From ASPEN presentations

Question 1

What is the primary disturbance seen with simple metabolic acidosis?

a. Decrease pCO2
b. Increase pCO2
c. Decrease HCO3-
d. Increase HCO3-

Answer 1

c. Decrease HCO3-

the acid base disorder is metabolic, it is primarily due to a change in the base component bicarbonate (HCO3-). Metabolic acidosis is a result of a decrease in HCO3-.

Question 2

A patient presents with a metabolic acidosis. Which ABG pattern fits this disorder?

a. Decreased pH, decreased HCO3-
b. Decreased pH, increased PCO2
c. Increased pH, increased HCO3-
d. Increased pH, decreased PCO2

Answer 2

a. Decreased pH, decreased HCO3-

acidosis is reflected in a low pH; metabolic acidosis is a result of a decrease in HCO3-.

Question 3

For a patient with metabolic acidosis, what is the appropriate method of compensation seen on an ABG?

a. Hyperventilation leading to an increase in pCO2
b. Hyperventilation leading to a decrease in pCO2
c. Hypoventilation leading to an increase in pCO2
d. Hypoventilation leading to an increase in pCO2

Answer 3

b. Hyperventilation leading to a decrease in pCO2

in metabolic disorders, the lungs will attempt to compensate in order to restore a normal pH. Since this is an acidosis, hyperventilation will occur in order to blow off / lower the pCO2 (the acidic component) and increase the pH. Hypoventilation leads to increased pCO2 which would worsen acidosis.

Question 4

Which of the following can lead to metabolic alkalosis?

a. Pulmonary embolism
b. Septic shock
c. High nasogastric output
d. Morphine overdose

Answer 4

c. High nasogastric output

High nasogastric output leads to a metabolic alkalosis through loss of chloride-rich fluids from the stomach and contraction alkalosis from fluid depletion. Pulmonary embolism presents with shortness of breath and rapid respiratory rate which would lead to a respiratory alkalosis; lactic acidosis occurs during septic shock which would lead to an anion gap metabolic acidosis; morphine overdose presents with depressed respirations leading to increased pCO2 and respiratory acidosis.

Question 5

Anion gap is calculated for which type of acid-base disorder?

a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

Answer 5

a. Metabolic acidosis

anion gap is helpful to determine the class of metabolic acidosis present (normal or elevated anion gap) to guide treatment

Question 6

A 56-year-old male with h/o diabetes on insulin, now with inability to eat while undergoing chemotherapy due to tongue cancer. Which formula would you start with?

A. Diabetes formula
B. Standard formula
C. Immune-modulating

Answer 6

B. Standard formula

ASPEN Clinical guidelines don’t recommend diabetes formulas. Immune modulating formulas should be used with caution.

Question 7

A 25-year-old female with TBI after MVA. She is preparing to dismiss to rehab and still has nasogastric feeding tube. RDN recommends transition to intermittent feeding to mimic meal times in rehab. Patient develops watery diarrhea on day 1 of intermittent feeding. What should RDN recommend first?

A. Change to fiber containing formula.
B. X-ray for verification of tube tip
C. Pharmacy review of medications

Answer 7

B. X-ray for verification of tube tip

EN was going well until patient was changed from continuous feeding to intermittent feeding. The clinician should suspect the tube may have migrated into the small bowel and thus bolus feeding is likely causing dumping.

Question 8

A 70-year-old male with dysphagia s/p stroke is now dismissing home after a 1 month rehab stay. When is the ideal time to provide HEN education?

