Learning Assessment Questions

Question 1

Which of the following sodium concentrations (mEq/L) is the most appropriate choice to use when formulating a parenteral nutrition plan for a patient with high output ileostomy?
a. 38.5 mEq sodium per Liter
b. 77 mEq sodium per Liter
c. 115 mEq sodium per Liter
d. 154 mEq sodium per Liter

Answer 1

d. 154 mEq sodium per Liter

Question 2

A patient presents with hypotonic hyponatremia and is currently on setraline. What type of subtype of hyponatremia would you suspect?
a. hypovolemic
b. Euvolemic
c. Hypervolemic
d. None of the above

Answer 2

b. Euvolemic

Question 3

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 3

d. all of the above

Question 4

A patient is noted to have a serum magnesium of 1.5 mg/dl. Serum creatinine is 2.2 mg/dL. What is an appropriate recommendation for magnesium sulfate IV ?
a. Magnesium supplementation not indicated
b. 16 mEq magnesium sulfate
c. 24 mEq magnesium sulfate
d. 48 mEq magnesium sulfate

Answer 4

b. 16 mEq magnesium sulfate

Question 5

A patient presents with peaked T waves on ECG and serum K of 6.5 mEq/L. 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 5

b. Calcium gluconate

Question 6

How many mEq potassium is in 20 mmol of potassium phosphate

Answer 6

30 mEq K

1.5 mEq K in 1 mmol potassium phosphate

Question 7

True or false. Peripheral parenteral nutrition is a nutritional support option for patients receiving long term parenteral nutrition?

Answer 7

False

Question 8

2 in 1 PN will have intravenous lipid emulsion piggybacked along with the PN. What is appropriate hang time for ILE when piggybacked with a 2 in 1 PN?
a. 8 hrs
b. 12 hrs
c. 18 hrs.
d. 24 hrs

Answer 8

b 12 hrs

Question 9

What is a 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 9

b. 900 mOsm/L

Question 10

Which of the following elements can compromise TNA (3 in 1) PN stability?
a. amino acid final concentration <4%
b. dextrose final concertation <10%
c. ILE final concentration <2%
d. All of the above

Answer 10

D. All of the above

Question 11

Which of the following lipid injectable emulsions (ILE) contains the highest amount of phytosterol?
a. FO-ILE
b. OO-SO-ILE
c. SO-MCT-OO-FO-ILE
d.SO-ILE

Answer 11

d. SO_ILE

Question 12

For calcium and phosphate stability what should be added to TPN first? Last?

Answer 12

phosphate first add calcium last

Question 13

Which pH is most favorable for TNA?

Answer 13

pH 6-9

Question 14

What is the primary disturbance seen with simple metabolic acidosis?
a. decrease pCO2
b. Increase pCO2
c. decrease HCO3-
d. Increase HCO3-

Answer 14

c. decrease HCO3’

Question 15

A patient present with 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 15

a. decreased pH, decreased HCO3-

Question 16

For a patient with metabolic acidosis, what is the appropriate method of compensation as seen on 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 a decrease in PCO2

Answer 16

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 17

Which of the following can lead to metabolic alkalosis?
a. pulmonary embolism?
b. septic shock
c. high NG output
d. morphine overdose

Answer 17

c. high NGT output

Question 18

Anion gap is calculated for which type of acid base disorder?
a. metabolic acidosis
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis

Answer 18

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

Question 19

Which of the following questions should be considered when determining if a study should potentially impact your practice?
a. Are the subjects like my patients?
b. what institution completed the study?
c. did the study include an adequate number of charts/
d. is there significant p value?

Answer 19

A rational
Prior to translating research into practice, the practitioner should first consider the consistency and congruence of the patient population with their own practice, as well as the quality of the evidence.

Question 20

Which of the following components could be used to determine malnutrition or nutrition risk in the ICU patient?
a. NFPE
b. Severity of disease
c. measurement of muscle mass
d. all of the above

Answer 20

d. all of the above
Malnutrition is highly prevalent in ICU patients. It is imperative this disease state is recognized and documented. This can be done through the use of a nutrition-focused nutritional exam and determination of nutrition risk based on diet/weight history, presence of chronic disease and current disease severity.

Question 21

Protein demand iin ICU patients is influenced by:
a. age
b. treatments
c. injury
d. all of the above

Answer 21

d. all of the above
In addition to the patient’s injury or “reason for admission”, several other factors may impact the patients’ inability to receive protein (lack of feeding) and increased protein demand. Some of these include the patient’s age and associated frailty, bedrest (inactivity), inflammatory response, obesity associated sarcopenia, insulin resistance and treatment effects (e.g. continuous renal replacement therapy

Question 22

A physician would like to start enteral nutrition on a patient with severe pneumonia requiring vasopressors what is recommended?
a. start with gastric trophic feeds and monitor abdominal exam
b. start with small bowel trophic feeds and monitor abdominal exam
c. start with gastric full feeds and monitor abdominal exam
d. start with small bowel full feeds and monitor exams

Answer 22

a. start with gastric trophic feeds and monitor abdominal exam
The goal for this patient is to provide the benefits of early enteral nutrition without the risks of feeding a bowel that may not be optimally perfused. This patient may have decreased motility, which when combined with poor oxygenation of the bowel mucosa could result in non-occlusive bowel necrosis. Because there is a slight risk (<1%) of this occurring with even trophic feeding, it is important to monitor the patient closely for tolerance of feeding. This can be done by following gastric residual volumes for signs of tube feeding product (a sign of poor motility in this patient) and the patient’s abdominal exam for increased distention. If the patient was fed directly into the small bowel, there would be a delay in recognizing poor motility.

