From CSPEN Class Flashcards by DJ Shaw

A 35-year-old female presents to clinic with diarrhea, weight loss, and abnormal liver function tests. Her PCP also noted that the patient was vitamin D and iron deficient with anemia. On physical examination, the patient has a very pruritic maculopapular rash with vesicular eruptions on her lower legs. An EGD is performed, and a mosaic pattern with nodularity is noted in the second portion of the duodenum. Which of the following is most likely cause of the patient’s symptoms?
a.Crohn’s
b.Celiac disease
c.Whipple disease
d.Peptic ulcer disease

b.Celiac disease

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A 19-year-old woman with ahx of Crohn’s ileitis since the age of 13 presents for ongoing care. She has been on several medications for Crohn’s disease over the course of her diagnosis. Her disease is isolated to the terminal 30cm of her ileum and ileocecal valve. Despite adequate medication compliance and dosing, her disease remains active. She complains of 4-5 loose, watery stools a day, bloating, and mild abdominal pain. She has a microcytic anemia, signs of fat and lean muscle wasting, and osteopenia. She is determined to have failed medical management and undergoes an ileocecectomy. Which of the following vitamins is she most likely to eventually need to take as a supplement?
a. folate
b. Vitamin B12
c. Vitamin A
d. Vitamin E

b. Vitamin B12

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Which of the following characteristics of an initial enteral feeding regimen would be most appropriate for a patient with SBS?
a.fiber-free, energy-dense formula administered via bolus infusion
b.hydrolyzed, elemental formula that is high in MCT
c. isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion
d.semi-elemental, peptide-based formula administered nocturnally

isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion

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The first B vitamin deficiency to manifest in people with alcoholism is usually:
a.niacin
b.pantothenic acid
c.B6
d.thiamine

d.thiamine

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Which of the following is a benefit of EN compared with parenteral nutrition or no nutrition?
a. maintenance of normal gallbladder function
b. reduced GI bacterial translocation
c. more efficient nutrient metabolism
d. all of the above

d. all of the above

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High protein, hypocaloric EN providing 65% to 70% of energy needs, as determined by indirect calorimetry, is recommended for ICU patients with which of the following conditions?
a. malnutrition
b. obesity
c. liver failure
d. acute respiratory distress syndrome

b. obesity

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What is the estimated calorie target to achieve for patients with malnutrition within 48-72hours of intubation in the ICU?
a. 65-70% or more of needs
b. 80% or more of needs
c. 100% of needs
d. none of the above

b. 80% or more of needs

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Risk factors for aspiration include all of the following except:
a. Malnutrition
b. use of naso-/oro-feeding tube
c. bolus EN feeding
d. supine position

a. Malnutrition

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A 55-year-old man presented to the hospital after a traumatic fall from a ladder. Pt is intubated and sedated. SDH and acute renal failure. Nephrology consulted, and starting CVVHD. What type of enteral formula would best meet his needs?
a. A formula restricted in fluid, protein, and electrolytes
b. A formula not restricted in protein but restricted in fluid and electrolytes
c. A formula restricted in fluid but not restricted in protein or electrolytes
d. A formula not restricted in fluid or protein but restricted in electrolytes

c. A formula restricted in fluid but not restricted in protein or electrolytes

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A 60-year-old, critically ill patient has been tolerating a standard 1kcal/ml enteral feeding formula well for the past week. She begins having frequent bouts of loose stools, requiring placement of a rectal tube. What should be the clinician’s next suggestion?
a. change to a peptide-based formula
b. determine the cause of diarrhea
c. add pre- and probiotics to the feeding regimen
d. change to a fiber-supplemented formula

b. determine the cause of diarrhea

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What should a clinician do when considering the use of enteral formulas marketed for specific disease conditions?
a. Use formulas as indicated by the product manufacturer to meet patient’s needs
b. Use specialty polymeric formulas for all patients
c. Use specialty formulas only when patients exhibit signs and symptoms of intolerance to standard polymeric formulations
d. Evaluate the studies used to support the use of specialty formulas and apply clinical judgment to select the appropriate enteral product for the individual patient.

d. Evaluate the studies used to support the use of specialty formulas and apply clinical judgment to select the appropriate enteral product for the individual patient.