A. Throughout the rehab stay
B. The morning of dismissal
C. At home after dismissal
D. All of the above

Answer 8

D. All of the above

Question 9

A patient presents with hypotonic hyponatremia and is currently on sertraline. What subtype of hyponatremia would you suspect?

a. Hypovolemic
b. Euvolemic
c. Hypervolemic
d. None of the above

Answer 9

b. Euvolemic

Sertraline is a selective serotonin reuptake inhibitor (SSRI) which is a known drug class associated with SIADH, a type of euvolemic hypotonic hyponatremia

Question 10

Which of the following is/are important considerations when ordering parenteral potassium supplementation?

a. Location of patient
b. Type of intravenous access
c. Renal function
d. All of the above

Answer 10

d. All of the above

All of the above are considerations related to the ordering, compounding and administration of parenteral potassium to prevent untoward adverse effects

Question 11

Which of the following is used in the treatment of hyperkalemia, but does not produce a reduction in serum potassium concentration?

a. Furosemide
b. Calcium gluconate
c. Albuterol
d. Insulin

Answer 11

b. Calcium gluconate

Calcium works to stabilize the myocardium during hyperkalemia and does not have any effect on serum potassium levels. The other agents listed produce a reduction in potassium concentration either through increased elimination (furosemide) or intracellular shift (albuterol, insulin).

Question 12

How many mEq of potassium (K+) is in 20 mmol of potassium phosphate?

a. 15
b. 20
c. 30
d. 40

Answer 12

c. 30

1 mmol KPhos is equal to 1.5 mEq K+; therefore, 20 mmol KPhos = 30 mEq K+ (20 x 1.5 = 30).

Question 13

In patients with severe and persistent diarrhea which of the following is NOT commonly followed and repleted?
A. Potassium
B. Vanadium
C. Selenium
D. Magnesium

Answer 13

B. Vanadium

Diarrhea, especially when it is severe, can deplete the body of potassium and magnesium fairly quickly. Selenium can also be depleted if the diarrhea is prolonged as seen in short bowel syndrome with or without long term (>3 months) total parenteral nutrition. Vanadium is a trace element, but the importance to the human body is not clear at this time.

Question 14

In which disease process would it be contraindicated to administer intravenous fat emulsions with parenteral nutrition?

A. Pancreatitis due to trauma
B. Gallstone pancreatitis
C. Alcoholic pancreatitis
D. Pancreatitis in a patient with familial dyslipoproteinemia (hypertriglyceridemia)

Answer 14

D. Pancreatitis in a patient with familial dyslipoproteinemia (hypertriglyceridemia)

Intravenous lipid is generally considered contraindicated in lipoid nephrosis, allergy to the intravenous lipid and in patients who have a familial dyslipoproteinemia

Question 15

Factors that are good prognostic markers in the short bowel patient include all of the following except:
A. <80% small bowel affected
B. Colon and ileocecal valve present
C. Site of resection: Entire Ileum
D. No other GI involvement in the remaining bowel

Answer 15

C. Site of resection: Entire Ileum

In patients who have short bowel syndrome, good prognostic markers include the following: no other GI involvement in the remaining bowel, less than 80% of the small bowel affected, jejunal resection is better than ileal resection, and that the colon is present with the ileocecal valve intact and the remaining colon is not diseased

Question 16

Ben is a 23 y.o. male who has been hospitalized for multiple fractures following a fall while hiking about 2 and half weeks ago. He went to surgery soon after admission to repair his pelvic and right femur fractures. Following surgery he developed respiratory distress and was transferred to the surgical intensive care unit and intubated. He has been in the ICU for 2 weeks but now will be transferred to the floor following extubation (he is breathing on his own). He has been receiving enteral nutrition support since his transfer to the ICU. Based on the following information and using the ASPEN/AND malnutrition characteristics, what type of etiology-based malnutrition would you diagnosis for Ben?

Ht: 5’ 8” Current Weight: 153 lbs. Usual Weight: 162 lbs.
Laboratory data: all are normal except glucose is 101 mg/dL (NL= 70-99) and serum albumin level is 2.9 mg/dL (NL = 3.5-5).

a. Starvation-related malnutrition
b. Acute disease-related malnutrition
c. Chronic disease-related malnutrition
d. Marasmus and kwashiorkor

Answer 16

b. Acute disease-related malnutrition

Ben was a healthy young male prior to his accident therefore he is exhibiting acute disease-related malnutrition

Question 17

The Academy/A.S.P.E.N. characteristics for detecting malnutrition include assessing which of the following?

a. Handgrip strength and food intake
b. Excess calorie intake and laboratory data
c. Nails for signs of micronutrient deficiencies and percent weight change
d. Loss of fat mass and medication usage

Answer 17

a. Handgrip strength and food intake

the Academy/ASPEN malnutrition characteristics include assessing food intake, weight history, evaluation of fat and muscle stores, presence of edema and handgrip strength.

