PN

Question 1

A pregnant patient is admitted with hyperemesis gravidarium (HEG). Which of the following is a clinical indication for PN use?

1: Vomiting NOT controlled with supportive care within 48 hours
2: Intolerance to EN trial and supportive care measures
3: Patient refusal of EN tube placement
4: Fluid and electrolyte imbalances

Answer 1

2: Intolerance to EN trial and supportive care measures

Question 2

Rapid intravenous infusion of potassium phosphate may result in

1: thrombophlebitis.
2: hypercalcemia.
3: metabolic alkalosis.
4: vitamin D deficiency

Answer 2

1: thrombophlebitis

Question 3

What is the most common complication associated with PN administration?

1: Hypophosphatemia
2: Renal dysfunction
3: Sepsis
4: Hyperglycemia

Answer 3

4: Hyperglycemia

Question 4

Which of the following additives has the greatest risk of destabilizing the intravenous fat emulsion (IVFE) in a total nutrient admixture (TNA)?

1: Sodium chloride
2: Calcium acetate
3: Iron dextran
4: Potassium phosphate

Answer 4

4: Iron dextran

Question 5

Which of the following factors has been associated with an increase in prescribing errors related to PN formulations?

1: Standardized PN order form
2: Calculation of PN dosages
3: PN components ordered as amount per day
4: PN components listed in same sequence on order form as PN label

Answer 5

2: Calculation of PN dosages

Question 6

According to the A.S.P.E.N. Safe Practices Guidelines, which of the following is the best method to express the dextrose content on the label of a PN formulation in order to avoid misinterpretation?

1: Volume of the percent of original concentration added (e.g., 500 mL of 50% dextrose)
2: Grams per liter (e.g., 250 g/L)
3: Percent of final concentration after admixture (e.g., 35% dextrose)
4: Grams per 24-hour nutrient infusion (e.g., 225 g/day)

Answer 6

4: Grams per 24-hour nutrient infusion (e.g., 225 g/day)

Question 7

All of the following are considered to be mandatory for the PN order form EXCEPT

1: general statement warning of the potential for PN formulation incompatibilities.
2: contact number for the person writing the order.
3: hangtime guidelines.
4: recommended PN laboratory tests

Answer 7

4: recommended PN lab tests

Question 8

According to the A.S.P.E.N. Safe Practices Guidelines, the following are strongly recommended for inclusion on the PN label EXCEPT

1: route of administration.
2: dose of macronutrients for 24 hours.
3: dosing weight.
4: location of venous access device

Answer 8

4: location of venous access device

Question 9

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.

1: 1830 kcal, 90 grams protein, 40 grams fat, 2625 mL
2: 2010 kcal, 90 grams protein, 40 grams fat, 2400 mL
3: 1830 kcal, 90 grams protein, 45 grams fat, 2625 mL
4: 1470 kcal, 90 grams protein, 45 grams fat, 2400 mL

Answer 9

3: 1830 kcal, 90 grams protein, 45 grams fat, 2625 mL

Question 10

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

Answer 10

4: 25.3 kcal/kg/day

Question 11

In the critically ill obese patient, specific guidelines for the provision of calories and protein have been recommended by both the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition. For a patient with a BMI > 30 kg/m2, which of the following choices best reflects those recommendations for parenteral and enteral nutrition?

1: 15-20 kcal/kg ideal body weight/day & less than 2.0 g/kg ideal body weight/day
2: 15-20 kcal/kg ideal body weight/day & greater than or equal to 2.0 g/kg ideal body weight/day
3: 22–25 kcal/kg ideal body weight/day & less than 2.0 g/kg ideal body weight/day
4: 22–25 kcal/kg ideal body weight/day & greater than or equal to 2.0 g/kg ideal body weight/day

Answer 11

4: 22–25 kcal/kg ideal body weight/day & greater than or equal to 2.0 g/kg ideal body weight/day

Question 12

Which of the following is a strong indication for the use of parenteral nutrition (PN)?

1: High output fistula
2: Crohn’s disease
3: Pancreatitis
4: Hyperemesis gravidarum

Answer 12

1: High output fistula

Question 13

When is parenteral nutrition (PN) indicated in severe burn patients?

1: Total body surface area burn exceeds 20%
2: As soon as possible after admission due to extremely high caloric needs
3: Enteral nutrition is contraindicated or unlikely to meet nutrition needs
4: Within 7-10 days after hospital admission

Answer 13

3: Enteral nutrition is contraindicated or unlikely to meet nutrition needs

Question 14

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

Answer 14

4: severely malnourished

Question 15

Which of the following is a strong indication for PN support in a cancer patient?