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T/F ASPEN routinely recommends the use of elemental formulas for Crohn’s disease, ulcerative colitis, and short gut syndrome.

false

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T/F ASPEN recommends routine elemental and disease-specific formulas be avoided in critically ill patients

true

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If a nasoenteric feeding tube cannot be unclogged using water flushes, what is the next most reliable method for unclogging the tube before it is replaced?
a Administer cola through the tube, and let it sit for a few hours
b. Administer Clog Zapper, and flush within 30-60minutes
c.Wait a few hours to see whether the clog dissolves spontaneously
d. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1-2hours (or longer), and then flush with warm water

d. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1-2hours (or longer), and then flush with warm water

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You perform a telephone evaluation of a patient who relates increased redness, pain, and swelling around his existing low-profile gastrostomy tube (G-tube). He has not been seen in the clinic for more than 6 months and, when asked, states that he has been doing quite well on his enteral tube feeds. In fact, the patient states that he has gained over 20 lbs. You would proceed as follows:

a. Congratulate him on gaining the weight and tell him to continue his present tube feeding plan
b. If possible, have him come to clinic or call the clinician managing the tube to rule out buried bumper syndrome
c. Direct him to put some triple antibiotic around the site and call back in a couple of weeks if the discomfort continues
d. Tell him to put hot packs on it, take acetaminophen, and rest for a few days

b. If possible, have him come to clinic or call the clinician managing the tube to rule out buried bumper syndrome

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An 18-year-old female patient with cystic fibrosis had a standard-profile, solid internal bolster, 20-French percutaneous endoscopic gastrostomy tube placed 1 year ago because of her inability to take in enough energy orally and weight loss. She has done very well, with her weight stabilizing and no complications of the PEG. The original tube is now getting stiff and cracking, and the patient wants a replacement tube. The patient has a very supportive family environment, is very active, and is concerned about the cosmetic appearance of the tube itself. What type of replacement tube would you recommend?
A .Standard-profile, 20-Fr percutaneous G-tube with solid internal bolster
B .Standard-profile, 20-Fr percutaneous G-tube with balloon internal bolster
C .Low-profile, 20-Fr percutaneous G-tube with solid internal bolster
D. Low-profile, 20-Fr percutaneous G-tube with balloon internal bolster

D. Low-profile, 20-Fr percutaneous G-tube with balloon internal bolster

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Which of the following actions is most appropriate for enhancing gastric emptying during the administration of EN?
a. Keep the bed in Trendelenburg position
b. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous
c .Switch to an enteral formulation with a higher fat content
d. Switch to an enteral formulation with a higher protein content

b. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous

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Which of the following is the most appropriate initial action for the management of tube feeding-associated diarrhea?
a. Change to an enteral formulation with fiber
b. Review the patient’s medication administration record to determine whether hyperosmolar agents are being administered.
c. Change to a peptide-based enteral formulation
d. Use an anti-motility agent

b. Review the patient’s medication administration record to determine whether hyperosmolar agents are being administered.

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Which of the following methods is not recommended to minimize contamination of enteral feeding formula?
a. Washing hands and donning clean gloves before preparing enteral formula
b. Immediate use of enteral formula from a newly opened container
c. Infusing reconstituted powdered formulas or formulas with added modular components in one bag for up to 8 hours
d. Changing an ‘open’ feeding container every 24hrs

c. Infusing reconstituted powdered formulas or formulas with added modular components in one bag for up to 8 hours (4hrs is correct)

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What is the optimal nutrition support for a malnourished patient when enteral nutrition is not feasible for a prolonged period?
a. Central parenteral nutrition
b. Nasogastric enteral tube feedings
c. Postpyloric enteral tube feedings
d. Peripheral parenteral nutrition

a. Central parenteral nutrition

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In which patient condition or treatment could PN elicit an improved patient outcome?
a. Cancer chemotherapy
b. Preoperative care of surgery patients with upper GI cancer (when started 7 days prior to Sx)
c. Allogeneic bone marrow transplantation (not yet proven to show benefit)
d. Critical illness

b. Preoperative care of surgery patients with upper GI cancer (when started 7 days prior to Sx)

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Central parenteral nutrition (CPN) is contra-indicated in which of the following conditions?
a. DNR and deemed to warrant comfort measures
b. peritonitis
c. intestinal hemorrhage
d. high-output fistulas

a. DNR and deemed to warrant comfort measures

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PN should be discontinued when which of the following criteria are met?
a. A clear liquid diet is ordered
b. Tube feeding is initiated at 10% of goal rate
c. Solid food is well tolerated by mouth
d. Advancement to a regular diet is poorly tolerated

c. Solid food is well tolerated by mouth

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What is the nutritional value of the following PN order? 2400 mL with 300 grams dextrose and 90 grams protein in addition to 225 mL 20% IVFE.

What is the osmolarity of this solution?