Question 18

Which of the following is not examined for subcutaneous fat loss?

a. Orbital region
b. Temporalis region
c. Upper arm area
d. Thoracic and lumbar regions

Answer 18

b. Temporalis region

areas to assess for fat loss include the orbital and buccal regions of the face, the triceps region, and the ribs, quadriceps, patellar and gastrocnemius regions.

Question 19

Which of the following areas are examined for muscle mass?

a. Temporalis, clavicles and subscapular bone region
b. Clavicle, orbital and iliac crest regions
c. Quadriceps, orbital and temporalis regions
d. Mid-axillary line, gastrocnemius and orbital regions

Answer 19

a. Temporalis, clavicles and subscapular bone region

Rationale: areas to assess for muscle loss include the temporalis and buccal regions, clavicular, biceps, ribs & scapular regions.

Question 20

A nutrition-focused physical exam may reveal which of the following in a patient with iron deficiency anemia?

a. Splinter hemorrhages, Beau’s lines and temporal wasting
b. Bleeding gums, Muerkle lines and bitot spot
c. Koilonychias, atrophic filiform papillae and night blindness
d. Pale conjunctiva, koilonychias and glossitis

Answer 20

d. Pale conjunctiva, koilonychias and glossitis

when completing a nutrition-focused physical exam, iron deficiency anemia may be manifested by pale conjunctiva, glossitis, chelosis, angular stomatitis, interossei muscle and koilonychias in the nails.

Question 21

Peripheral parenteral nutrition is a nutritional support option for patients receiving long term parenteral nutrition.
A. True
B. False

Answer 21

False

Peripheral PN is a short term option for the provision of nutrition support. It is limited by large amounts of fluids required to deliver adequate nutrition. Those who have significant malnutrition, severe metabolic stress, large nutrient needs, fluid restrictions, or the need for prolonged PN are not candidates for Peripheral PN

Question 22

2-in-1 PN will have intravenous lipid emulsion (ILE) piggybacked along with the PN. What is the appropriate hang time for ILE when piggybacked with a 2-in-1 PN?
A. 8 hours
B. 12 hours
C. 18 hours
D. 24 hours

Answer 22

B. 12 hours

Current recommendations state that ILE within a TNA should have a maximum hang time of 24 hours. Recommendations also state than ILE piggybacked into a 2-in-1 PN solution should have a maximum hang time of 12 hours. Tubing should also be changed every 12 hours when ILE is piggybacked with 2-in-1 PN. These recommendations also state that if ILE is to be infused separately over > 12 hours, the dose should be divided into two parts with a new container and tubing every 12 hours.

Question 23

What is the safe osmolarity limit for the administration of peripheral PN?
A. 500 mOsm/L
B. 900 mOsm/L
C. 1200 mOsm/L
D. 1500 mOsm/L

Answer 23

B. 900 mOsm/L

To minimize extravasation and pheblitis risk, the recommended osmolarity limit for peripheral PN is < 900 mOsm/L.

Question 24

Which of the following elements can compromise TNA (3-in-1 PN) stability?
A. Amino acid final concentration < 4%
B. Dextrose final concentration < 10%
C. ILE final concentration < 2%
D. All of the above

Answer 24

D. All of the above

TNA stability is compromised by the following: amino acid final concentration < 4%, dextrose final concentration < 10%, ILE final concentration < 2%, high cation concentrations (Ca++, Mg, iron), and admixture of dextrose directly with ILE.

