Home Nutrition Module

Question 1

Question: 1 

When evaluating the home environment for a patient receiving parenteral nutrition, which of the following is required?

1: Access to telephone

2: Isolated infusion area

3: Back-up electrical generator

4: Dedicated refrigerator

Answer 1

1: Access to telephone
Patients receiving home parenteral nutrition require a home/cellular telephone or other means of contacting someone outside of the home in the event of a medical emergency. The appropriate health care personnel or emergency center must be contacted as soon as possible. If there is frequent interruption of electrical service, a back-up battery-powered infusion pump may be needed. A back-up electrical generator is not required. An isolated infusion area and dedicated refrigerator are not required, but an area that can be used for supply storage is required.

Question 2

Question: 2 

Which of the following are considered the lowest risk candidates for initiation of parenteral nutrition (PN) in the home setting would be

1: infants.

2: teenagers.

3: intravenous drug abusers.

4: diabetic patients.

Answer 2

2: teenagers.

Infants, intravenous drug abusers, patients with diabetes, fluid and electrolyte/acid-base disorders, and those at risk for refeeding syndrome may not be ideal candidates for initiation of PN in the home setting. Patients with these conditions may need more frequent monitoring and clinical assessment than can be managed at home. Teenagers are typically not thought to be at high risk for problems when PN is initiated in the home setting.

Question 3

Question: 3

Following initial certification of parenteral nutrition by Medicare, after what length of time is recertification required?

1: 6 months

2: 1 year

3: 1 month

4: Never

Answer 3

1: 6 months
After initial certification for parenteral nutrition is obtained, recertification is required after 6 months of therapy. The recertification process is used to document the patient’s continued need for therapy; additional recertifications may be requested on an individual basis.

Question 4

Question: 4
Which of the following diagnoses would meet Medicare Part B coverage criteria to qualify a beneficiary for home enteral nutrition?

1: Dysphagia

2: Aspiration pneumonia

3: Anorexia

4: Malnutrition

Answer 4

1: Dysphagia

Home enteral nutrition is a covered Medicare Part B benefit for a patient who has a permanent non-function or disease of the structures that normally permit food to reach the small bowel or for a disease of the small bowel that impairs digestion and absorption of an oral diet. The beneficiary must require tube feeding to provide sufficient nutrients to maintain weight and strength commensurate with their overall health status. The patient’s condition could be either anatomic, e.g. obstruction due to head and neck cancer or reconstructive surgery, or due to a motility disorder, e.g. severe dysphagia following a stroke. Enteral nutrition is not covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia or nausea.

Question 5

Question: 5 

Medicare reimbursement for home and community-based professional nutrition educational services provided by a registered dietitian is restricted to patients who

1: live alone.

2: have cancer.

3: are over the age of 65.

4: have diabetes or renal disease.

Answer 5

4: have diabetes or renal disease.
At this time Medicare reimbursement for home and community-based professional nutrition educational services provided by a registered dietitian with a Medicare provider number, only covers patients with diabetes, pre-dialysis kidney disease, and those who are post-kidney transplant. A patient whose doctor or other healthcare provider refers them for the services also qualifies. Professional intervention/monitoring for home parenteral nutrition patients is not a covered benefit under Medicare.

Question 6

Question: 6 

Managed care and private insurance companies often use which established criteria/guidelines when approving coverage for home parenteral nutrition?

1: Medicare criteria

2: State-funded Medicaid program criteria

3: Oley Foundation criteria

4: A.S.P.E.N. Standards for Specialized Nutrition Support: Home Care Patients

Answer 6

1: Medicare criteria

Insurance coverage for home EN and PN varies by type of program as well as individual plans. Government programs (eg. Medicare and Medicaid) have strict coverage criteria and require detailed history, tests and nutritional data to determine eligibility. Coverage policies and reimbursement for EN and PN also vary with private payers and managed care organizations and frequently require preauthorization or precertification. Most require that the therapy be medically necessary and the sole source of nutrition. Many insurance policies establish their own criteria for EN and PN, while others follow the guidelines for coverage set forth by Medicare.

Question 7

Question: 7 

The most common complication seen after percutaneous endoscopic gastrostomy (PEG) tube placement is:

1: Buried bumper syndrome

2: Peristomal infection

3: Gastric ulceration

4: Colocutaneous fistulas


Answer 7

2: Peristomal infection

Post-procedural complications present days to months after placement. Infection around the insertion site is a relatively common post-procedural complication reported in up to 30% of tubes placed. Buried bumper syndrome is a result of erosion of the internal bolster into the gastric mucosa and occurs in 0.3-2.4% of patients. Ulceration of the gastric mucosa is caused by excessive tension between the external and internal bolster which leads to erosion and bleeding. This occurs in only 0.3-2.5% of cases. Colocutaneous fistulas occur when the colon is inadvertently punctured during placement. It is extremely rare, occurring in only 0-0.27% of cases.

