1. An 82-year-old woman is admitted after a fall. She has unintentionally lost 8 kg over 4 months, has a poor appetite and her BMI is 18 kg/m². She is eating less than half of her meals on the ward.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Recommend fluid restriction to improve appetite.
B. Start parenteral nutrition immediately without assessment.
C. Identify malnutrition risk and refer for nutritional assessment and oral nutrition support if appropriate.
D. Advise that weight loss is expected with ageing.
E. Start long-term antibiotics.
2. A 49-year-old man with alcohol dependence has eaten very little for 12 days. His BMI is 15.8 kg/m² and baseline phosphate is low. The team plans to restart nutrition.
Which ONE of the following is the most appropriate concern?
A. Nutrition should be restarted at full requirements immediately.
B. Electrolyte monitoring is unnecessary if feeding is oral.
C. Refeeding syndrome occurs only with parenteral nutrition.
D. Thiamine is only needed after neurological symptoms appear.
E. He is at high risk of refeeding syndrome and needs cautious feeding, thiamine and electrolyte monitoring.
3. A 74-year-old man has a nasogastric tube inserted for feeding after a stroke. Before the first feed, the nurse asks whether the tube position needs checking.
Which ONE of the following is the most appropriate advice?
A. Confirm tube position according to local policy before feeding or administering medicines.
B. Begin feeding if the patient is not coughing.
C. Flush with milk to confirm position.
D. Start feed overnight and check position the next morning.
E. Assume correct placement if the tube was inserted by an experienced nurse.
4. A 62-year-old man with bowel obstruction is started on parenteral nutrition through a central venous catheter. He later develops fever, rigors and raised inflammatory markers.
Which ONE of the following is the most appropriate medicines-related concern?
A. Parenteral nutrition prevents bloodstream infection.
B. Fever is expected in all patients receiving nutrition support.
C. The feed should be infused faster to reduce infection risk.
D. Catheter-related bloodstream infection should be considered and assessed urgently.
E. Oral iron is the immediate treatment.
5. A 55-year-old man taking phenytoin is started on continuous enteral feeding via a nasogastric tube. Two weeks later, he has a breakthrough seizure and his phenytoin level is low.
Which ONE of the following is the most appropriate pharmacist intervention?
A. Stop enteral feeding permanently.
B. Review the timing of phenytoin administration with feeds and monitor levels.
C. Give phenytoin with calcium supplements to improve absorption.
D. Switch immediately to oral iron.
E. Ignore the level because enteral feeding cannot affect medicines.
6. A 70-year-old woman with a new PEG tube is prescribed several modified-release tablets to be crushed and given via the tube.
Which ONE of the following is the most appropriate pharmacist action?
A. Crush all medicines together to reduce administration time.
B. Mix medicines directly into the enteral feed bag.
C. Give all medicines with orange juice through the tube.
D. Use only parenteral nutrition from now on.
E. Review formulation suitability because some modified-release medicines should not be crushed.
7. A 78-year-old man with chronic kidney disease is on a renal ward. His potassium is 6.1 mmol/L and he has been drinking large quantities of orange juice and using a salt substitute.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Discuss dietary potassium sources and salt substitute use with the renal team or dietitian.
B. Recommend increasing orange juice for vitamin C.
C. Advise using potassium-containing salt substitutes routinely.
D. Reassure that diet cannot affect potassium.
E. Start oral iron to lower potassium.
8. A 33-year-old woman with Crohn’s disease has a high-output ileostomy. She reports dizziness, thirst and reduced urine output. Her stoma output has been over 2 litres daily.
Which ONE of the following is the most appropriate action?
A. Recommend plain water only and no salts.
B. Advise stopping all fluids.
C. Treat as uncomplicated constipation.
D. Seek urgent clinical review because high-output stoma can cause dehydration and electrolyte disturbance.
E. Start loperamide without assessing hydration or electrolytes.
9. A 45-year-old woman has dysphagia following a stroke. She coughs when drinking thin fluids. Speech and language therapy recommends thickened fluids.
Which ONE of the following is the most appropriate rationale?
A. Thickened fluids treat iron-deficiency anaemia.
B. Thickened fluids increase vitamin B12 absorption.
C. Thickened fluids are used to increase calorie content only.
D. Thickened fluids may reduce aspiration risk in patients with unsafe swallow.
E. Thickened fluids replace all medicines.
10. A 58-year-old man taking warfarin wants to start a diet containing large amounts of kale and spinach daily. His INR has previously been stable.