1: Abdominal tumor resulting in an unresolved small bowel obstruction for greater than seven days
2: Metastatic cancer, receiving palliative care
3: Receiving concurrent chemotherapy and radiation therapy
4: Mild malnutrition, scheduled for tumor resection surgery in three days

Answer 15

1: Abdominal tumor resulting in an unresolved small bowel obstruction for greater than seven days

Question 16

When should PN be used in Crohn’s disease?

1: As a primary therapy to rest the bowel
2: Only after failure to tolerate EN
3: To prevent associated malnutrition
4: Preoperatively regardless of nutrition status

Answer 16

2: Only after failure to tolerate EN

Question 17

Current recommendations regarding safe administration of intravenous fat emulsion (IVFE) include

1: IVFE hang time up to 24 hours when included as part of a total nutrient admixture (TNA).
2: IVFE hang time up to 24 hours when administered as an infusion separate from PN.
3: Use of a 0.22 micron filter when administering a TNA to remove microorganisms from a contaminated PN.
4: Use of a 1.2 micron filter when administering a TNA to remove microorganisms from a contaminated PN

Answer 17

1: IVFE hang time up to 24 hours when included as part of a total nutrient admixture (TNA)

Question 18

Which of the following is the most appropriate distal catheter tip placement of a peripherally inserted central catheter (PICC)?

1: Cephalic vein
2: Superior vena cava
3: Internal jugular vein
4: Supraclavicular vein

Answer 18

2: Superior vena cava

Question 19

Which of the following is a disadvantage of a peripherally-inserted central catheter (PICC)?

1: High rate of catheter malposition
2: High risk of pneumothorax
3: Requires repeated skin puncture
4: Only available with single lumen

Answer 19

1: High rate of catheter malposition

Question 20

When is it most appropriate to start PN infusion in a patient with a new central venous catheter inserted at the bedside without fluoroscopy?

1: Immediately
2: After auscultating for catheter tip placement
3: After chest X-ray confirms correct placement of catheter tip
4: After ensuring there were no complications with insertion

Answer 20

3: After chest X-ray confirms correct placement of catheter tip

Question 21

According to the Centers for Disease Control and Prevention (CDC), which of the following is true regarding peripherally inserted central catheter (PICC) line care?

1: Scheduled replacement is recommended to prevent catheter-related blood stream infections (CRBSIs)
2: Remove the PICC line immediately if fever develops
3: Use routine guidewire exchange of PICC line to prevent CRBSIs
4: Remove the PICC line only if it is suspected or known to be the source of infection

Answer 21

4: Remove the PICC line only if it is suspected or known to be the source of infection

Question 22

PN solutions should NOT be infused via a catheter inserted in which vein?

1: Basilic
2: Femoral
3: Subclavian
4: Internal jugular

Answer 22

2: Femoral

Question 23

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

Answer 23

1: 10% dextrose and 3% amino acid

Question 24

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

Answer 24

1: Increased amino acid concentration

Question 25

Free glutamine supplementation in PN is limited by

1: the presence of intravenous fat emulsion (IVFE) in a total nutrient admixture (TNA) formula.
2: expense of the commercially available product.
3: physical stability after compounding.
4: the presence of calcium in the PN

Answer 25

3: physical stability after compounding

Question 26

The primary difference between renal and standard intravenous amino acid formulas is that renal formulas contain a higher proportion of which type of amino acids?

1: Non-essential
2: Conditionally essential
3: Essential
4: Branched-chain

Answer 26

3: Essential

Question 27

Branched-chain amino acid formulas would be most appropriate for

1: a patient with a recent diagnosis of hepatocellular cancer.
2: prevention of a first episode of hepatic encephalopathy in a patient who has undergone a transjugular intrahepatic portosystemic shunt (TIPS) procedure.
3: initial management of acute hepatic encephalopathy.
4: a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources despite optimal pharmacotherapy

Answer 27

4: a cirrhotic patient with chronic encephalopathy who is intolerant of standard protein sources despite optimal pharmacotherapy

Question 28

Failure to provide linoleic and alpha linolenic acids with PN will most likely result in

1: metabolic acidosis.
2: hyperglycemia.
3: metabolic bone disease.
4: essential fatty acid deficiency (EFAD)

Answer 28

4: essential fatty acid deficiency (EFAD)

Question 29

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

Answer 29

4: avoiding serum triglyceride levels >400 mg/dL

Question 30

Which of the following best describes an intravenous fat emulsion (IVFE) produced by the transesterification of fatty acids to form a composite triglyceride molecule?

1: Single oil
2: Multi-oil
3: Structured
4: Physical mixture

Answer 30

3: Structured
When two or more oils are mixed together, the emulsion product is called a physical mixture. Medium-chain fatty acid (MCFA)/Long-chain fatty acid (LCFA) structured lipids are similar to MCFA/LCFA physical mixtures in that they combine the properties of the two types of fatty acids. However, the structured lipid is created through hydrolysis of TG and transesterification of fatty acids to form a composite triglyceride molecule that has various proportions of both MCFA and LCFA.