Question 8

Question: 8 

Which of the following enteral feeding schedules should be recommended to patients and their families when preparing for home enteral nutrition?

1: Schedule feedings outside of normal meal times

2: Schedule feedings during meal times

3: A schedule that allows for integration of feeding into the patient’s and family’s lifestyle

4: Feeding schedule that separated the patient during meal times to minimize the family’s discomfort with the process


Answer 8


3: A schedule that allows for integration of feeding into the patient’s and family’s lifestyle

In the home, enteral feeding should be integrated into the patient’s and family’s typical way of living. Separation of the patient from the family during meal times may have a negative impact on the family structure, although the administration of tube feeding may not be accepted by some at the dinner table. A compromise may be necessary to meet all the family members’ needs. Participation in conversations and socialization at the dinner table is encouraged. When possible in the home setting, the administration schedule should be structured to simulate normal meal times. Evidence demonstrates that patients and their caregivers quickly adapt the prescribed enteral feeding regimen to suit themselves and their home circumstances.

Question 9

Question: 9

Patient education materials for home enteral and parenteral nutrition patients should be written at what grade level?

1: 6th

2: 9th

3: 10th

4: 12th

Answer 9

1: 6th

The estimated mean U.S. reading level is 8th grade. A 5th or 6th grade level is recommended for patient education materials.

Question 10

Question: 10 

During discharge education, which of the following is the BEST way for a home nutrition support provider to know if a patient and/or caregiver understands enteral tube feeding delivery?

1: Verbal description of proper techniques

2: Written explanation of proper techniques

3: Appropriate responses to questions asked

4: Return demonstration of procedure techniques


Answer 10

4: Return demonstration of procedure techniques

Research shows that one of the most effective ways to improve understanding of discharge teaching while simultaneously addressing health literacy is the “teach-back” process. The “teach-back” process is an active process in which the learner can demonstrate health care skills and verbalize home care instructions. This process allows the educator to verify understanding, to correct inaccurate information, and to reinforce new home care skills.

Question 11

Question: 11

Which of the following is NOT a frequently reported concern of caregivers of patients receiving enteral tube feedings?

1: Guilt

2: Causing harm

3: Social embarrassment

4: Fatigue

Answer 11


2: Causing harm

Patient harm is not typically a significant concern in EN since administration and care are relatively simple. Caregivers of patients receiving enteral nutrition (EN) express guilt that they are able to eat an oral diet. Enteral feedings administered in public may cause social embarrassment. Fatigue is a result of nocturnal feedings or frequent enteral care during the day that requires additional work for the caregiver.

Question 12

Question: 12

The maximum time an open system enteral feeding formulation container should be used in the home setting is

1: 6 hours.

2: 8 hours.

3: 10 hours.

4: 12 hours.

Answer 12

4: 12 hours.
Open system enteral feeding containers should have a hang time of no more than 12 hrs at home and 8 hrs in the hospital. Open system enteral feeding containers are more likely to be exposed to contaminants. Closed system enteral feeding containers have a longer hang time of up to 24-48 hrs.

Question 13

Question: 13 

Skin care around a feeding tube site should be accomplished by cleaning with

1: alcohol.

2: mild soap and water.

3: iodine-povidone.

4: hydrogen peroxide.

Answer 13

2: mild soap and water.

Skin care around a feeding tube site should be accomplished by cleaning with mild soap and water, rinsing and drying thoroughly. Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure. Routine use of antibiotic ointments is not advised, and dressings at the tube insertion site are not necessary unless there is drainage.

Question 14

Question: 14 

Which of the following data should be collected in the home care provider’s performance improvement plan?

1: First-dose precautions

2: Discharge instructions

3: Hospital readmission

4: Consent for care

Answer 14

3: Hospital readmission

Nutrition support is a high-risk, problem-prone treatment and should be addressed in the home care provider’s performance improvement and outcome measurement activities. Data to be collected should include but not be limited to mortality, hospital readmission, complications, patient/family satisfaction, and problem reporting and resolution. Although first-dose precautions, discharge instructions, and consent for care are an important part of planning for a home nutrition support patient they are not traditionally an integral component of a performance improvement plan.

Question 15

Question: 15 

Initially, how often should electrolytes be monitored in a patient on home parenteral nutrition support?

1: Daily

2: Weekly

3: Monthly

4: Bi-monthly

Answer 15

2: Weekly

A.S.P.E.N. recommends weekly monitoring of serum glucose, electrolytes, blood urea nitrogen, creatinine, magnesium and phosphorus until the patient is clinically stable. Some patients may warrant more frequent lab monitoring.