Which ONE of the following is the most appropriate advice?
A. Avoid all green vegetables permanently.
B. Keep vitamin K intake consistent and arrange INR monitoring if diet changes significantly.
C. Double warfarin immediately.
D. Stop warfarin while eating green vegetables.
E. Green vegetables have no relevance to warfarin.
11. A 70-year-old man has microcytic anaemia. His haemoglobin is 88 g/L, MCV is low and ferritin is low. He reports fatigue but no chest pain or haemodynamic instability.
Which ONE of the following is the most appropriate initial treatment consideration?
A. Start folic acid without checking iron status.
B. Treat with vitamin B12 injections only.
C. Reassure because microcytosis is normal with ageing.
D. Start oral iron replacement if appropriate while investigating the underlying cause.
E. Start long-term anticoagulation.
12. A 67-year-old man is newly diagnosed with iron-deficiency anaemia. He has no obvious dietary cause and reports a change in bowel habit over 3 months.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Ensure investigation for possible gastrointestinal blood loss or malignancy is considered.
B. Recommend treating with iron only and no further assessment.
C. Advise that bowel symptoms are unrelated to anaemia.
D. Recommend stopping all medicines.
E. Suggest high-dose folic acid as first-line treatment.
13. A 29-year-old woman is prescribed oral ferrous sulfate for iron-deficiency anaemia. She reports nausea and constipation after one week.
Which ONE of the following is the most appropriate advice?
A. Stop iron permanently because gastrointestinal effects mean allergy.
B. Take iron with calcium tablets to improve absorption.
C. Increase to four tablets daily.
D. Switch to warfarin.
E. Review tolerability and consider dose timing, formulation change or reduced frequency if appropriate.
14. A 61-year-old man taking oral iron notices his stools have become darker. He has no abdominal pain, dizziness, haematemesis or tarry offensive stools.
Which ONE of the following is the most appropriate explanation?
A. This always indicates gastrointestinal bleeding.
B. This confirms iron treatment is not being absorbed.
C. Dark stools can occur with oral iron, but red flags for bleeding should be assessed.
D. He should take aspirin to reverse the colour change.
E. He should stop all food containing iron.
15. A 42-year-old woman has symptomatic iron-deficiency anaemia and cannot tolerate several oral iron preparations despite dose adjustment. Her haemoglobin remains low.
Which ONE of the following may be considered after clinical review?
A. Long-term oral folic acid only.
B. Intravenous iron if oral treatment is unsuitable or ineffective.
C. Vitamin K therapy.
D. Allopurinol.
E. No further treatment.
16. A 76-year-old woman has macrocytic anaemia, glossitis, numbness in her feet and unsteady gait. Vitamin B12 deficiency is suspected.
Which ONE of the following is the most appropriate action?
A. Give folic acid alone and review in 6 months.
B. Reassure because neurological symptoms are unrelated.
C. Wait for anaemia to become severe before treating.
D. Arrange prompt assessment and treatment because neurological features may become irreversible.
E. Start oral iron only.
17. A 64-year-old man has macrocytic anaemia. Folate is low but vitamin B12 results are not yet available. He reports tingling in his feet.
Which ONE of the following is the most appropriate pharmacist concern?
A. Vitamin B12 deficiency should be excluded or treated before giving folic acid alone.
B. Folic acid treats all causes of neuropathy.
C. Iron deficiency is the only cause of macrocytosis.
D. Neurological symptoms prove folate deficiency only.
E. No treatment is ever needed for macrocytosis.
18. A 59-year-old woman has pernicious anaemia with previous neurological symptoms. She asks whether she can stop her hydroxocobalamin injections now that her blood count is normal.
Which ONE of the following is the most appropriate advice?
A. Stop immediately and restart only if anaemia returns.
B. Replace injections with iron tablets.
C. Use folic acid only.
D. Take vitamin C instead.
E. Continue long-term vitamin B12 replacement as advised because pernicious anaemia usually requires ongoing treatment.
19. A 38-year-old woman with epilepsy takes sodium valproate and is planning pregnancy. She asks about vitamins.
Which ONE of the following is the most appropriate pharmacist action?
A. Recommend standard-dose vitamin C only.
B. Reassure that folic acid is unnecessary.
C. Urgently signpost for specialist review and discuss folic acid needs because valproate has major pregnancy safety concerns.