Question 25

Which of the following items can increase calcium and phosphorus solubility?
A. The use of calcium gluconate
B. Addition of phosphate first with calcium toward the end of sequence
C. Store refrigerated
D. All of the above

Answer 25

D. All of the above

Calcium and phosphorus solubility is increased by a lower pH, the use of calcium gluconate salt, adding phosphate first and calcium toward the end of preparation, and storage of the PN refrigerated. The clinician can also review large calcium doses and determine the need based on clinical status

Question 26

In a patient receiving intravenous fat emulsion, which of the following levels should be monitored?

1. Serum glucose
2. Serum ammonia
3. Serum cholesterol
4. Serum triglyceride

Answer 26

4. Serum triglyceride

Question 27

Increased acetate supplementation in parenteral nutrition is most likely to be required in

1. respiratory failure.
2. intractable diarrhea.
3. prolonged vomiting.
4. furosemide treatment

Answer 27

2. intractable diarrhea.

Question 28

Dermatitis and alopecia are symptoms of

1. hypophosphatemia.
2. magnesium deficiency.
3. vitamin A deficiency.
4. essential fatty acid deficiency

Answer 28

4. essential fatty acid deficiency

Question 29

A 58-year-old patient has acute renal failure following abdominal aortic aneurysm repair. Dialysis is planned. If the patient’s BUN is 90 mg/dL and creatinine 8 mg/dL, the most appropriate enteral formula for this patient would provide

1. 0.5 g protein/kg/day mainly as essential amino acids.
2. 1 g protein/kg/day mainly as essential amino acids.
3. 0.5 g protein/kg/day as both essential and nonessential amino acids.
4. 1 g protein/kg/day with both essential and nonessential amino acids

Answer 29

4. 1 g protein/kg/day with both essential and nonessential amino acids

Question 30

Complaints of altered taste and smell are common symptoms of deficiency of which trace element?
1. Zinc
2. Copper
3. Selenium
4. Chromium

Answer 30

1. Zinc

Question 31

Indirect calorimetry provides a measure of
1. basal metabolic rate.
2. past 24-hour dietary intake.
3. energy expenditure.
4. calorie needs for weight gain

Answer 31

3. energy expenditure.

Question 32

Which of the following is most appropriate during transition from central parenteral nutrition support to enteral nutrition support?

1. Dextrose should be infused peripherally to avoid hypoglycemia
2. Transition to enteral nutrition should be discontinued if diarrhea develops
3. Some parenteral nutrition should be maintained until the patient has demonstrated tolerance to enteral nutrition
4. Central venous access should be discontinued as soon as the patient’s nutritional requirements are met by a combination of enteral and peripheral parenteral support

Answer 32

3. Some parenteral nutrition should be maintained until the patient has demonstrated tolerance to enteral nutrition

Question 33

During parenteral nutrition, the infusion of large amounts of dextrose increases electrolyterequirements for

1. sodium and potassium.
2. sodium and phosphorus.
3. potassium and chloride.
4. potassium and phosphorus

Answer 33

4. potassium and phosphorus

Question 34

Metabolic consequences of the refeeding syndrome include
1. hyperkalemia.
2. hypoglycemia.
3. hypermagnesemia.
4. hypophosphatemia

Answer 34

4. hypophosphatemia

Question 35

An 85-year-old man receiving tube feeding due to dysphagia develops increased stooling and has
a temperature of 38.3° C. Which of the following should be done?
1. Obtain stool cultures
2. Decrease water flushes
3. Begin diphenoxylate/atropine
4. Change to a fluid-restricted tube feeding formula

Answer 35

1. Obtain stool cultures

Question 36

Which of the following is a metabolic adaptation to simple starvation?
1. Decrease in urinary nitrogen losses
2. Increase in hepatic glucose production
3. Decrease in utilization of body fat stores
4. Increase in cerebral glucose utilization

Answer 36

1. Decrease in urinary nitrogen losses

Question 37

The small bowel usually has an absorption capacity of approximately
1. 400 mL/day.
2. 1 L/day.
3. 2 L/day.
4. 9-12 L/day

Answer 37

4. 9-12 L/day