Question 31

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

Answer 31

3: Copper and manganese
Reductions in manganese and copper dosing should be considered in patients with hepatobiliary disease due to impaired excretion. Manganese is a contaminant found within the PN solution components, thus patients will likely receive small doses of manganese even if eliminated from the PN trace element prescription.

Question 32

Which of the following PN components is NOT a source of aluminum contamination?

1: Heparin
2: Albumin
3: Calcium Gluconate
4: Regular insulin

Answer 32

4: Regular insulin
Aluminum contamination occurs primarily from the introduction of raw materials during the manufacturing process. Product sources of primary concern include calcium and phosphate salts, heparin, and albumin. In response to the evidence linking the use of parenteral drug products containing aluminum to morbidity and mortality.

Question 33

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

Answer 33

1: Manganese
Toxicity may occur in pediatric and adult patients on long-term PN therapy supplemented with manganese. Cholestatsis and biliary obstruction may also increase the risk of toxicity, but is not always present. The early phase of manganese toxicity is characterized by weakness, anorexia, headache, and apathy followed by Parkinson-like features including muscle rigidity, mask-like face, staggered gait, and fine tremor.

Question 34

When compared to the Dietary Reference Intakes (DRIs) for fat-soluble vitamins given orally, the DRIs for parenterally administered fat-soluble vitamins are

1: lower.
2: equal.
3: two times higher.
4: four times higher

Answer 34

1: lower
The DRI for parenteral administration of the fat-soluble vitamins are less than the DRIs for the orally given fat-soluble vitamins. Requirements are lower because there is no loss from the gastrointestinal tract when the doses are given intravenously.

Question 35

When compared to the Dietary Reference Intakes (DRIs) for water-soluble vitamins given orally, the DRIs for parenterally administered water-soluble vitamins are

1: one-third.
2: one-half.
3: equal.
4: higher

Answer 35

4: higher
The DRIs for parenterally administered water-soluble vitamins are higher than the DRIs for orally given water-soluble vitamins. Patients receiving PN are considered more stressed and may require a higher intake of the water-soluble vitamins.

Question 36

According to USP Chapter 797, a PN solution prepared from 8.5% amino acid solution with electrolytes and 70% dextrose, with multivitamins, trace elements, and Famotidine added would be classified as

1: no risk.
2: low risk.
3: medium risk.
4: high risk.

Answer 36

3: medium risk
Compounding of PN using manual or automated devices during which there are multiple injections, detachments, and attachments of nutrient source products to the device or machine to deliver all nutritional components to a final sterile container is classified as medium-risk (i.e. as in the question above).

Question 37

Which of the following best describes national standards for the safe practices in preparing PN?

1: There are four different identified risk levels based on potential for instability
2: The lower the risk level, the shorter the “beyond use date” will be
3: The expiration date is a term based on drug stability
4: Sterility refers to the absence of any microorganism in the compounded preparation

Answer 37

4: Sterility refers to the absence of any microorganism in the compounded preparation
There are three different risk levels (low, medium and high) based on the potential for microbial contamination. The higher the risk level, the shorter the “beyond use date” will be, which refers to both chemical stability and product sterility. Expiration date is a term that only refers to stability of the compound. Sterility refers to the absence of any viable microorganism.

Question 38

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.

Answer 38

1: a translucent band at the surface of the emulsion separate from the remaining TNA dispersion

Question 39

Which of the following complications is most likely to occur when transitioning a critically ill patient from parenteral to enteral nutrition?

1: Hypocalcemia
2: Hypercalcemia
3: Hypoglycemia
4: Hyperglycemia

Answer 39

4: Hyperglycemia
When transitioning from parenteral to enteral nutrition, patients may receive nutrients in excess during overlap of therapy leading to hyperglycemia. Appropriate adjustments to limit carbohydrate intake to 4 mg/kg/min can prevent this metabolic complication.

Question 40

Rapid intravenous infusion of sodium or potassium phosphate may result in

1: tetany.
2: hypercalcemia.
3: metabolic alkalosis.
4: vitamin D deficiency.

Answer 40

1: tetany.
Rapid infusion of phosphate can result in tetany due to an abrupt decrease in serum calcium concentration. Since phosphate salts are acidifying in nature, alkalosis would not be anticipated.

Question 41

Which of the following should be monitored regularly in an adult home PN patient receiving IVFE?