D. Advise stopping valproate immediately without medical advice.
E. Replace valproate with oral iron.
20. A 72-year-old man with alcohol dependence is admitted confused and ataxic. He has nystagmus and poor nutritional intake. Wernicke’s encephalopathy is suspected.
Which ONE of the following is the most appropriate treatment consideration?
A. Oral iron as urgent treatment.
B. Prompt high-dose thiamine treatment before or with carbohydrate administration.
C. Vitamin D only.
D. Fluid restriction as the sole treatment.
E. Delayed outpatient dietetic review only.
21. A 69-year-old woman rarely leaves home and has diffuse bone pain and proximal muscle weakness. Her vitamin D level is very low.
Which ONE of the following is the most appropriate treatment consideration?
A. Long-term warfarin.
B. Oral iron only.
C. Folic acid only.
D. Thiamine only.
E. Vitamin D replacement and assessment of calcium and bone health.
22. A 46-year-old man who has had bariatric surgery presents with fatigue, glossitis and paraesthesia. He has poor adherence to long-term supplements.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Reassure because supplementation is only needed for 1 month after surgery.
B. Recommend stopping all supplements to reduce nausea.
C. Assess for nutritional deficiencies such as vitamin B12, iron and folate and support long-term supplementation.
D. Treat as uncomplicated reflux only.
E. Give loperamide.
23. A 37-year-old woman follows a strict vegan diet and reports fatigue and numbness in her toes. Her MCV is raised and vitamin B12 is low.
Which ONE of the following is the most appropriate counselling point?
A. Vegan diets may require reliable vitamin B12 supplementation or fortified foods.
B. Vitamin B12 is abundant in unfortified plant foods.
C. Oral iron treats vitamin B12-related neuropathy.
D. B12 deficiency cannot occur if folate intake is high.
E. Treatment is unnecessary if haemoglobin is normal.
24. A 6-year-old child has a metabolic disorder and must avoid phenylalanine. The parent asks whether medicines containing aspartame matter.
Which ONE of the following is the most appropriate advice?
A. Aspartame is always safe in phenylketonuria.
B. Check medicines for aspartame or phenylalanine content and seek specialist advice if unsure.
C. Phenylketonuria affects only protein in food, not medicines.
D. Double the medicine dose if aspartame is present.
E. Avoid all medicines permanently.
25. A 53-year-old man receiving parenteral nutrition has rising blood glucose, triglycerides and liver enzymes. He is otherwise stable.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Increase lipid content automatically.
B. Stop all monitoring because parenteral nutrition is complete.
C. Replace parenteral nutrition with oral iron.
D. Review parenteral nutrition composition, monitoring results and metabolic complications with the nutrition team.
E. Add warfarin to prevent hyperglycaemia.
26. A patient receiving enteral nutrition has a blocked feeding tube. Staff ask whether they should crush multiple tablets together and push them through with force.
Which ONE of the following is the most appropriate advice?
A. Use appropriate flushing and administration procedures and review medicine formulations to prevent blockage.
B. Force the mixture through using a small syringe.
C. Mix all tablets with thickened feed.
D. Add potassium chloride to dissolve the blockage.
E. Stop all medicines permanently.
27. A 24-year-old woman with anorexia nervosa has BMI 14.9 kg/m², bradycardia and low phosphate. She is being considered for nutritional rehabilitation.
Which ONE of the following is the most appropriate concern?
A. She can be refed at full calorie requirements immediately.
B. Bradycardia indicates low risk.
C. Refeeding syndrome is not possible in eating disorders.
D. Nutrition should be delayed for several months.
E. She needs urgent specialist assessment with cautious refeeding and electrolyte monitoring.
28. A 66-year-old man with coeliac disease has ongoing diarrhoea and iron-deficiency anaemia. He admits he sometimes eats foods containing gluten.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Recommend stopping all gluten-free products.
B. Treat with loperamide only.
C. Explore gluten exposure, adherence and need for dietetic or specialist review.
D. Advise gluten cannot affect iron levels.
E. Start warfarin.
29. A 70-year-old man has jaundice, dark urine, raised bilirubin and reticulocytosis. His haemoglobin is falling and haemolysis is suspected.
Which ONE of the following is the most appropriate interpretation?