1830 kcal, 90 grams protein, 40 grams fat, 2625 mL
2010 kcal, 90 grams protein, 40 grams fat, 2400 mL
1830 kcal, 90 grams protein, 45 grams fat, 2625 mL
1470 kcal, 90 grams protein, 45 grams fat, 2400 mL

(300x5=1500, 90x10=900 for a total 2400+ some for the electrolytes)
3. 1830 kcal, 90 grams protein, 45 grams fat, 2625 mL

1000mosm/L

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A patient who weighs 75 kg is receiving 65 mL/hour of a 2-in-1 PN solution that contains 117 grams protein and 273 grams dextrose in addition to 250 mL of 20% IVFE. What is the daily caloric content of this regimen per kg body weight? ) 1. 27.5 kcal/kg/day 2. 21.9 kcal/kg/day 3. 26.5 kcal/kg/day 4. 25.3 kcal/kg/day

(117x4=468kcal, 273x3.4=928kcal, 50gfat=500kcal for a total of 1896kcal dived by 75kg= 25.3kcal/kg What is the osmolarity of this solution? (117x10=1170, 273x5=1365 for a total of 2535+some for electrolytes 4. 25.3 kcal/kg/day

Which of the following PN formulas can be safely administered through a peripheral catheter? 1. 10% dextrose and 3% amino acid 2. 20% dextrose and 3% amino acid 3. 10% dextrose and 6% amino acid 4. 20% dextrose and 6% amino acid

1. 10% dextrose and 3% amino acid

Which of the following is an indication for the use of parenteral nutrition (PN)? a. High output fistula b. Crohn's disease c. Pancreatitis d. Hyperemesis gravidarum

a. High output fistula

The routine use of perioperative parenteral nutrition (PN) is indicated for patients with a non-functioning GI tract who are: 1. Normally nourished. 2. Mildly to moderately malnourished. 3. Mildly malnourished with secondary co-morbidities. 4. Severely malnourished.

4. Severely malnourished.

Which of the following may increase the risk of phlebitis with peripherally administered parenteral nutrition (PPN)? a. Osmolarity equal to or less than 900 mOsm/L b .Potassium 100mEq/L c. Calcium less than 5mEq/L d. Addition of heparin to the PPN

b .Potassium 100mEq/L (any >40 mEq is not tolerated)

What is the smallest pore size filter that is recommended for TNA (3-in-1)? a. 0.22 um (used for 2 in 1) b. 0.5 um c. 1.2 um d. 5 um

c. 1.2 um

Which of the following will increase the solubility of calcium and phosphate in a PN formulation? a. Use of calcium as the chloride salt b. Use of phosphate as the sodium salt c. Increased amino acid concentration d. Increased temperature

c. Increased amino acid concentration

According to recommendations by the National Advisory Group on Standards and Practice guidelines for parenteral nutrition formulations and the ASPEN safety consensus, the amount of dextrose used in preparation of a PN formulation is required to appear on the label as: a. The percentage of original concentration and volume (e.g. dextrose 50% water, 500ml) b. The percentage of final concentration after admixture (e.g. dextrose 25%) c. Grams per liter of PN admixed (e.g. dextrose 250g/L) d. Grams per day (e.g. dextrose 250g/d)

d. Grams per day (e.g. dextrose 250g/d)

A 75-year-old female with moderate malnutrition is status-post radical cystectomy with ileal conduit. She weighs 50kg, and she has a 20-gauge IV access in the left cephalic vein. She is initiated on a peripheral parenteral nutrition (PPN) solution at 125ml/h. This formula contains 210 grams of dextrose, 75 grams of amino acids, and 45 grams of IVFE. Which of the following complications is she at greatest risk for developing? 1. Fluid overload 2. Hypertriglyceridemia 3. Azotemia 4. Hyperglycemia

1. Fluid overload; providing 60ml/kg 1800mOsm total/3L per day= 600mOsm/L (DON’T FORGET TO DO IT PER LITER IF DATA IS PROVIDED, ASSUME 1L IF NO VOLUME IS PROVIDED IN THE QUESTION)

The adverse effects of intravenous fat emulsion (IVFE) administration in adults is best prevented by 1. Supplementing with L-carnitine. 2. Avoiding infusion rates >0.05 grams/kg/hour. 3. Using 10% IVFE preparations. 4. Avoiding serum triglyceride levels >400 mg/dL

4. Avoiding serum triglyceride levels >400 mg/dL

A long term PN patient experiences Parkinson-like extrapyramidal symptoms. Which trace element toxicity is most likely to present with these symptoms? 1. Manganese 2. Copper 3. Zinc 4. Selenium

1. Manganese

What biochemical evidence indicates essential fatty acid deficiency (EFAD)? 1. A serum triglyceride level < 50 mg/dL 2. A lymphocyte absolute count < 1000/microliter 3. A serum cholesterol level < 100 mg/dL 4. A triene to tetraene ratio > 0.2

4. A triene to tetraene ratio > 0.2

According to the A.S.P.E.N. PN Safety Consensus Recommendations, which of the following best describes safe PN compounding? 1. The preparation with automated compounding devices (ACDs) ensures an error free process 2. All healthcare providers should have the ability to override soft and hard limit alerts from ACDs 3. Manual compounding of PN is appropriate when volumes of a PN component to be mixed are less than the ACD can accurately deliver 4. The preparation of compounded sterile preparations (CSPs) for all patient populations should be done at the same time.