Question 16

Question: 16 

All patients admitted to the home care provider shall undergo nutrition screening using subjective and/or objective criteria within

1: 24 hours.

2: 48 hours.

3: 72 hours.

4: 96 hours.

Answer 16

3: 72 hours.

Screening to identify nutritionally at-risk patients is an important part of the nutrition care process for patients receiving home nutrition support. All patients accepted by a home care provider should undergo nutrition screening using subjective and/or objective criteria within 72 hours of acceptance or on the initial home visit. The result of the nutrition screen shall be documented. Patients identified on initial screen as nutritionally-at-risk shall be referred to the provider for further orders regarding nutrition assessment and intervention. Patients identified as not nutritionally-at-risk shall be re-screened at regularly specified intervals or when their clinical or nutrition status changes.

Question 17

Question: 17 

Which of the following vascular access devices (VADs) should not be used for home parenteral nutrition (HPN)?

1: Hickman catheter

2: Peripherally-inserted central catheter (PICC)

3: Midline catheter

4: Implanted port


Answer 17

3: Midline catheter

Placement of a permanent VAD is essential prior to discharging a patient on HPN therapy. Patients should not be sent home with a temporary catheter for HPN use. VADs must be placed in the central venous system to accommodate hyperosmolar HPN solutions. Types of VADs approved for HPN administration include: (1) tunneled central venous catheters ; (2) implanted ports; and, (3) peripherally inserted central catheters. Midline catheters are short-term VADs typically used for therapies lasting 2-4 weeks.

Question 18

Question: 18 

According to Medicare (and Medicaid) guidelines, under the prosthetic device act, home enteral nutrition (HEN) is covered for a patient who

1: cannot meet his/her nutrition requirements by oral intake.

2: has documented weight loss of 10% in 3 months and refuses to eat.

3: has a permanent disease of the structures that normally permit food to reach the small bowel.

4: has a temporary (estimated as less than 3 months) impairment or disease of the mouth, esophagus or stomach that prevents food from reaching the small bowel.

Answer 18

3: has a permanent disease of the structures that normally permit food to reach the small bowel.

Under Medicare coverage guidelines for HEN, the beneficiary must meet one of two criteria: 1) a permanent non-function or disease of the structures that normally permit food to reach the small bowel; or 2) a disease of the small bowel that impairs digestion and absorption of an oral diet. The beneficiary must also meet the test of permanence, which is based on the judgement of the attending physician and is substantiated in the medical record. “Permanence” means that the condition is of indefinite duration, 90 days or greater. Permanence does not exclude the possibility of improvement. Additionally, the beneficiary must require tube feeding to maintain weight and strength commensurate with overall health status, and adequate nutrition must not be possible by dietary adjustment and/or oral supplements.

Question 19

Question: 19 

According to the Centers for Medicare and Medicaid Services, which of the following is an indication for home parenteral nutrition?

1: Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz

2: Gastrointestinal losses totaling 20% of oral intake

3: Need for bowel rest of 1-2 weeks duration

4: Failure to maintain weight on an oral diet

Answer 19

1: Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz

HPN is covered under the prosthetic device act of Medicare. For coverage, the patient must have documented evidence of inability to tolerate feeding through the enteral route. Typically, HPN is covered for patients with less than or equal to 5 feet of small bowel beyond the ligament of Treitz; gastrointestinal losses exceeding 50% of oral intake (2.5 to 3 liters per day in and > 1.25 to 1.5 L/day out). Bowel rest is required for at least 90 days and 20-35 calories per kilogram (kg) per day is prescribed. Other aspects of HPN require specific justification such as: calorie prescription outside the range of 20-35 calories per kg per day; protein outside the range of 0.8-1.5 grams per kg per day; and lipid use greater than 1500 grams per month.

Question 20

Question: 20 

Upon initiation of home parenteral nutrition (HPN), laboratory data should be obtained within

1: 24 hours.

2: 48 hours.

3: 72 hours.

4: 96 hours.


Answer 20

2: 48 hours.

Laboratory data should be obtained within 48 hours of HPN initiation. More frequent assessment of laboratory data may be required to ensure efficacy and prevent complications of nutrition support when initiated in the home.

Question 21

Question: 21 

Home infusion providers should have policies that address

1: reimbursement criteria for phone consultations.

2: availability of social workers to address psychosocial issues.

3: replacement of central venous catheter.

4: education, training, and evaluation of patient/caregiver competency.