A. Iron-deficiency anaemia is confirmed.
B. This is typical uncomplicated folate deficiency.
C. Oral iron should be started without further assessment.
D. Haemolytic anaemia should be considered and assessed urgently.
E. The results are normal in older adults.
30. A 68-year-old woman has fatigue, recurrent infections and bruising. Full blood count shows low haemoglobin, low neutrophils and low platelets.
Which ONE of the following is the most appropriate concern?
A. Isolated iron deficiency only.
B. Pancytopenia requiring urgent clinical assessment.
C. Normal ageing.
D. Vitamin D deficiency only.
E. Uncomplicated dehydration.
31. A 28-year-old man with sickle cell disease presents with severe limb pain consistent with previous painful crises. He has no fever, chest pain or shortness of breath.
Which ONE of the following is the most appropriate initial management principle?
A. Delay analgesia until imaging confirms the diagnosis.
B. Provide prompt analgesia and assessment according to an individualised sickle cell pain plan where available.
C. Treat with oral iron.
D. Avoid hydration assessment.
E. Give vitamin K as first-line treatment.
32. A 19-year-old woman with sickle cell disease presents with chest pain, fever, cough and oxygen saturation of 90% on air.
Which ONE of the following is the most appropriate action?
A. Treat as uncomplicated painful crisis only.
B. Recommend paracetamol and review tomorrow.
C. Delay assessment until routine haematology clinic.
D. Arrange urgent assessment for possible acute chest syndrome.
E. Start oral iron and discharge.
33. A 30-year-old man with known G6PD deficiency is prescribed an antibiotic. He asks why some medicines are avoided.
Which ONE of the following is the most appropriate explanation?
A. Some oxidant medicines can trigger haemolysis in G6PD deficiency.
B. G6PD deficiency causes iron overload in all cases.
C. All antibiotics are contraindicated.
D. Folic acid prevents all medicine reactions.
E. G6PD deficiency affects only platelet count.
34. A patient receiving chemotherapy contacts the pharmacy with temperature 38.4°C, shivering and feeling generally unwell 8 days after treatment.
Which ONE of the following is the most appropriate action?
A. Recommend paracetamol and call back in 48 hours.
B. Supply oral iron.
C. Reassure because fever is expected after chemotherapy.
D. Advise waiting for the next oncology appointment.
E. Arrange immediate assessment for possible neutropenic sepsis.
35. A 64-year-old man has a platelet count of 12 × 10⁹/L and new gum bleeding. He recently completed chemotherapy.
Which ONE of the following is the most appropriate pharmacist concern?
A. This platelet count rules out bleeding risk.
B. Oral iron should correct the platelet count immediately.
C. Severe thrombocytopenia with bleeding requires urgent clinical assessment.
D. The result is typical uncomplicated vitamin D deficiency.
E. No precautions are required.
36. A nurse asks why patient identification checks before blood transfusion are so strict, even when the patient is well known to the ward.
Which ONE of the following is the best explanation?
A. Checks are mainly for audit and do not affect patient safety.
B. Identification checks are only needed for first transfusions.
C. Compatibility testing removes the need for bedside checks.
D. Strict identity checks reduce the risk of wrong blood transfusion, which can be fatal.
E. Checks are unnecessary if the blood group is O negative.
37. Ten minutes after starting a red blood cell transfusion, a patient develops fever, chills, back pain and dark urine.
Which ONE of the following is the most appropriate immediate action?
A. Increase the transfusion rate.
B. Stop the transfusion and arrange urgent clinical assessment according to transfusion reaction policy.
C. Give the rest of the unit with paracetamol cover.
D. Ignore symptoms if observations are stable.
E. Start oral iron and continue transfusion.
38. A 79-year-old woman develops acute breathlessness, hypertension and pulmonary oedema during a blood transfusion. She has heart failure and chronic kidney disease.
Which ONE of the following complication should be considered?
A. Transfusion-associated circulatory overload.
B. Oral iron intolerance.
C. Folate deficiency.
D. Sickle cell painful crisis.
E. Refeeding syndrome.
39. A stable inpatient has chronic anaemia with haemoglobin of 72 g/L. The team asks whether transfusion is automatically required.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Transfuse all patients with anaemia regardless of symptoms.