3. Manual compounding of PN is appropriate when volumes of a PN component to be mixed are less than the ACD can accurately deliver

According to the A.S.P.E.N. PN Safety Consensus Recommendations all of the following are considered to be mandatory for the PN order form EXCEPT 1. Full generic name for each ingredient (unless brand name can identify unique properties of specific dosage form) 2. Recommended laboratory monitoring 3. Infusion schedule (continuous or cyclic) 4. Electrolytes ordered as complete salt form rather than individual ion

2. Recommended laboratory monitoring

According to the A.S.P.E.N. PN Safety Consensus Recommendations all of the following are considered to be mandatory for the inpatient PN label EXCEPT 1. Infusion rate expressed in mL/h 2. Beyond-use date and time. 3. Size of in-line filter (1.2 or 0.22 micron). 4. Electrolyte content expressed in individual ions.

4. Electrolyte content expressed in individual ions.

Creaming of a total nutrient admixture (TNA) appears as 1. A translucent band at the surface of the emulsion separate from the remaining TNA dispersion. 2. Yellow-brown oil droplets at or near the TNA surface. 3. A continuous layer of yellow-brown liquid at the surface of the TNA. 4. Marbling or streaking of the oil throughout the TNA.

1. A translucent band at the surface of the emulsion separate from the remaining TNA dispersion.

Which of the following reduces the risk of calcium phosphate precipitation in PN? 1. Increased amino acid concentration 2. Use of calcium chloride as the calcium salt 3. Increased temperature 4. Adding calcium salt immediately after adding phosphate salt

1. Increased amino acid concentration

Rapid intravenous infusion of sodium or potassium phosphate may result in 1. Tetany 2. Hypercalcemia 3. Metabolic alkalosis 4. Vitamin D deficiency

1. Tetany (muscle contraction from rapid decrease in Calcium)

Which one of the following factors is most likely to contribute to metabolic bone disease in PN-dependent patients? 1. Aluminum toxicity 2. Calcium supplementation 3. Moderate amino acid intake in PN 4. Balanced acetate load in PN

1. Aluminum toxicity

Which of the following components is NOT a major source of aluminum contamination in parenteral nutrition solutions? 1. Potassium phosphate 2. Sodium phosphate 3. Calcium Gluconate 4. Lipid injectable emulsion (ILE)

4. Lipid injectable emulsion (ILE)

Which of the following PN components is NOT a source of aluminum contamination? 1. Heparin 2. Albumin 3. Calcium Gluconate 4. Regular insulin

4. Regular insulin

The FDA currently recommends that daily intake of parenteral aluminum not exceed what amount? 1. 2 mcg/kg/day 2. 5 mcg/kg/day 3. 7 mcg/kg/day 4. 10 mcg/kg/day

2. 5 mcg/kg/day

Which of the following is the most common metabolic complication associated with PN? a. Hyperglycemia b. Essential fatty acid deficiency c. Azotemia d. Hyperammonemia

a. Hyperglycemia

One day after initiating PN in a critically ill adult patient, the patient’s laboratory values are as follows: serum potassium 3.1 mEq/L (normal: 3.4-4.8 mEq/L), serum phosphorus 1.6 mg/dL (normal 2.5-4.8) and serum magnesium, normal. The PN regimen is providing 90g protein, 150g dextrose, no lipid, minimum volume, potassium 80mEq, phosphate 40mmol, and standard doses of sodium, magnesium, calcium, vitamins and trace elements. The patient weighs 60kg and has a BMI of 18. The most appropriate response to these laboratory data is: a. Increase potassium and phosphate in the PN, and decrease macronutrient doses with tonight’s PN bag b. Provide supplemental IV doses of potassium and phosphate today, but do not change the macronutrient doses with tonight’s PN bag c. Increase potassium and phosphate in the PN, and advance dextrose to 225g with tonight’s PN bag d. Provide supplemental IV doses of potassium and phosphate today, advance dextrose to 225g with tonight’s bag

b. Provide supplemental IV doses of potassium and phosphate today, but do not change the macronutrient doses with tonight’s PN bag

Which of the following measure would be considered beneficial in a patient who develops cholestasis while receiving long-term PN that is infused over 12hrs nightly? a. Stop all oral and enteral intake b. Switch from a cyclic to a continuous method of PN administration c. Decrease lipid injectable emulsion dose from 1.5g/kg/d to 1g/kg twice weekly d. Increase protein dose from 1g/kg/d to 2g/kg/d

c. Decrease lipid injectable emulsion dose from 1.5g/kg/d to 1g/kg twice weekly

4. Which of the following PN modifications is recommended to help prevent and/or treat osteoporosis in a long-term PN patient? a. Maintain protein intake of at least 2g/kg/d b. Provide more than 20 mEq calcium per day c. Add injectable vitamin D to the PN formulation d. Provide 20-40 mmol phosphorus per day

d. Provide 20-40 mmol phosphorus per day

What biochemical evidence indicates essential fatty acid deficiency (EFAD)? 1: A serum triglyceride level < 50 mg/dL 2: A lymphocyte absolute count < 1000/microliter 3: A serum cholesterol level < 100 mg/dL 4: A triene to tetraene ratio > 0.2