Answer 21

4: education, training, and evaluation of patient/caregiver competency.
The education, training, and evaluation of patient/caregiver competency is very important for a quality teaching program to facilitate patient and provider independence. There is currently no reimbursement structure for compensation of phone consultations in the US. While it would be helpful in many cases to have social workers and other support agencies available, this is not necessary for a home care policy. They can make referrals as appropriate.

Question 22

Question: 22 

The referral process to a home infusion company for parenteral and enteral therapy includes scheduling all of the following EXCEPT

1: formula delivery.

2: adding equipment and supplies delivery.

3: infusion nursing care.

4: physical therapy.

Answer 22

4: physical therapy.
Home infusion providers are responsible for the delivery of nutritional products, appropriate supplies for the delivery of nutrition, and the nursing care required to educate about and monitor the prescribed therapy. Physical therapy, while often appropriate for a homebound patient, is not typically a responsibility of the home infusion company.

Question 23

Question: 23

Patients/caregivers should receive discharge instructions regarding home enteral nutrition by qualified members of the healthcare team. All of the following is essential information to be taught during education EXCEPT?

1: Volume of formula per feed and total daily volume

2: Administration method and schedule

3: Care of the enteral access device and infection control

4: Total calories and protein provided per day

Answer 23


4: Total calories and protein provided per day
A patient/caregiver should receive discharge instructions that include the name of the formula, total daily volume and route of administration, timing/duration of administration, care of the enteral access device, product hang-time and stability at room temperature, inspection of enteral products for defects and expiration dates, infection prevention and control (i.e., standard precautions), action to be taken in the event of late or missed administration of enteral nutrition and proper storage of opened and unused enteral products. Upon discharge, the patient should be given the contact information for the home care company. It is not necessary for the patient to know the protein and calorie provision. It can be provided if the patient wishes to have this information.

Question 24

Question: 24 

A patient on long-term home enteral nutrition suddenly develops nausea and vomiting. The most likely cause is

1: frequent use of sorbitol-containing medications.

2: gastric outlet obstruction.

3: low osmolarity formula.

4: sudden decrease in enteral feeding rate.

Answer 24

2: gastric outlet obstruction.

Causes of nausea and vomiting in the enterally fed patient may include: too rapid of a rate of bolus infusion, gastric outlet obstruction caused by feeding tube migration, excessive feeding volume, and gastroparesis. Gastric irritation or atony, distal obstruction, anxiety, other diseases, and medication may also cause these symptoms. Nausea and/or vomiting may be prevented or resolved by decreasing the rate or volume of enteral infusion. Frequent use of sorbitol-containing medications is a common cause of tube feeding-associated diarrhea, not nausea and vomiting.

Question 25

Question: 25 

The clinical manifestations of copper deficiency can be similar to what other micronutrient deficiency?

1: Vitamin B12

2: Manganese

3: Vitamin E

4: Zinc

Answer 25

1: Vitamin B12

Assessing micronutrient status in long-term home parenteral nutrition (HPN) consumers is challenging, requiring astute symptom observation. This may be complicated when one deficiency mimics another. Clinical manifestations of copper deficiency include leukopenia as well as neurological deterioration with sensory ataxia, lower limb spasticity, and paresthesias. These neurological presentations are also associated with vitamin B12 deficiency.

Question 26

Question: 26 

Which of the following is true concerning manganese and patients on long-term parenteral nutrition (PN)?

1: Manganese deficiency occurs in patients on PN for greater than 1 year

2: Hypermanganesemia has been reported only in patients with cholestasis

3: Manganese in commercial trace element preparations may result in hypermanganesemia

4: The best indicator of manganese status is serum manganese

Answer 26

3: Manganese in commercial trace element preparations may result in hypermanganesemia
Hypermanganesemia has been reported in >50% of home PN patients accompanied by clinically significant cerebral and hepatic complications. Manganese (Mn) is almost exclusively excreted via the hepatobiliary system. Therefore, reductions in Mn dosing should be considered in patients with hepatobiliary disease such as cholestatic liver disease. Patients at risk for developing Mn toxicity include those receiving long-term PN (>30 days), who develop obstruction of the biliary duct and are unable to excrete Mn. Supplemental Mn may need to be removed from the PN solution in long-term PN patients. Brain deposition of Mn can occur with IV Mn administration of 1.1 mg/day. Magnetic resonance imaging (MRI) can detect Mn toxicity but the procedure is expensive. The best method of monitoring Mn status is with whole blood Mn levels as they correlate well with MRI abnormalities.

Question 27

Question: 27 

Which of the following is the best way to determine chromium deficiency?