1: Fecal fat
2: Serum osmolarity
3: Prothrombin time
4: Retinol-binding protein

Answer 41

3: Prothrombin time
Pts receiving home PN are at risk of central venous thrombosis. Currently, the risk of thrombosis may be decreased by treatment with warfarin. In pts treated with low-dose warfarin, the intake of vitamin K may be important in influencing its anticoagulation effect. These patients may receive significant amounts of vitamin K from several different sources including diet and nutrition supplements, IV lipid emulsion, and IV supplementation with multivitamins.

Question 42

A patient receiving PN develops metabolic acidosis. Which serum electrolyte level needs to be monitored most closely?

1: Sodium
2: Chloride
3: Potassium
4: Magnesium

Answer 42

3: Potassium
Metabolic acidosis results in an extracellular shift of potassium, without changes in total body potassium. Correction of the underlying metabolic acidosis redistributes K+ into the intracellular space and corrects the hyperkalemia. Due to K+ involvement in muscle contraction, cardiac arrest is the most severe manifestation of hyperkalemia.

Question 43

Which of the following is a clinical sign of significant hyperphosphatemia?

1: Tachycardia
2: Tetany
3: Hyperventilation
4: Altered mental status

Answer 43

2: Tetany
The most common clinical manifestation of hyperphosphatemia is hypocalcemia due to calcium-phosphate precipitation, which can lead to tetany and other clinical manifestations of hypocalcemia. The risk of calcium-phosphate precipitation appears to increase when the serum calcium level multiplied by the serum phosphorus concentration exceeds 55-60 mg2/dL2.

Question 44

What biochemical evidence indicates essential fatty acid deficiency (EFAD)?

1: A serum triglyceride level < 100 mg/dL
2: A lymphocyte absolute count < 1000/microliter
3: A serum cholesterol level < 100 mg/dL
4: A triene to tetraene ratio > 0.4

Answer 44

4: A triene to tetraene ratio > 0.4
Biochemical evidence of EFAD is determined by a triene: tetraene ratio of more than 0.4 and can occur within 1 to 3 weeks in adults receiving IVFE-free PN.

Question 45

Concurrent infusion of IVFE and propofol would most likely cause

1: hyperglycemia.
2: hypertriglyceridemia.
3: azotemia.
4: hypernatremia.

Answer 45

2: hypertriglyceridemia.
Propofol, an anesthetic agent, is used for intensive care unit sedation. The vehicle for administering this drug is 10% IVFE. The concurrent administration of propofol and IVFE in PN can result in higher than recommended doses of IVFE and hypertriglyceridemia if appropriate adjustments are not made.

Question 46

Which component of 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

Answer 46

3: Intravenous fat emulsion (IVFE) and vitamins
In hospitalized patients or home patients receiving PN, the vitamin K requirement may be provided by daily infusion of IVFE or by using a vitamin preparation that contains vitamin K. Patients receiving vitamin K from either or both of these sources may require higher doses of warfarin to achieve target INR.

Question 47

When initiating a PN regimen that contains regular insulin, how often should capillary blood glucose levels be monitored?

1: Every 6 hours
2: Every 8 hours
3: Every 12 hours
4: Every 24 hours

Answer 47

1: Every 6 hours

Question 48

What risk is associated with the abrupt cessation of a parenteral nutrition solution that contains 50 units of regular insulin?

1: hypokalemia
2: rebound hypoglycemia
3: fluid overload
4: hypomagnesemia

Answer 48

2: rebound hypoglycemia

Question 49

In adult parenteral nutrition patients, intravenous fat emulsion (IVFE) use should be limited when serum triglyceride levels rise above

1: 400 mg/dL.
2: 300 mg/dL.
3: 200 mg/dL.
4: 100 mg/dL

Answer 49

1: 400 mg/dL.
Serum TG provide a reasonable estimate of body lipid clearance. Hypertriglyceridemia in adults has resulted in impaired pulmonary function, immune suppression and increased risk of pancreatitis. When serum TG levels exceed 400 mg/dL fat provision should to be decreased and this is typically accomplished by a reduction in the number of days IVFE is provided per week. One should remember to provide at a minimum the amount of IVFE to prevent EFAD. This can be accomplished by infusing 250 mL of a 20% IVFE once or twice weekly.

Question 50

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

Answer 50

2: 5 mcg/kg/day
Alterations in bone formation and mineralization, parathyroid hormone secretion, and urinary calcium excretion have been attributed to aluminum toxicity. The FDA currently recommends that all manufacturers list the maximum aluminum concentration at product expiration and that daily intake of parenteral aluminum not exceed 5 mcg/kg/day.

Question 51

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.

Answer 51

2: patients at risk for liver dysfunction.
Cycling of PN formulations should be considered for patients with or at risk for liver dysfunction, on long-term TPN or those who are stable and active and may benefit from infusion free periods.