4: A triene to tetraene ratio > 0.2

What is considered to be the most serious complication of significant hyperphosphatemia? 1: Osteoporosis and fractures 2: Soft tissue and vascular complications 3: Hypoventilation (seen more in hypophosphatemia) 4: Hypocalcemia

2: Soft tissue and vascular complications

A patient with refractory hypokalemia should be assessed for what related electrolyte disorder? 1: Hypernatremia 2: Hyponatremia 3: Hyperphosphatemia 4: Hypomagnesemia

4: Hypomagnesemia

Which component of parenteral nutrition (PN) is most likely to impact anticoagulation in a patient receiving warfarin? 1: Standard amino acids and electrolytes 2: Dextrose and trace elements 3: Intravenous fat emulsion (IVFE) and vitamins 4: Branched-chain amino acids and electrolytes

3: Intravenous fat emulsion (IVFE) and vitamins

In a patient with hepatobiliary disease, which of the following trace elements should be withheld or requires a dosage reduction when prescribing PN? 1: Zinc and manganese 2: Zinc and magnesium 3: Copper and manganese 4: Copper and magnesium

3: Copper and manganese

The clinical presentation of refeeding syndrome includes all of the following EXCEPT 1: respiratory failure. 2: seizures. 3: cardiac arrythmias. 4: dehydration

4: dehydration

Excess carbohydrate administration in PN has been associated with 1: hypercalcemia. 2: hepatic steatosis. 3: decreased CO2 production. 4: metabolic bone disease.

2: hepatic steatosis.

Patients with diabetes who are receiving PN 1: should have blood glucose checked every 8 hours. 2: have an increased incidence of catheter related infections. 3: have a maximum carbohydrate infusion rate of 5 mg/kg/min of dextrose. 4: should have initial insulin amount of 0.5-1.0 unit of regular insulin/gm dextrose infused.

2: have an increased incidence of catheter related infections.

Which of the following is a risk factor for the development of PN-associated liver complications in PN-dependent patients? 1: Prolonged use of soybean-based IVFE 2: Cyclic infusion of PN 3: Supplemental trophic enteral feeding 4: Medication therapy with ursodiol

1: Prolonged use of soybean-based IVFE

Manganese toxicity is a concern for long-term parenteral nutrition (PN) patients due to its presence in trace element mixtures and as a contaminant from other PN solution components. Symptoms of manganese toxicity are associated most commonly with accumulation of the mineral in which organ? 1: Kidney 2: Brain 3: Muscle 4: Heart

2: Brain

A rise in which of the following laboratory values would most likely indicate cholestasis? 1: Prothrombin time 2: Asparate aminotransferase/Alanine aminotransferase ratio 3: Cholesterol 4: Conjugated (direct) bilirubin

4: Conjugated (direct) bilirubin

During long-term PN administration, hepatobiliary complications can best be prevented by 1: adding carnitine to the PN formula. 2: discontinuing IV fat emulsion (IVFE). 3: converting to cyclic administration. 4: reducing chromium and magnesium.

3: converting to cyclic administration.

A critically ill patient has been receiving parenteral nutrition providing 45 kcals/kg. The consequences of providing excessive calories to a critically ill patient include all of the following EXCEPT 1: Fatty infiltration of the liver. 2: Ventilator weaning failure. 3: Elevated phosphate. 4: Elevated blood sugar.

3: Elevated phosphate.

Which one of the following co-morbidities is NOT a risk factor for the development of metabolic bone disease for a patient on long-term parenteral nutrition? 1: Crohn's disease 2: Ovarian cancer 3: Short bowel syndrome 4: Hypothyroidism

4: Hypothyroidism—hyperthyroid may lead to bone disease

A 40-year-old male receiving chronic PN therapy (initiated 15 years ago) secondary to massive bowel resection develops metabolic bone disease. His current 12-hour cyclic PN formula provides 5 g/kg/day dextrose, 2 g/kg/day protein and 1 g/kg/day of fat. What is the most appropriate intervention to reduce hypercalciuria? 1: Increase calcium gluconate 2: Decrease phosphorus supplementation 3: Shorten PN infusion time to 10 hours 4: Decrease amino acid content of PN solution

4: Decrease amino acid content of PN solution

Cycling parenteral nutrition is recommended in 1: patients receiving short term parenteral nutrition. 2: patients at risk for liver dysfunction. 3: patients at risk for parenteral nutrition-associated hyperglycemia. 4: bed-bound patients.

2: patients at risk for liver dysfunction.