1: Serum chromium levels

2: Empiric treatment when deficiency is suspected

3: Urinary chromium levels

4: Serum glucose to insulin ratio

Answer 27


2: Empiric treatment when deficiency is suspected

There are no known reliable indicators of chromium status. Treating hyperglycemic patients with chromium supplementation and observing for resolution of symptoms empirically is the best way to determine if the patient was chromium deficient. Chromium potentiates the action of insulin and has a role in glucose, protein, and lipid metabolism.

Question 28

Question: 28 

Which of the following is true concerning zinc status in long-term parenteral nutrition (PN) patients?

1: Serum zinc is a reliable indicator of zinc status

2: Parenteral doses of 50 mg/d have been proven safe

3: Parenteral zinc interferes with copper bioavailability

4: Zinc deficiency is the most commonly suspected trace element abnormality

Answer 28

4: Zinc deficiency is the most commonly suspected trace element abnormality
Most patients who require long-term PN have a dysfunctional gastrointestinal (GI) tract that can contribute to increased GI losses. These GI losses can increase zinc losses and thus increase zinc requirements. Therefore, it is not surprising that zinc is the most commonly suspected trace element abnormality in long-term PN patients. Serum zinc is not a reliable indicator of zinc status. It can be within normal limits, and the patient may be in a negative zinc status. Conversely, in the setting of systemic inflammatory response syndrome zinc levels will decline and remain low until resolution of the acute phase reaction. Zinc is dependent on adequate albumin levels, so caution should be used when interpreting zinc levels in the setting of hypoalbuminemia. Parenteral zinc doses of 30 mg and greater have been shown to produce adverse effects and toxicity. The interaction between zinc and copper occurs when taken through the GI tract, not when infused intravenously.

Question 29

Question: 29
Which of the following is true concerning aluminum contamination in long-term parenteral nutrition (PN)?

1: The amount on the manufacturer’s label is greater than measured amounts

2: Each PN bag must provide the amount of aluminum per liter

3: The clinical manifestations of aluminum toxicity are specific and sensitive

4: Aluminum toxicity is the primary etiology of parenteral nutrition-associated bone disease

Answer 29

1: The amount on the manufacturer’s label is greater than measured amounts

Manufacturers of large volume, small volume, and pharmacy bulk packages of components for PN must label each with the amount of aluminum anticipated to be in the product when the product expires. The amount on the label has been shown to be approximately 10 times more than what was actually measured in a PN bag prepared according to a patient’s prescription. Pharmacies are not required to list the aluminum content on each patient’s PN bag. The clinical manifestations of aluminum toxicity (neurological, hepatic, hematologic, and skeletal) are neither specific nor sensitive for aluminum toxicity. The etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors.

Question 30

Question: 30 

Which of the following is the MOST practical approach for managing micronutrients in long-term parenteral nutrition (PN) patients?

1: Obtain serum values for all vitamins and trace elements yearly
2: Perform a micronutrient assessment every 6 months

3: Provide micronutrients only when laboratory values indicate abnormal levels

4: Do not use commercial preparations; provide each micronutrient individually

Answer 30

2: Perform a micronutrient assessment every 6 months

Currently, the most practical approach to managing micronutrients and monitoring micronutrient status in long-term PN patients is to perform a micronutrient assessment every 6 months. During this assessment, the clinician reviews nutrient intake, potential nutrient losses, medications, and medical/surgical history, and performs a nutrition-focused physical examination. Every patient should receive micronutrients daily unless there is a potential or identified nutrient toxicity. Whenever a nutrient is omitted or added to standard micronutrient recommendations, the patient should be monitored for a potential deficiency or toxicity that could develop over time. Laboratory values are not always reliable indicators. Normal levels can give a false sense of security when in fact the patient is deficient or toxic.

Question 31

Question: 31 

Failure to monitor which micronutrient in long-term parenteral nutrition (PN) patients is most likely to result in toxicity?

1: Manganese

2: Zinc

3: Folate

4: Molybdenum

Answer 31

1: Manganese

Hypermanganesemia can occur in all patients on long-term PN, regardless of liver function. Current trace element additives for PN contain greater than five times the current estimated requirement for manganese. There are several published reports of hypermanganesemia, some symptomatic, and some not, in patients on long-term PN. Manganese toxicity symptoms include headache and Parkinson-like abnormalities. While zinc and folic acid are important nutrients, not all patients are at risk for those specific deficiencies, and toxicity symptoms are not reported in those using standard PN. There is little found in the literature about molybdenum deficiency or toxicity in long-term PN patients, and routine monitoring is not recommended.

Question 32

Question: 32 

A malnourished patient with metastatic ovarian cancer is diagnosed with an inoperable partial mechanical small bowel obstruction. She is taking small amounts of a full liquid diet by mouth, but is unable to take enough nutrition to maintain her weight. She has lost 12% of her body weight in the past 2 months. According to current Medicare guidelines, this patient’s home parenteral nutrition (HPN) will be covered under which of the following circumstances?

