitive to increased salt levels. The DASH diet is high in both
fruits and vegetables. Cognitive Level: Comprehension Nursing Process: Implementation Client Need:
Health Promotion and Maintenance
Nutritional intervention in heart failure is aimed at a reduction in fluid retention and sodium limitation in
order to:
A) reduce afterload.
B) reduce preload.
C) increase end-diastolic volume.
D) increase central venous pressure. - ✔✔B) reduce preload.
Interventions in heart failure are designed to reduce fluid retention, thereby reducing the preload.
A patient is receiving enteral nutritional feeding. Which intervention should be included to reduce the
risk of aspiration?
A) Maintain head of bed at less than 30 degrees.
B) Deflate the endotracheal tube cuff during feeding administration.
C) Feed into the small bowel rather than the stomach.
D) Hold feedings for gastric residual volume of 50 mL. - ✔✔C) Feed into the small bowel rather than the
stomach.
Pulmonary aspiration of enteral formulas and subsequent pneumonia is a serious complication of enteral
feeding in critically ill patients. To reduce the risk of pulmonary aspiration of formula during enteral
feeding, the nurse must keep the head of the bed elevated unless contraindicated; temporarily stop
feedings when the patient must be supine for prolonged periods; position the patient in the right lateral
decubitus position when possible to encourage gastric emptying; use postpyloric feeding methods; keep
the cuff of the endotracheal tube inflated as much as possible during enteral feeding, if applicable; and
be alert to any increase in abdominal distention. Except in selected high-risk patients, there is little
evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL.
When a papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely,
resulting in:
, A) acute myocardial infarction.
B) aortic valve failure.
C) cardiac murmur.
D) systemic venous congestion. - ✔✔C) cardiac murmur.
A dysfunction of the chordae tendineae or of a papillary muscle can cause incomplete closure of an
atrioventricular valve, which results in backflow of blood into the atrium and produces a murmur. If a
papillary muscle in the left ventricle ruptures, the mitral valve leaflets do not close completely. Clinically,
this causes acute mitral regurgitation and an audible murmur that can be auscultated with a
stethoscope.
Aortic valve dysfunction pathologically alters the:
A) left atrium.
B) left ventricle.
C) right ventricle.
D) mitral valve. - ✔✔B) left ventricle.
Aortic valve dysfunction from any cause not only affects the valve leaflets but also pathologically alters
the shape of the left ventricle.
A physiologic cardiac shunt occurs when there is mixing of deoxygenated blood (usually venous blood
with reduced oxygen content) with arterial oxygenated blood. In the heart, this is demonstrated by:
A) atrial septal defect.
B) patent foramen ovale.
C) thebesian veins.
D) ventricular septal defect. - ✔✔C) thebesian veins.
The thebesian veins are small vessels that connect capillary beds directly with the cardiac chambers via
irregular endothelium-lined sinuses within the myocardium. The thebesian veins add a small quantity of
deoxygenated blood to the oxygenated blood in the left ventricle.
An important intracellular structure, essential for cardiac contraction, that stores calcium ions for release
and use after depolarization is the:
A) sarcoplasmic reticulum.
B) sarcomere.
C) sarcolemma.
D) transverse tubules. - ✔✔A) sarcoplasmic reticulum.
An extremely important intracellular structure that is necessary for successful contraction is the
sarcoplasmic reticulum. Calcium ions are stored in the sarcoplasmic reticulum and released for use after
depolarization.
The time from the beginning of the cardiac action potential (AP) until the time when the fiber can accept
another AP is called the:
A) excitability period.
B) depolarization period.
C) relative refractory period.
D) absolute refractory period. - ✔✔D) absolute refractory period.