A 70-kg adult patient receiving PN providing 3000 kcal/day presents with mild to moderate elevations of serum aminotransferases and mild elevations of bilirubin and serum alkaline phosphatase. This patient is most likely exhibiting what type of PN-associated liver disease (PNALD)? 1: Hepatic steatosis 2: Cholestasis 3: Gallbladder sludging 4: Fulminant hepatic failure

1: Hepatic steatosis

The best approach to prevent PN-induced cholelithiasis is administration of 1: choline. 2: cholecystokinin-octapeptide (CCK-OP). 3: ursodiol. 4: oral or enteral feeding.

4: oral or enteral feeding.

A PN-dependent patient with an average daily ileostomy output of 3L presents with BUN/serum creatinine ratio of 30:1 and mild hyponatremia. What is the most appropriate PN intervention for this patient? 1: Increase sodium, restrict protein 2: Increase sodium, increase fluid 3: Increase fluid, restrict protein 4: Decrease sodium, increase fluid

2: Increase sodium, increase fluid

An alert and oriented adult patient is receiving a continuous infusion of a standard, fiber-containing formula through an 8-Fr NG tube. Drugs administered via bolus administration through the side port of the tube are phenytoin suspension 400mg daily and nizatidine 150mg every 12hrs. The feeding tube becomes occluded and must be removed. A new tube NG tube is placed. Which of the following measures is most appropriate for preventing occlusion of the new tube? A. Replace the 8French tube with an 18French NG tube B. Flush the feeding tube with 15ml water before/after administering each medication C. Discontinue the fiber-containing enteral feeding, and initiate feeding with a fiber-free formulation D. Hold the feeding infusion for 2 hours before and after administering the phenytoin

B. Flush the feeding tube with 15ml water before/after administering each medication

The EN formulation for a home patient receiving EN through a PEG was recently changed from a high-protein, fiber-containing, 1kcal/ml formula to the only available 1.5kcal/ml formula available in the store. The new product is marketed for use in patients with compromised pulmonary function and contains low amounts of carbohydrate, 55% of energy from fat, about 15% less protein/day than the 1kcal/ml formulation, and no fiber. What component of the new formulation is most likely to contribute to interactions resulting from slow gastric emptying? A. Lower fiber content B. Lower protein content C. Higher fat content D. Higher energy density

C. Higher fat content

Which of the following is the preferred method of administering a hospitalized patient’s antihypertensive medication when tube feeding is started due to poor oral intake? A. By the oral route B. As an oral liquid via the feeding tube C. As a crushed tabled via the feeding tube D. By the IV route

A. By the oral route

A medication that is ordered as a liquid to be administered via the feeding tube is available in the pharmacy in the IV form, as a capsule, and as a film-coated tablet. What is the most appropriate and cost-effective choice for administration of this medication? A. Administer the IV form via the IV route B. Administer the IV form via the feeding tube C. Make a slurry of the capsule’s powder and administer via the feeding tube D. Crush the tablet to a fine powder and administer via the feeding tube (not this one since a film coated tablet will be sticky and hard to break down)

C. Make a slurry of the capsule’s powder and administer via the feeding tube

Which of the following commonly used medications in TBI is not associated with a reduction in measured energy expenditure? a.propranolol b.mannitol c.pentobarbital d.rocuronium

b.mannitol

Which of the following is most strongly correlated with improved mortality in TBI? a.Strict avoidance of parenteral nutrition b.Early initiation of nutrition c.High protein content in nutrition formula d.Supplementation of vitamins C and E

b.Early initiation of nutrition

Metabolic changes following SCIs depend on the level of cord injury and the extent of injuries. Which of the following statements is true? a.The energy expenditure following SCI is approximately 48% higher than that following TBI b.To accurately assess the energy requirements for a patient with SCI, multiply the REE (calculated with the Harris-Benedict equation) by an injury factor of 1.6 and then again by an activity factor of 1.2 c.A modified body mass index scale has been proposed for individuals with SCI, with healthy normal categorized as 18 to 22 d.Patients with chronic SCI require approximately 30-33kcal/kg/d depending on physical activity

A modified body mass index scale has been proposed for individuals with SCI, with healthy normal categorized as 18 to 22

Which of the following statements regarding subarachnoid hemorrhage (SAH) is false? a.High doses of folic acid should be administered to reduce the likelihood of a second hemorrhagic stroke b.Energy expenditure is higher for patients with SAH than for those with ischemic stroke c.Concentrated enteral nutrition may be necessary if fluid intake is restricted to minimize cerebral edema d.Bedside or formal swallow studies should be performed to confirm that the patient does not have dysphagia before an oral diet is initiated

a.High doses of folic acid should be administered to reduce the likelihood of a second hemorrhagic stroke