B. Use platelets instead of red cells.
C. Consider symptoms, cause of anaemia, comorbidities and local transfusion thresholds before deciding.
D. Use vitamin K instead.
E. Avoid investigating the cause if transfusion is given.
40. A patient with capacity refuses a blood transfusion for religious reasons. The medical team asks how to proceed.
Which ONE of the following is the most appropriate approach?
A. Transfuse covertly if haemoglobin is low.
B. Ignore the refusal during emergencies.
C. Ask relatives to override the patient.
D. Document refusal only after transfusion.
E. Respect the informed refusal and discuss acceptable alternatives and blood conservation strategies.
41. A 50-year-old man taking warfarin has started a very low-calorie diet and stopped eating most vegetables. His INR becomes unstable.
Which ONE of the following is the most appropriate counselling point?
A. Major dietary changes can affect INR stability, so warfarin monitoring and dietary consistency are important.
B. Warfarin is unaffected by nutrition.
C. Vitamin K intake should vary as much as possible.
D. Stop warfarin whenever dieting.
E. Take vitamin K supplements without telling the clinic.
42. A patient with chronic alcohol dependence is admitted malnourished. He is prescribed glucose-containing fluids before receiving vitamins.
Which ONE of the following is the most appropriate pharmacist concern?
A. Glucose treats thiamine deficiency.
B. Vitamins should be avoided in alcohol dependence.
C. Thiamine should be considered before or with glucose to reduce Wernicke’s encephalopathy risk.
D. Oral iron prevents Wernicke’s encephalopathy.
E. No monitoring is required.
43. A 71-year-old woman receiving chemotherapy has been prescribed filgrastim after a previous episode of febrile neutropenia. She asks why it is being used.
Which ONE of the following is the most appropriate explanation?
A. It treats iron deficiency.
B. It reverses anticoagulation.
C. It treats vitamin B12 deficiency.
D. It prevents all infections permanently.
E. It stimulates neutrophil production and may reduce the risk or duration of neutropenia in selected patients.
44. A 63-year-old man with chronic lymphocytic leukaemia asks whether live vaccines are suitable during active immunosuppressive treatment.
Which ONE of the following is the most appropriate advice?
A. Live vaccines are always safe in immunosuppression.
B. Specialist advice is needed because live vaccines may be contraindicated.
C. Live vaccines should be doubled to improve response.
D. Antibiotics replace all vaccines.
E. Immunosuppression affects only red blood cells.
45. A 74-year-old woman with B12 deficiency has been taking folic acid purchased online. Her anaemia has improved but her numbness and balance problems are worsening.
Which ONE of the following is the most appropriate interpretation?
A. Folic acid cures B12-related neuropathy.
B. Oral iron should be added and no further review is needed.
C. Neurological symptoms are unrelated to vitamin deficiency.
D. Folic acid may improve blood counts while allowing B12-related neurological damage to progress.
E. This proves she has iron deficiency.
46. A 60-year-old man with metastatic cancer has poor appetite, weight loss and early satiety. His family ask whether oral nutritional supplements may be useful.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Oral nutritional supplements are never used in cancer.
B. Supplements replace symptom assessment.
C. Assess intake, symptoms and goals of care, and consider dietetic referral and oral nutritional support if appropriate.
D. Recommend force-feeding without review.
E. Start parenteral nutrition in all cases.
47. A 77-year-old woman is prescribed ferrous sulfate once daily. She also takes levothyroxine every morning.
Which ONE of the following is the most appropriate advice?
A. Separate iron and levothyroxine administration because iron can reduce levothyroxine absorption.
B. Take both together to improve thyroid control.
C. Stop levothyroxine while taking iron.
D. Take iron only once a month.
E. Replace iron with calcium.
48. A 66-year-old man receiving enteral feeding has persistent diarrhoea. He is also receiving antibiotics and liquid medicines containing sorbitol.
Which ONE of the following is the most appropriate pharmacist contribution?
A. Stop enteral feeding permanently without assessment.
B. Diagnose feed intolerance without reviewing medicines.
C. Add senna.
D. Ignore because diarrhoea is inevitable with tube feeding.
E. Review medicines, infection risk and feed regimen as possible contributors to diarrhoea.
49. A 34-year-old pregnant woman has iron-deficiency anaemia. She is prescribed oral iron and asks why treatment needs to continue after haemoglobin improves.
Which ONE of the following is the most appropriate explanation?