1: The physician must write an order for the patient to be nil per os or “nothing by mouth”

2: Medical record must include a radiology report documenting the presence of partial small bowel obstruction

3: Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option

4: No further documentation is necessary to confirm coverage

Answer 32

3: Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option

Medicare has stringent guidelines for the use of HPN. The diagnosis of nonfunctional gastrointestinal tract is critical to ensure coverage. The diagnosis of partial small bowel obstruction alone will not quality a person for HPN under present Medicare guidelines. An enteral tube feeding trial must be attempted and shown to fail or explain why a feeding tube is not an option. Medicare criteria for HPN include massive small bowel resection (= 5 feet of small bowel distal to the Ligament of Treitz), short bowel syndrome (enteral losses exceed 50% of enteral intake), weight loss 10% in =3 months (serum album below 3.4g/dL, fecal fat tests demonstrating malabsorption or serum albumin below 3.4g/dL, gastrointestinal motility disorder refractory to maximum prokinetic medication, diagnostic test showing dysmotility, complete mechanical bowel obstruction (inoperable), or bowel rest for at least 3 months (severe exacerbation of regional enteritis or proximal enterocutaneous fistula and tube feeding distal is not possible, symptomatic pancreatitis). HPN therapy must also be required for at least 90 days, and weight maintenance cannot be possible using other methods (enteral feeding or pharmacological interventions).

Question 33

Question: 33 

According to current Medicare guidelines, coverage for an enteral feeding pump can be justified under which of these circumstances?

1: The patient is being fed using a jejunal feeding tube

2: The patient states that bolus tube feedings interrupt his daily schedule; his preference is to infuse feedings during the night using a pump

3: The patient’s caregiver has difficulty preparing several bolus feedings each day

4: The patient would like enteral feedings to infuse quickly.

Answer 33

1: The patient is being fed using a jejunal feeding tube

Under Medicare guidelines, enteral infusion pumps are covered only with documentation that gravity feeding is not tolerated or contraindicated for situations such as reflux, aspiration, dumping syndrome, glycemic control, circulatory overload, slow infusion rate, or jejunal feeding.

Question 34

Question: 34 

Serum conjugated bilirubin level is elevated in an adult patient with short bowel syndrome. The patient has been receiving a 12-hour cycle of 3-in-1 home parenteral nutrition (HPN) solution. The clinician’s initial plan may include

1: removal of all trace elements from HPN.

2: increasing lipid calories to prevent essential fatty acid deficiency.

3: evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion.

4: addition of carnitine and choline to the HPN.

Answer 34

3: evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion.

Parenteral nutrition associated cholestasis (PNAC) is a condition of impaired secretion of bile or frank biliary obstruction that may occur in adult patients receiving long-term parenteral nutrition (PN). Elevated serum conjugated bilirubin (defined as a concentration >2 mg/dL) is an indicator for cholestasis. The prevalence of chronic cholestasis in patients with intestinal failure has been observed to increase with longer duration of PN usage. The development of liver complications is primarily due to excessive energy intake from dextrose and/or intravenous fat emulsion. Manganese and copper may become elevated in patients with cholestasis because they are excreted via the biliary tract. Although the dose of manganese and copper may need to be reduced or eliminated, the removal of all trace elements is not warranted. After other causes of liver dysfunction have been addressed, carnitine may be added to PN if a deficiency exists. However, the role of carnitine in the prevention of PNAC in adults has not been established. Choline deficiency also may be related to the development of PN-associated liver dysfunction, but there is no commercially available injectable choline preparation and benefits of supplementation have not been proven.

Question 35

Question: 35 

Which trace element deficiency is most likely to occur in long-term parenteral nutrition (PN)-dependent patients after 3 to 6 months of therapy?

1: Iron

2: Copper

3: Chromium

4: Manganese

Answer 35

1: Iron
Iron is not a component of the parenteral nutrition (PN) formulation in part to avoid potential contribution to microbial growth and damaging oxidative reactions. Parenteral iron should be considered in conditions of iron deficiency when the oral route is ineffective or not tolerated. Patients with iron deficiency anemia may present with fatigue, headache, pallor, reduced work performance, impaired behavioral and intellectual performance, and impaired ability to maintain body temperature. Iron dextran may be added to dextrose and amino acid PN solutions only after the patient has been given a test dose of iron dextran to evaluate tolerance and avoid anaphylactic reactions. The dextran formulation, or bound iron, is preferable to other forms of intravenous iron to add to PN. Serum iron and ferritin levels should be monitored routinely every 1 to 3 months if a repletion dose is added to the PN solution to prevent iron overload.

Question 36

Question: 36 

Medicare approved indications for home parenteral nutrition (HPN) include which of the following?

1: Supplement to enteral nutrition

2: End-stage renal disease (ESRD)

3: Long-term loss of gastrointestinal function

4: Delayed gastric emptying

Answer 36


3: Long-term loss of gastrointestinal function

Medicare requires home parenteral nutrition be required for long-term therapy, usually greater than 90 days with evidence of loss of gastrointestinal function and when enteral feedings have failed. Supplemental HPN is rarely covered at home by Medicare. ESRD is not an indication for PN in and of itself as ESRD is not a diagnosis involving the small bowel or the bowel’s ability to absorb nutrients. Medicare will approve HPN if there is evidence of fat malabsorption.

Question 37

Question: 37 

Third-party payors (insurance companies) are LEAST likely to reimburse which of the following home enteral nutrition expenses?

1: Feeding bags and tubing

2: Enteral feeding pumps

3: Enteral formula

4: IV pole and/or syringes

Answer 37

3: Enteral formula

Financial concerns are a strong contributor to stress in the specialized nutrition support patient. It is vital for the patient and health care providers to understand the benefits provided by the patient’s insurance coverage to ensure compliance with reimbursement and to contain the cost of treatment. Many third-party payors equate the costs of enteral formulas to “ groceries” and do not cover this expense, while they will cover the costs of an enteral pump and supplies. If the patient cannot afford the cost of the formula, the dietitian may be able to recommend an alternate formula or store brand that is less expensive. Other options for financial assistance include nonprofit organizations or indigent care programs. Formula is covered under Medicare Part B, but the patient will be financially responsible for 20% of the Medicare approved amount. If the patient has a supplement or secondary insurance, it will usually pick up the 20% that Medicare does not cover.

Question 38

Question: 38 

To meet the Medicare payor criteria for home enteral or parenteral nutrition, the patient’s condition must be considered to be “of long and indefinite duration”. Which length of time below meets Medicare’s test of permanence requirement?

1: 30 days.

2: 60 days.

3: 90 days.

4: 120 days.

Answer 38

3: 90 days.

EN and PN are primarily covered under the “prosthetic device” benefit under the Medicare Part B program. This provision requires a permanent dysfunction of a body organ. For EN or PN to be reimbursed by Medicare, the therapy requirements must fit into a defined benefit category and be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body part.” For either therapy, there must be “provision of sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status,” and the condition must have a “permanent impairment of long and indefinite duration” of at least 3 months.

Question 39

Question: 39 

When transitioning a patient from hospital to home parenteral nutrition (HPN) support, screening criteria should include which of the following?

1: Transportation needed to make it to lab draws

2: Presence of electricity and sanitary water supply in the home

3: Cellular telephone access

4: A caregiver

Answer 39

2: Presence of electricity and sanitary water supply in the home

Sanitary water supply and electricity are needed to safely administer parenteral nutrition. Parenteral nutrition solution requires refrigeration; there will be storage space needed for other associated supplies. Lab draws may be obtained by homecare nurses. The availability of a cellular phone is beneficial, but not essential when determining patient candidacy for HPN. If the assessment is made that the patient has the ability to be educated regarding the prescribed therapy, there is no need for a caregiver to be available to the patient at home.

Question 40

Question: 40 

Home-prepared or blenderized enteral nutrition (EN) formulations should be discarded after

1: 6 hours.

2: 12 hours.

3: 24 hours.

4: 48 hours.

Answer 40

3: 24 hours.

The use of home-prepared or blenderized EN formulations requires additional attention to nutrient content and safe food handling and storage practices. These formulas should be discarded after 24 hours. Hang time for blenderized or reconstituted formula is 4 hrs.

Question 41

Question: 41 

Which of the following is a non-profit organization identified as a resource for home nutrition patients and their caregivers?

1: Academy of Nutrition and Dietetics

2: American Society for Parenteral and Enteral Nutrition

3: Oley Foundation

4: American Society for Clinical Nutrition

Answer 41

3: Oley Foundation

The Oley Foundation is a national, independent, non-profit organization that distributes information, organizes conference activities, and provides emotional support for patients and caregivers. Families may avail themselves of the Foundation’s many resources including bimonthly newsletters (Lifeline Letter), videos, regional coordinators, and an information clearinghouse.

Question 42

Question: 42 

Patients receiving home parenteral nutrition (HPN) who belong to a support group are shown to experience which of the following?

1: Higher reactive depression

2: Lower quality of life (QOL)

3: Fewer hospital readmissions

4: Increased incidence of catheter-related sepsis

Answer 42

3: Fewer hospital readmissions

In a case-control study comparing two groups of patients affiliated with a national support or educational organization with nonaffiliated controls, the affiliated patients were found to have a significantly higher QOL, less reactive depression, and a lower incidence of catheter-related sepsis.