A 35-year-old female presents to clinic with diarrhea, weight loss, and abnormal liver function tests. Her PCP also noted that the patient was vitamin D and iron deficient with anemia. On physical examination, the patient has a very pruritic maculopapular rash with vesicular eruptions on her lower legs. An EGD is performed, and a mosaic pattern with nodularity is noted in the second portion of the duodenum. Which of the following is most likely cause of the patient’s symptoms? a.Crohn’s b.Celiac disease c.Whipple disease d.Peptic ulcer disease

b.Celiac disease

b.Vitamin B12

.A nutrition support clinician was consulted on the second day of hospitalization about a patient who presented with severe acute pancreatitis and required mechanical ventilation. A recent, dynamic contrast-enhanced CT scan revealed necrosis involving 30% of the pancreatic gland and a small 4cm pseudocyst in the tail of the gland. Which of the following should the clinician recommend? a.Continue NPO with no enteral feeding, noting that the necrosis may require surgical intervention b.Start the patient on PN because the patient is mechanically ventilated and has a pseudocyst c.Place a nasojejunal tube and being enteral feeding, providing no more than 10-20ml/hr d.Place a nasojejunal tube, begin tube feeding, advance to goal over the first 24-48hrs

Place a nasojejunal tube, begin tube feeding, advance to goal over the first 24-48hrs

Which of the following is true? a.The immune response of the gut remains intact when a patient is maintained on PN b.The immune response of the gut remains intact when a patient is maintained on EN c.Loss of gut integrity may allow bacteria of gut origin to infect distant organ sites, but this issue is improved with bowel rest d.Enteral feedings should be stopped if the ileus is noted radiographically

The immune response of the gut remains intact when a patient is maintained on EN

His medical therapy includes methotrexate and sulfasalazine. Supplementation should include: a.folate, B12, iron b.Pyridoxine, thiamine, magnesium c.B12, vitamin C, manganese d.folate, vitamin C, copper

a.folate, B12, iron

Your patient has just been diagnosed with pancreatic insufficiency. Which lab tests are appropriate? a.Vitamin A, 25OHD, iron panel b.25OHD, folate, iron panel c.Vitamin A, folate, PT d.Vitamin A, 25OHD, alpha-tocopherol, PT

d.Vitamin A, 25OHD, alpha-tocopherol, PT

What is the best serial marker of nutritional status in pediatric patients with liver disease? a.fat-soluble vitamin levels b.upper extremity anthropometric measurements c.prealbumin d.weight/length or BMI e.A and D

b.upper extremity anthropometric measurements

In the nutritional therapy of Wilson’s disease, which should be avoided? a.grapefruit b.red meat c.endive d.lobster

d.lobster

Hypomagnesemia in liver transplant patients is most likely associated with which anti-rejection therapy? a.Tacrolimus b.Antithymocyte globulin c.Sirolimus d.methylprednisone

Tacrolimus

Which of the following is a complication associated with sirolimus use? a.hypertriglyceridemia b.impaired wound healing c.opportunistic infection d.all of the above

hypertriglyceridemia

Patients with asthma often require multiple courses of oral corticosteroids to control symptoms. What is not a nutrition concern in these patients? a.growth failure b.poor weight gain c.glucose intolerance

b.poor weight gain

Mucositis is one of the complications affecting the nutrition status of the pediatric oncology patient. Which chemotherapy agent is most likely to lead to the development of mucositis? (pg 487) a.methotrexate * b.cyclophosphamide * c.vincristine * d.carboplatin

a.methotrexate (also affects folate)

Survivors of childhood cancer can be at greater risk for osteoporosis due to a.history of corticosteroid use b.history of methotrexate-containing regimen c.inadequate calcium and vitamin D intake d.all of the above

d.all of the above

Niacin, Iron, copper, zinc, biotin, riboflavin a.peri-orifice distributed dermatitis, glossitis, alopecia b.glossitis, cheilosis, pallor c.dysphagia, microcytosis, vegan diet, menorrhagia d.transverse leukonychia, alopecia, dermatitis, dysgeusia e.anemia, hypopigmented hair, osteopenia f.diarrhea, dermatitis, dementia, death

Niacin: F Iron: C Copper: E Zinc: D Biotin: A Riboflavin: B

You are asked to evaluate the growth status of 5-year-old with cerebral palsy and history of dysphagia and feeding tube; she wears ankle braces and ambulates independently. What is the appropriate reference to use? a.WHO growth charts b.CDC growth charts c.Cerebral palsy I GMF-CS for tube fed children (walks without limitation) d.Cerebral palsy II GMF-CS for tube-fed children (walks with limitations)

c.Cerebral palsy I GMF-CS for tube fed children (walks without limitation)

Which is the most reliable for estimated body fat and lean tissue? a.skinfold anthropometry b.BIA c.BMI d.dual x-ray absorptiometry (DXA)

d.dual x-ray absorptiometry (DXA)