A. Iron is continued indefinitely in all patients.
B. Continuing iron after haemoglobin normalises helps replenish iron stores.
C. Iron prevents all pregnancy complications.
D. Iron should stop as soon as symptoms improve.
E. Iron replaces folic acid in pregnancy.
50. A 57-year-old man with chronic kidney disease has normocytic anaemia. Iron studies are adequate and erythropoietin deficiency is suspected.
Which ONE of the following is the most appropriate treatment consideration?
A. Treat with antibiotics only.
B. Start warfarin.
C. Give folic acid without monitoring.
D. Consider specialist review for erythropoiesis-stimulating therapy where appropriate.
E. Reassure that anaemia is unrelated to kidney disease.
Nutrition and Blood Questions
Answers and Rationale
1. C
Unintentional weight loss, low BMI and poor intake indicate malnutrition risk. The pharmacist should help identify risk and support referral for nutritional assessment, oral nutrition support and monitoring.
2. E
Very low BMI, prolonged poor intake and low phosphate indicate high refeeding risk. Nutrition should be restarted cautiously with thiamine, electrolyte replacement and close monitoring.
3. A
Nasogastric tube position must be confirmed before feeding or medicine administration to reduce the risk of pulmonary administration and aspiration-related harm.
4. D
Parenteral nutrition through a central line carries a risk of catheter-related bloodstream infection. Fever and rigors require urgent assessment, cultures and review of line management.
5. B
Continuous enteral feeding can reduce phenytoin absorption in some patients. Administration timing, tube flushing and therapeutic drug monitoring should be reviewed.
6. E
Modified-release medicines may become unsafe or ineffective if crushed. Medicines for enteral tube administration should be reviewed for formulation suitability and safer alternatives.
7. A
Orange juice and salt substitutes can contain significant potassium. In hyperkalaemia and CKD, dietary potassium sources and salt substitute use should be reviewed with the renal team or dietitian.
8. D
High-output stoma can rapidly cause dehydration, electrolyte disturbance and acute kidney injury. Dizziness, thirst and reduced urine output are concerning and require urgent review.
9. D
Thickened fluids may help reduce aspiration risk in patients with dysphagia and unsafe swallow. They should be used according to speech and language therapy recommendations.
10. B
Warfarin effect can be influenced by vitamin K intake. Patients should aim for dietary consistency and seek INR monitoring if making major dietary changes.
11. D
Low haemoglobin, low MCV and low ferritin indicate iron-deficiency anaemia. Oral iron is appropriate if tolerated, but the underlying cause should also be investigated.
12. A
Iron-deficiency anaemia in an older man, especially with bowel habit change, requires investigation for gastrointestinal blood loss or malignancy. Iron treatment alone is insufficient.
13. E
Oral iron commonly causes gastrointestinal adverse effects. Tolerability can often be improved by adjusting timing, formulation or dosing frequency while maintaining treatment goals.
14. C
Dark stools are common with oral iron. However, symptoms such as tarry offensive stools, dizziness, abdominal pain or vomiting blood would require assessment for bleeding.
15. B
Intravenous iron may be considered when oral iron is not tolerated, ineffective or unsuitable. The decision should be made after clinical review of cause, severity and risks.
16. D
B12 deficiency can cause neurological symptoms such as paraesthesia, gait disturbance and neuropathy. Delayed treatment can lead to irreversible neurological damage.
17. A
Folic acid can correct anaemia while allowing neurological complications of B12 deficiency to progress. B12 deficiency should be excluded or treated when neurological symptoms are present.
18. E
Pernicious anaemia usually requires long-term vitamin B12 replacement because absorption is impaired. Normal blood counts do not mean treatment can be stopped.
19. C
Valproate has major pregnancy safety concerns, so urgent specialist review is needed before pregnancy. Folic acid requirements should also be discussed as part of preconception care.
20. B
Wernicke’s encephalopathy is a medical emergency related to thiamine deficiency. Thiamine should be given promptly, ideally before or with carbohydrate administration.
21. E
Low vitamin D with bone pain and proximal muscle weakness suggests osteomalacia. Vitamin D replacement and assessment of calcium and bone health are appropriate.
22. C
Bariatric surgery increases the risk of long-term nutritional deficiencies, including B12, iron and folate. Lifelong supplementation and monitoring are often required.
23. A
People following a strict vegan diet need reliable B12 from fortified foods or supplements. B12 deficiency can cause macrocytosis and neurological symptoms.