Question 43

Question: 43 

Which of the following is true regarding parenteral nutrition (PN)-associated metabolic bone disease?

1: Cyclic PN reduces the risk of developing metabolic bone disease

2: Excessive dietary protein may lead to a positive calcium balance

3: All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry

4: Adequate supplementation of calcium and phosphorus is achieved with PN

Answer 43


3: All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry

A negative calcium balance with an 80% increase in urinary calcium excretion has been reported in cyclic patients. Excessive protein is known to enhance calcium excretion leading to a negative calcium balance. The risk of a calcium-phosphate precipitation limits the amounts of calcium and phosphorus provided by the PN solution. Dual-energy x-ray absorptiometry (DEXA) is generally performed every 1-3 years. DEXA is recommended for patients in long-term PN.

Question 44

Question: 44

Which of the following strategies is a common cause for feeding tube occulsion?

1: Optimal flushing between medications

2: Administration of high protein/high fiber formula

3: Choosing liquid medication over pill

4: Frequent checking of gastric residuals

Answer 44


2: Administration of high protein/high fiber formula

Medications in liquid form are less likely to clog than crushed pills and should be used if available. Regardless, each medication should be given separately with a water flush before and after each medication administration. Water is the flush of choice. Two reports have demonstrated superiority of prophylactic use of pancreatic enzymes to prevent tube occlusion compared to standard water flushes.

Question 45

Question: 45 

Which of the following is a key concept that should be included in the post-discharge teaching regimen for a home parenteral nutrition (HPN) patient?

1: Reimbursement requirements

2: Normal values for electrolytes

3: Signs and symptoms of hypo/hyperglycemia

4: Components of the parenteral nutrition (PN) formula

Answer 45


3: Signs and symptoms of hypo/hyperglycemia
While all of these items are important, the signs and symptoms of hypo/hyperglycemia should be an integral component in instruction of the HPN patient. Reimbursement issues should be addressed prior to discharge, as well as stability of the patient’s electrolyte values and components of the PN formulation.

Question 46

Question: 46 

Which of the following is true regarding the concept of qualilty of life in HPN patients?

1: Most patients believe that the HPN access catheter has little effect on their self-image or self-esteem

2: Patients with chronic bowel disease seem to cope less effectively than patients with acute gastrointestinal trauma

3: Social isolation is not an issue since most infusions are cycled over night

4: Adjusting to HPN is easier for patients who have stability in their personal lives

Answer 46


4: Adjusting to HPN is easier for patients who have stability in their personal lives
Patients who have been able to maintain stability in their personal lives towards employment, family support and financial security, seem to adjust better to HPN and have a more positive outlook on the future. A source of concern for most HPN patients is the cosmetic effect of the catheter. Patients with chronic bowel disease seem to cope more effectively since they often see relief from frequent hospitalizations and abdominal discomfort. While HPN is often cycled at night, the inability to eat can significantly affect social quality of life.

Question 47

Question: 47 

Which of the following is true of aluminum toxicity in patients receiving long-term parenteral nutrition?

1: The clinical manifestations of aluminum toxicity are specific and sensitive

2: Aluminum toxicity is the primary etiology of parenteral nutrition-associated bone disease

3: Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia

4: Modern manufacturing practices have eliminated the risk of aluminum toxicity

Answer 47

3: Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia

Home PN patients at increased risk for aluminum toxicity include those with renal failure and iron deficiency anemia. The kidneys are responsible for unbound aluminum excretion. The majority of aluminum in the blood stream is bound to protein, primarily transferrin, and cannot be excreted. The clinical manifestations of aluminum toxicity (neurological, hepatic, hematologic, and skeletal) are neither specific nor sensitive for aluminum toxicity. The etiology of parenteral nutrition-associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors. Since many components of PN have an affinity for aluminum, there is still a risk for aluminum toxicity in patients on long term PN support.

Question 48

Question: 48 

Which of the following describes a benefit of ethanol as a lock solution?

1: There is no known microbial resistance

2: Ethanol can be used as a procoagulant agent

3: Lock therapy has no effect on biofilm formation

4: Fibrin deposition in the catheter lumen increases

Answer 48

1: There is no known microbial resistance

There is no known microbial resistance to ethanol. A 70% ethanol lock solution has been shown toreduce catheter-related blood stream infections (CRBSIs) attributed to its antimicrobial action through protein denaturation and diffusion through the polysaccharide matrix of a biofilm, as well as prevention of fibrin sheath formation. Ethanol has been used as an anticoagulant in clinical practice.