Question 23

Which of the following would be preferred approach to the lipid componenet of PN in the first week of ICU stay?
a. withhold lipids for the first week
b. Use 100% soy bean lipids emulsion
c. Use a 4 oil lipid emulsion

Answer 23

c. Use a 4-oil lipid emulsion
Two meta-analysis (the last completed in 2020) have demonstrated less infection risk in patients receiving fish-oil containing lipid emulsions versus those without fish oil. Guidelines suggest soy-limiting steps should be taken, even when alternative lipids are not available during the first week of ICU stay. After that soy-bean based lipids should be provided to at least meet the patients essential fatty acid needs or as a caloric source as needed.

Question 24

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 24

Answer = 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 25

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 25

Answer = 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 26

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 26

Answer = 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 27

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). 69
a. Starvation-related malnutrition
b. Acute disease-related malnutrition
c. Chronic disease-related malnutrition
d. Marasmus and kwashiorkor

Answer 27

Answer = B; Rationale: Ben was a healthy young male prior to his accident therefore he is exhibiting acute disease-related malnutrition.

Question 28

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 28

Answer = A; Rationale: the Academy/ASPEN malnutrition characteristics include assessing food intake, weight history, evaluation of fat and muscle stores, presence of edema and handgrip strength

Question 29

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 29

Answer = B; Rationale: 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 30

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 30

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

Question 31

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 31

Answer = D; Rationale: 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 32

Initiation and advancement of which of the following macronutrients in neonatal parenteral nutrition should take a “start low and go slow” approach due to potential complications?
A. Amino acids
B. Dextrose
C. Intravenous fat emulsions

Answer 32

Answer = B; Rational: Dextrose must be initiated at a minimum level based on the glucose infusion rate (GIR) of the parenteral nutrition solution and the blood glucose of the patient. The GIR is then advanced by 1-2 mg/kg/min each day as the neonate’s blood glucose values tolerate to a maximum of 10-14 mg/kg/min. Unlike older pediatric/adult patients, neonates 88
especially the very premature may respond erratically to insulin therapy so the titration of dextrose in PN must be closely monitored. Amino acids are essential to neonates to prevent negative nitrogen balance but may be initiated at goal quantities within the first 24 hours of life. Intravenous fat emulsions are generally well tolerated by the majority of pediatric patients and while the recommendations are to start at 0.5-1 g/kg/day, higher initiation levels have been used (i.e., 2-3 g/kg/day).

Question 33

Which of the following is the optimal ratio of calcium to phosphate for short term use of neonatal parenteral nutrition solutions to optimize bone mineralization?
A. 0.5 mol:1 mol
B. 1.3 mol:1 mol
C. 2 mol:1 mol

Answer 33

Answer = B; Rationale: In short-term PN, a Ca:P of 1.3:1 mol:mol (1.7:1 mg:mg) is associated with the best calcium and phosphate retention based on quantitative ultrasonography. Since the longest study assessing this has only lasted a total of 6 weeks, true recommendations regarding long-term PN therapy cannot be made.

Question 34

The use of human milk often requires fortification of additional macro/micronutrient supplementation. If the fortification is from commercially available infant formula, which of the following supplements is necessary?
A. Folic acid
B. Vitamin D
C. Multivitamin with iron

Answer 34

Answer = C; Rational: When human milk is fortified with commercially available infant formula, some micronutrients are provided from the formula but there are still overall deficiencies in several nutrients. While vitamin D may be needed (Answer B), a more appropriate supplement would be a multivitamin with iron (Answer C) to provide a more complete supplementation plan. Folic acid (Answer A) is primarily needed for supplementation of human milk which is fortified with human milk-based fortification.

Question 35

When determining calorie needs for an obese hospitalized child which of the following is recommended?
a. The Harris-Benedict equation
b. The Schofield equation
c. Indirect calorimetry
d. EER using adjusted body weight
2. Which of the following are indications for enteral

Answer 35

c. Per ASPEN guidelines it is recommended that indirect calorimetry be used to determine calorie needs of the obese hospitalized child secondary to the inaccuracy of predictive equations

Question 36

Which of the following are indications for enteral nutrition support?
a. Short-bowel syndrome
b. Prematurity
c. Cerebral palsy
d. Biliary atresia
e. All of the above

Answer 36

e. All are indications for enteral nutrition support. However, in some circumstances parenteral nutrition may also be used as an adjunctive therapy

Question 37

Which of the following measures are used to evaluate if a child is malnourished?
a. weight
b. height
c. MUAC
d. TSF
e. a, b, c, d
f. a, b, c

Answer 37

f. According to the Consensus Statement of AND/ASPEN: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition), weight, height and MUAC are used to identify and classify pediatric malnutrition. Overall nutrient intake in relation to estimated needs is another factor to consider when there are two ore more data points available.

Question 38

If a child on parenteral nutrition support is cholestatic, which trace element may need to be removed from the parenteral nutrition?
a. Selenium
b. Zinc
c. Manganese
d. Chromium

Answer 38

4. c. Manganese may need to be removed from parenteral nutrition in children with cholestasis because it is excreted in the bile and may contribute to neurotoxicity if not properly excreted.

Question 39

What is the hang time for enteral feedings consisting of human breast milk?
a. 4 hours
b. 6 hours
b. 8 hours
c. 12 hours

Answer 39

a. Recommendations state that powdered, reconstituted formula, human breast milk, and enteral formula with additives should have a 4-hour hang time.