24. B
Aspartame is a source of phenylalanine and can be relevant in phenylketonuria. Medicine excipients should be checked and specialist advice sought if uncertain.
25. D
Parenteral nutrition can cause metabolic complications such as hyperglycaemia, hypertriglyceridaemia and liver test abnormalities. The regimen and monitoring should be reviewed by the nutrition team.
26. A
Blocked tubes can result from unsuitable formulations, poor flushing or mixing medicines together. Proper administration technique and formulation review reduce blockage risk.
27. E
Very low BMI, bradycardia and low phosphate indicate medical risk and high refeeding risk. Specialist assessment, cautious refeeding and electrolyte monitoring are required.
28. C
Persistent symptoms and iron-deficiency anaemia in coeliac disease may reflect ongoing gluten exposure, poor adherence or another cause. Dietetic or specialist review is appropriate.
29. D
Jaundice, falling haemoglobin and reticulocytosis suggest increased red cell destruction. Haemolytic anaemia requires assessment of cause and severity.
30. B
Low red cells, white cells and platelets indicate pancytopenia. This may reflect marrow failure, malignancy, medicines or severe deficiency and requires urgent clinical assessment.
31. B
Sickle cell painful episodes require prompt analgesia and assessment. Individualised pain plans help ensure timely and appropriate treatment.
32. D
Chest pain, fever, cough and hypoxia in sickle cell disease suggest acute chest syndrome. This is a serious complication requiring urgent assessment and treatment.
33. A
G6PD deficiency increases susceptibility to oxidative haemolysis from certain medicines, foods or infections. Medicine choice should take this risk into account.
34. E
Fever and systemic illness after chemotherapy may indicate neutropenic sepsis. This is an emergency requiring immediate assessment and empirical treatment.
35. C
A platelet count of 12 × 10⁹/L with bleeding indicates high bleeding risk. Urgent clinical assessment is needed to determine supportive treatment, including possible platelet transfusion.
36. D
Wrong blood transfusion can cause fatal haemolytic reactions. Strict patient identification and bedside checks are essential even when staff know the patient.
37. B
Fever, chills, back pain and dark urine soon after transfusion may indicate an acute haemolytic transfusion reaction. The transfusion should be stopped and the patient assessed urgently.
38. A
Acute breathlessness, hypertension and pulmonary oedema during transfusion in a patient with heart failure suggests transfusion-associated circulatory overload. The transfusion should be assessed urgently.
39. C
Red cell transfusion decisions should consider haemoglobin, symptoms, cause of anaemia, comorbidities and local thresholds. Transfusion should not replace investigation and treatment of the cause.
40. E
A patient with capacity can refuse transfusion. The decision should be respected, documented and supported by discussion of acceptable alternatives and blood conservation strategies.
41. A
Large dietary changes can alter vitamin K intake and affect warfarin control. Patients should aim for consistency and inform the anticoagulation clinic when changing diet.
42. C
Malnourished patients with alcohol dependence are at risk of thiamine deficiency and Wernicke’s encephalopathy. Thiamine should be considered before or alongside glucose.
43. E
Filgrastim is a granulocyte colony-stimulating factor that stimulates neutrophil production. It may be used in selected patients to reduce neutropenia risk or duration.
44. B
Live vaccines may be contraindicated during significant immunosuppression. Specialist advice is required to assess timing, vaccine type and immune status.
45. D
Folic acid can improve the anaemia of B12 deficiency while neurological damage continues. Worsening numbness and balance problems require urgent B12 assessment and treatment.
46. C
Cancer-related weight loss requires assessment of intake, symptoms, treatment burden and goals of care. Oral nutritional support and dietetic referral may be appropriate.
47. A
Iron salts can reduce levothyroxine absorption if taken together. Separating administration times and monitoring thyroid function can help maintain thyroid control.
48. E
Diarrhoea during enteral feeding may be caused by medicines, antibiotics, infection, feed rate or formula. A structured review is needed before assuming feed intolerance.
49. B
Iron therapy is usually continued after haemoglobin improves to replenish iron stores. Stopping as soon as symptoms improve may lead to recurrence.
50. D
Chronic kidney disease can cause anaemia through reduced erythropoietin production. Specialist review may consider erythropoiesis-stimulating therapy, iron optimisation and monitoring.
Here are 50 multiple-choice questions designed to mimic the GPHC exam itself. At the bottom of the page you will find answers and rationale for each question.