The nutrition support team is revising its PN ordering procedures to prepare for the implementation of computerized order entry. The best way to order nutrients for pediatric PN patients is a.amount per day b.amount per kg per day c.amount per liter d.percent concentration

b.amount per kg per day

A PN order is being evaluated for adequate calcium and phosphorus stability. Which factor negatively affects solubility? a.decreased calcium concentration b.increased dextrose concentration c.decreased amino acid concentration d.addition of cysteine

c.decreased amino acid concentration

An infant dependent on PN has developed cholestasis with a Dbili>2mg/dL. Which of the following trace minerals should be monitored for adjustment in supplementation? a.selenium b.copper c.zinc d.chromium

b.copper

Which of the following answers best reflects dietary modifications that may prevent the development of nephrolithiasis-related renal failure? a.calcium-restricted diet with increased water intake b.low fat diet with adequate phosphorus repletion and increased free water intake c.low fat diet and oxalate- and calcium-restricted diet d.low fat diet, oxalate-restricted diet and adequate hydration

d.low fat diet, oxalate-restricted diet and adequate hydration

Because of the malabsorptive process present in SBS, patients have a high risk for micronutrient deficiencies. Which of the following answers is correct regarding monitoring and repletion of micronutrients in SBS? a.if patients are receiving PN, there is no reason to monitor micronutrients because the PN should satisfy all micronutrient needs b.micronutrients should be checked periodically. Micronutrients can usually be repleted via the oral route c.micronutrients should be checked monthly. Repletion should be administered in high doses both intravenously and orally d.micronutrients should be checked annually, and all micronutrients should be repleted intravenously because patients with SBS cannot absorb micronutrients orally

b.micronutrients should be checked periodically. Micronutrients can usually be repleted via the oral route

Which of the following answers best describes how a clinician determines the most appropriate feeding route (oral, enteral, parenteral, or a combination) for a patient with SBS? a.all patients with SBS need lifelong TPN; if their energy and protein needs are met with PN, they can eat whatever they want for comfort b.to avoid the risk of PN-associated complications, PN should always be discontinued as soon as oral intake or enteral nutrition is initiated c.the nutrition regimen should be individualized to meet the needs of the particular person d.insurance reimbursement plays the major role in deciding the feeding route

c.the nutrition regimen should be individualized to meet the needs of the particular person

Which of the following characteristics of an initial enteral feeding regimen would be most appropriate for a patient with SBS? a.fiber-free, energy-dense formula administered via bolus infusion b.hydrolyzed, elemental formula that is high in MCT c.isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion d.semi-elemental, peptide-based formula administered nocturnally

c.isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion

A nutrition support clinician was consulted on the second day of hospitalization about a patient who presented with severe acute pancreatitis and required mechanical ventilation. A recent, dynamic contrast-enhanced CT scan revealed necrosis involving 30% of the pancreatic gland and a small 4cm pseudocyst in the tail of the gland. Which of the following should the clinician recommend? a.Continue NPO with no enteral feeding, noting that the necrosis may require surgical intervention b.Start the patient on PN because the patient is mechanically ventilated and has a pseudocyst c.Place a nasojejunal tube and being enteral feeding, providing no more than 10-20ml/hr d.Place a nasojejunal tube, begin tube feeding, advance to goal over the first 24-48hrs

d.Place a nasojejunal tube, begin tube feeding, advance to goal over the first 24-48hrs

Which of the following nutrition regimens is appropriate for a patient with less than 2 Ranson criteria and an Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score of less than 9 (nonsevere) who has no pancreatic necrosis on CT scan? a.Begin volume resuscitation, provide narcotic analgesia and advance to an oral diet as soon as it is tolerated b.Begin PN in the first 24hours of admission because the patient has acute pain c.Keep NPO for at least 7 days d.Use PN in the first 24hrs, and then switch to an oral diet

A. Begin volume resuscitation, provide narcotic analgesia and advance to an oral diet as soon as it is tolerated

B. Immune response of the gut remains intact when a patient is maintained on EN Loss of gut integrity has been demonstrated in patients hospitalized for pancreatitis who are maintained on PN and gut disuse while awaiting surgery. Villi in these patients become shortened, then lost. Patients placed on PN with gut disuse have greater exposure to endotoxins and greater oxidant stress. Assess clinical signs of feeding intolerance because radiographic information on ileus may be misleading.

Which of the following is an example of a malabsorptive procedure for weight loss? a.gastric band b.sleeve gastrectomy c.biliopancreatic diversion with duodenal switch d.gastric balloon

c.biliopancreatic diversion with duodenal switch

For patients with colitis or proctitis after colon resection and proximal diversion of the fecal stream, which of the following represents an effective first-line treatment? a.short-chain fatty acid enemas b.Hydrocortisone enemas c.Topical 5-aminosalicylic acid d.Fecal microbiota transplant

a.short-chain fatty acid enemas

What is the definition of ANH? (artificial nutrition and hydration) a. a medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth b.provision of specialized nutrients orally, enterally, or parenterally with therapeutic intent c.nutrition provided through the GI tract via tube, catheter, or stoma that delivers nutrients distal to the oral cavity d.administration of nutrients and fluid intravenously to maintain the patient’s nutrition status during acute illness

a. a medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth