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CNSC 2022 > Test Your Knowledge Questions > Flashcards

Test Your Knowledge Questions Flashcards

1
Q

Which of the following practices is most likely to succeed in improving oral nutrients intake in patients with a prolonged history of wt loss d/t N and depressed appt?

  1. Providing a high energy oral liquid supplement 3 times daily.
  2. Offering 6 small, low fat meals daily
  3. Ordering fiber supplemented snacks 3 times daily
  4. Planning primarily solid meals and limiting fluids
A
  1. Offering 6 small, low fat meals daily

Pt with prolonged depressed appt may not be able to tolerate 3 big meals due to decline of stomach’s adaptive accommodation. High fat foods also slow gastric emptying, leading to nausea. High energy and high fiber foods also slow gastric emptying.

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2
Q

Which of the following statements explains why fermentable fiber is a beneficial addition to EN formulas?

  1. Colonic bacteria act on the fiber to produce SCFA that provide an energy source to the intestinal mucosa.
  2. Colonic bacteria act on the fiber to produce SCFA, which, in turn, exert trophic effects on the intestinal mucosa.
  3. Fermentable fiber may help control D b slowing gastric emptying.
  4. All of the above.
A
  1. All of the above.
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3
Q

Which of the following nutrients is added to rehydration liquids to promote H20 absorption in pt with D?

  1. Na + Glucose
  2. Amino acids
  3. Long chain FAs
  4. Alcohol.
A
  1. Na + Glucose

The presence of Na in the small intestine lumen promote the absorption of Glucose. When more Na is absorbed, more H20 in the lumen is absorbed.

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4
Q

Which of the following is the largest component of total energy expenditure?

  1. RMR
  2. Thermogenic effect of digestion
  3. Physical activity
  4. Metabolic stress
A
  1. RMR

RMR constitute up to 60-75% of TEE.

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5
Q

Which of the following is the most commonly used method for assessing energy expenditure?

  1. Indirect calorimetry
  2. Predictive equations
  3. The reverse Fick equation
  4. Doubly labeled water
A
  1. Predictive equations

The use of predictive equations is the most common method. IC is the most accurate method but it is limited due to equipment and not all pt can tolerate the measurement.

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6
Q

Which parameter is meausred when using IC?

  1. Heat loss
  2. Catabolic rate
  3. Gas exchange
  4. Free energy balance
A
  1. Gas exchange

IC measure respiratory gas exchange, the difference btw inspire and expired O2 and CO2. If testing conditions are proper then respiratory gas exchange equal metabolic gas exchange

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7
Q

You are determining the energy intake target for a 53 y.o, critically ill male pt who is about to start EN. He is 170 cm tall and wt is 150kg. His BMI is 51.9 and his IBW is 70kg, Temp is 37.3 Cel and min ventilation is 12.5L/min. Based on the 2016 ASPEN guidelines for calculating goal energy intake for critically ill pt, which energy value would you use?

A
  1. 1750 (25kcal/kg IBW)

ASPEN guidelines for calculating energy intake for energy intake for obese pt. BMI 30-40: 11-14kcal/kg actual BW, BMI>50, 22-25kcal/kg IBW.

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8
Q

Which of the following is true about the net chemical reaction of glucose metabolism?

  1. Pyruvate is the final product
  2. O2 is required for ATP synthesis
  3. Both H20 and CO2 are produced
  4. CO2 is produced but H20 is not
  5. H20 is produced but CO2 is not.
A
  1. Both H20 and CO2 are produced

Pyruvate is the final product of glycolysis. It then leave the cytoplasm and enter the mitochondria. Pyruvate can be broken down in the aerobic and anaerobic pathways. Both pathways produce ATP. After all energy has been released, CO2 and O2 are the final products.

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9
Q

Which of the following incorrectly pairs a metabolic process with its site of occurrence?

  1. Glycolysis and cytosol
  2. TCA cycle and mitochondrial membrane
  3. ATP phosphorylation and cytosol and mitochondria
  4. ETC and mitochondrial membrane
  5. Oxidative decarboxylation of pyruvate and mitochondria.
A
  1. TCA cycle and mitochondrial membrane

The TCA cycle takes place in the mitochondria.

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10
Q

Which of the following is least likely to occur during oxygen debt?

  1. Build up of lactic acid
  2. Build up of pyruvate
  3. Decrease in pH
  4. Increased fatigue
  5. Shortage of ATP
A
  1. Build up of pyruvate

During anaerobic condition, pyruvate accepts a proton from NADH => NAD+, producing lactic acid. At physiological pH, this turn into Lactate, which lower pH and only 2 ATP is produced. A shortage of ATP=> muscle fatigue.

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11
Q

Which of the following statements best describes the human gut microbiota?

  1. the human gut microbiota is established by the age of 3 and few factors influence it.
  2. Trillions of bacteria currently comprise the human gut microbiota.
  3. the human gut microbiota is highly dependent on the host for survival but provides little benefit to the host.
  4. the human gut microbiota is not influenced by the mode of infant delivery.
A
  1. Trillions of bacteria currently comprise the human gut microbiota.
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12
Q

Which of the following statements best describes a probiotic?

  1. A live organism used to make yogurt
  2. A “live non pathogenic organism (bacteria or yeast) which when administered in adequate amt confers a health benefit to the host.
  3. Probiotics are on the GRAS list and therefore can be safely provided to all humans receiving nutrition support therapy.
  4. The mechanisms of probiotics are well known, making probiotic therapy a great addition to nutrition support therapy.
A
  1. A “live non pathogenic organism (bacteria or yeast) which when administered in adequate amt confers a health benefit to the host.
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13
Q

Which of the following statements best describes a prebiotic?

  1. All Fibers are considered prebiotic
  2. Prebiotics are synthetic compounds
  3. Prebiotics are dietary polysaccharides that escape digestion by host enzymes, are fermented by the gut microbiota and influence the gut microbiota pattern in a beneficial manner.
  4. All prebiotics are fermented to yield the same SCFAs
A
  1. Prebiotics are dietary polysaccharides that escape digestion by host enzymes, are fermented by the gut microbiota and influence the gut microbiota pattern in a beneficial manner.

Prebiotic are often thought of as fibers, but not all fibers are fermentable and not all fermentable fibers yield the same amount of SCFAs.

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14
Q

What are some of the possible ramifications of activation of the enzyme phospholipase A2?

  1. COX dependent, eicosanoid mediated inflammatory reactions
  2. Enzymatic degradations of resolvins and protectins
  3. Desaturation of linoleic acid within lipids
  4. Chylomicron maturation
A
  1. COX dependent, eicosanoid mediated inflammatory reactions
    The activation of phospholipase A2 leads to the release of Arachidonic acid, which then lead to intracellular metabolic activity via the COX pathway.
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15
Q

How might propofol, when provided to pt wihitn a 10% ILE, increase the risk of hyperTG?

  1. Propofol causes acute uptake of TG by the microvilli of the small intestine.
  2. Propofol is known to activate the release of TGs from adipose tissues.
  3. The increased presence of lipsomes in the propofol ILE may interfere with chylomicron and pseudo chylomicron metabolism
  4. The presence of sedative in the ILE prevents phospholipid formation which results in an increased levels of TGs in the blood.
A
  1. The increased presence of lipsomes in the propofol ILE may interfere with chylomicron and pseudo chylomicron metabolism
    Liposomes are produced during ILE productions which can lead to the formation of Lispoprotein X. Lispoprotein X can inhibit lipoprotein lipase and hepatic lipase enzyme activity which can affect the metabolism of TGs.
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16
Q

Which ionized form of a SCFA is though to be the most important to colonic health and why?

  1. Myristate
  2. Caproate
  3. Butyrate
  4. Valerate
A
  1. Butyrate

Butyrate is thought to modify inflammatory activity and promote colon health.

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17
Q

Which of the following statement is true relating to HCl and protein digestions?

  1. HCl aids in the conversion of pepsin to pepsinogen
  2. HCl denatures protein structures to make them more susceptible to enzymatic action
  3. HCl is secreted by the parietal cells within the duodenum in response to dietary protein
  4. HCl’s release is stimulated by the hormone insulin.
A
  1. HCl denatures protein structures to make them more susceptible to enzymatic action

HCl is secreted by the parietal cells within the stomach, it converts pepsinogen to pepsin and its secretion is d/t gastrin.

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18
Q

During protein metabolism, BCAA

  1. Are extracted primarily by the liver after a protein containing meal
  2. Are released by the skeletal muscle at a higher rate than other AA.
  3. Serve as the primary fuel sources for enterocytes.
  4. Produce oxidative wastes during metabolism within the skeletal muscle, which are removed and alanine and glutamine.
A
  1. Produce oxidative wastes during metabolism within the skeletal muscle, which are removed and alanine and glutamine.
    BCAA are extracted by the skeletal muscle, released at a lower rate compared to other AA. Nitrogen waste products during BCAA oxidation within the skeletal muscle are removed by alanine and glutamine
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19
Q

Protein perform all of the following physiological functions except

  1. Provide a major source of energy
  2. Maintain acid base balance
  3. Contribute to immune defense
  4. Serve as a mode of transport for substances
A
  1. Provide a major source of energy

CHO and fats are the major sources of energy

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20
Q

The rate of protein turnover in catabolic, critically ill pt

  1. Does not change
  2. Decreases
  3. Increases
  4. Is not affected by nutrition support
A
  1. Increases

Nutrition support improve protein synthesis somewhat but does not affect protein degradation.

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21
Q

The administration of 1 L of 0.9% sodium chloride to a normonatremic pt will increase the intravascular and interstitial fluid compartments by:

  1. 1000mL and 0mL respectively
  2. 0 mL and 1000mL respectively
  3. 750mL and 250mL respectively
  4. 250mL and 750mL respectively
A
  1. 250mL and 750mL respectively

An isotonic solution like normal saline will not increase osmotic gradient, therefore the 1L will enter and remain in the ECF. Within ECF, the intravascular fluid increases by 25% and the rest is the interstitial fluid.

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22
Q

Assuming the same wt and serum Na concentration, which the following pt has the greatest free water deficit?

  1. a 35 y.o man
  2. a 75 y.o man
  3. a 35 y.o woman
  4. a 75 y.o woman
A
  1. a 35 y.o man

Free water deficit = TBW x [1-(140/serum sodium)]. TBW varies depending on age and amount of LBM. Young men tends to have the highest amount of LBM, therefore, the highest greatest free water deficit.

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23
Q

A pt with severe intractable N/V is at risk for which of the following acid base disorder?

  1. Hyperchloremic metabolic alkalosis
  2. Hyperchloremic metabolic acidosis
  3. Hypochloremic metabolic alkalosis
  4. Hypochloremic metabolic acidosis
A
  1. Hypochloremic metabolic alkalosis

Prolonged N/V can lead to loss of HCl leading to metabolic acidosis and excess of alkali.

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24
Q

What amt of retinol is the equivalent to 24mcg of beta-carotene from food?

  1. 2 mcg
  2. 4 mcg
  3. 1 mcg
A
  1. 2 mcg

1 mcg retinol has the vit A activity of 12 mcg beta carotene.

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25
Q

Which of the following nutrients does not engage in conversion of homocysteine to methionine?

  1. Choline
  2. Vit D
  3. B12
  4. Folate
A
  1. Vit D

B12 and folate are needed for the conversion of homocysteine to methionine, choline may be used for this conversion

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26
Q

The first B vitamin deficiency to manifest in people with alcoholism is usually

  1. Niacin
  2. Pantothenic acid
  3. B6
  4. Thiamin
A
  1. Thiamin

Small amt of thiamin is stored in the liver, therefore it is usually the first to be deficient during malabsorption and inadequate intakes

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27
Q

Which of the following trace elements is regulated at the level of absorption but not excretion?

  1. Zinc
  2. Copper
  3. Manganese
  4. Iron
A
  1. Iron

Iron is regulated at the absorption phase and it is hard to excrete iron except during blood loss

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28
Q

Which of the following is an example of a pt condition anticipated to manifest with a severe systematic inflammatory response?

  1. Anorexia nervosa with a BMI of 15
  2. Major depression with compromised dietary intake and 5% wt loss
  3. Homebound older adult with restricted access to food and 10% wt loss
  4. Thermal burn injury of 2nd and 3rd degree covering 15% of body surface areas.
A
  1. Thermal burn injury of 2nd and 3rd degree covering 15% of body surface areas.
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29
Q

A physician informs you that a pt has a serum albumin of 2.8g/dL and prealbumin of 14mg/dL and askes whether these lab findings mean the pt is malnourished. What is the most appropriate response?

  1. The pt’s protein intake is inadequate, and the pt should receive prompt nutrition support
  2. Together, these markers indicate that pt has moderate protein energy malnutrition
  3. Considering of medical hx, clinical diagnosis, and lab signs of the inflammatory response would help you interpret these findings
  4. For most hospitalized pt, albumin and prealbumin have excellent sensitivity and specificity to identify malnutrition
A
  1. Considering of medical hx, clinical diagnosis, and lab signs of the inflammatory response would help you interpret these findings

Albumin and prealbumin may be reduced due to the systematic response to inflammation, injury and disease and may not be a reflection of malnutrition.

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30
Q

Which of the following is one of the best validated screening indicators of malnutrition risk?

  1. Pt reports a nonvolitional wt loss
  2. Pt reports following a low CHO, wt loss diet
  3. Pt is 2 days s/p laparoscopic cholecystectomy
  4. Pt reports a recent flu like febrile illness
A
  1. Pt reports a nonvolitional wt loss
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31
Q

Which of the following is a benefit of EN compared with PN or no nutrition?

  1. Maintenance of the normal gallbladder function
  2. Reduced GI bacterial translocation
  3. More efficient nutrient metabolism
  4. All of the above.
A
  1. All of the above.
    EN provided nutrients in the small intestine which stimulate the release of CKK which help maintain gallbladder function. Presence of nutrients also provide GI structure support and help prevent bacterial translocation. EN also mimic oral feeding and can help promote more efficient metabolism
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32
Q

High protein hypocaloric EN feeing providing 65% - 70% of energy needs, as determined by IC, is recommended for ICU pt with which of following condition?

  1. Malnutrition
  2. Obesity
  3. Liver failure
  4. ARDS
A
  1. Obesity

Research support that obese pt benefit from high protein, low calories feeding to help preserve LBM.

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33
Q

Risk factors for aspiration include all the following except?

  1. Malnutrition
  2. Use of naso/oro feeing tube
  3. Bolus EN feeding
  4. Supine position
A
  1. Malnutrition
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34
Q

A 55 y,o man presented to the hospital after a traumatic fall from a ladder while working at home. A CT scan of the head showed significant subdural hematoma with midline shift. After admission to the ICU, the pt was intubated and sedated, with and orogastric tube to suction and removal of 200mL of gastric consent. The pt;s abdomen was soft and nondistended. Nephrology was consulted and the pt was started on continuous HD. What type of EN formula would best meet his needs?

  1. A formula restricted in fluid, protein and electrolytes
  2. A formula not restricted in protein but restricted in fluid and electrolytes
  3. A formula restricted in fluid but not in protein and electrolytes
  4. A formula not restricted in fluid or protein but in electrolytes.
A
  1. A formula restricted in fluid but not in protein and electrolytes

No need for protein restriction bc pt is on HD. Some AKI pt may need fluid restriction but not all.

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35
Q

A 60 yo critically ill pt has been tolerating a standard 1kcal/mL EN formula well for the past week. She begins having frequent bouts of loose stools, requiring the placement of a rectal tube. What should the clinician’s next suggestion?

  1. Change to a peptide based formula
  2. Determine the cause of D
  3. Add pre and probiotics to the feeding regimen
  4. Change to a fiber supplemented formula
A
  1. Determine the cause of D

The formula that pt has been tolerating well for a week is not the likely cause. Assessment is needed to determine if a medication or perhaps C.diff is the culprit. If all else fail, then consider changing formula

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36
Q

What should a clinician do when considering the use of EN formulas marketed for specific disease condition?

  1. Use formulas as indicated by the product manufacturer to meet pt’s needs
  2. Use standard polymeric formulas for all pts
  3. Use specialty formulas only when pt exhibits signs and symptoms of intolerance to standard polymeric formulas
  4. Evaluate the studies used to support the use of specialty formulas and apply clinical judgment to select the appropriate EN product for the individual pt.
A
  1. Evaluate the studies used to support the use of specialty formulas and apply clinical judgment to select the appropriate EN product for the individual pt.

Standard polymeric formulas are indicated for most pt but the clinician should use judgement based on studies to apply them for specific pt.

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37
Q

If a nasoenteric feeding tube can not be unclogged using water flushes, what is the next most reliable method to unclog the tube before it is placed?

  1. Administer cola through the tube and let it sit for a few hours
  2. Administer Clog Zapper, and flush within 30-60min
  3. Wait a few hours to see whether the clog dissolves spontaneously
  4. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1-2 hours or longer, and then flush with warm water.
A
  1. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1-2 hours or longer, and then flush with warm water.

Pancreatic enzyme has been found to have a 90% success rate in unclogging tube when it is allowed to sit for 1-2 hours or longer. If the clog is from a medication or does not clear the first time then it may need to be replaced. Clog Zapper is not as effective as pancreatic enzyme

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38
Q

You perform a telephone eval of a pt who relates increased redness, pain, and swelling around his existing low profile G tube. He has not been seen in the clinic for more than 6m and when asked, states that he has been doing quite well on his TF. In fact, the pt states he has gained over 20lb. You would proceed as follows.

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

When a pt gain or lose a significant amt of wt, buried bumper syndrome may results, which may results from the growth of the gastric mucosa partially or completely over the internal bumper or excess pressure on the tissues in btw the abdominal wall and gastric mucosa, usually d.t excessive tension btw the internal and external bumpers or a partially deflated balloon

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39
Q

An 18 y.o female pt with CF had a standard profile, solid internal bolster, 20 Fr PEG tube placed a year ago bc of her inability to take in enough energy orally and wt loss. She has done very well, with her wt stabilizing and no complications of the PEG. The original tube is now getting stiff and cracking, and the pt wants a replacement tube. The pt 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 recommended?

  1. Standard profile, 20 Fr PEG tube with solid internal bolster
  2. Standard profile, 20 Fr PEG tube with balloon internal bolster.
  3. Low profile, 20 Fr PEG tube with solid internal bolster
  4. Low profile, 20 Fr PEG tube balloon internal bolster.
A
  1. Low profile, 20 Fr PEG tube balloon internal bolster.

The pt would benefit from a Low profile tube bc she is very active. Also a solid internal bolster would last longer but can cause significant discomfort when removed and require a clinic or hospital visit to be replaced.

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40
Q

Which of the following actions is most appropriate for enhancing gastric emptying during the administration of EN?

  1. Keep the bed in the Trendelenburg position
  2. Decrease the rate of a continuous feeding infusion or change from bolus to continuous feeding.
  3. Switch to an enteral formulation with a higher fat content
  4. Switch to an enteral formulation with a higher protein content.
A
  1. Decrease the rate of a continuous feeding infusion or change from bolus to continuous feeding.

Factors that delay gastric emptying include bolus feed, increased rate of infusion and increased fat content and infusion of formula at colder than room temp.

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41
Q

Which of the following is the most appropriate initial action for the management of tube feeding associated D?

  1. Change to an EN formula with fiber
  2. Review the pt’s med administration record to determine whether hyperosmolar agents are being administered
  3. Change to a peptide based EN formula
  4. Use and antimotility agent.
A
  1. Review the pt’s med administration record to determine whether hyperosmolar agents are being administered

After this initial intervention and if no med is found, consider checking for C.diff. If not C.diff then changing to formula with fiber. Changing to peptide based or using antimotility agent should be used if other intervention failed.

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42
Q

Which of the following methods is not recommended to minimize contamination of EN formula?

  1. Washing hands and donning clean gloves before preparing EN formulas
  2. Immediate use of EN formula from a newly open container
  3. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours
  4. Changing an open feeding container every 24 hours
A
  1. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours

Reconstituted powdered formulas should only be infused for no more than 4 hours.

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43
Q

What is optimal nutrition support for a malnourished pt when EN is not feasible for a prolonged period?

  1. Central PN
  2. Nasogastric EN
  3. Post pyloric EN
  4. PPN
A
  1. Central PN

Central PN may be beneficial for malnourished pt when EN is not feasible.

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44
Q

In which pt condition or treatment could PN elicit an improved pt outcome?

  1. Cancer chemotherapy
  2. Preoperative care of surgery pt with upper GI cancer
  3. Allogeneic bone marrow transplantation
  4. Critical illness
A
  1. Preoperative care of surgery pt with upper GI cancer

A review of literature has reported improved outcomes in pt with upper GI cancer when PN is initiated 7 days before surgery.

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45
Q

CPN is contraindicated in which of the following condition?

  1. DNR status
  2. Peritonitis
  3. Intestinal hemorrhage
  4. High output fistula
A
  1. DNR status

PN is indicated in Peritonitis, Intestinal hemorrhage and High output fistula. Pt with DNR on comfort measure should not be getting PN

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46
Q

PN should be discontinued when which of the following criteria are met?

  1. A CL diet is ordered
  2. TF is initiated at 10% of goal rate
  3. Solid food is well tolerated by mouth
  4. Advancement to a regular diet is poorly tolerated
A
  1. Solid food is well tolerated by mouth
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47
Q

Which of the following may increase the risk of phlebitis with PPN?

  1. Osmolarity = or < than 900mOsm/L
  2. K 100 mEQ/L
  3. Ca < 5mEQ/L
  4. Addition of heparin to the PPN
A
  1. K 100 mEQ/L

K can be very irritating to infuse. Concentration should be less than 60mEq/L and preferably less than 40mEq/L.

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48
Q

What is the smallest pore size filter that recommended for TNA?

  1. 0.22 um
  2. 0.5um
  3. 1.2 um
  4. 5 um
A
  1. 1.2 um

A 1.2 um filter is used for TNA mixture. It can filter out large microorganism, but is not a sterile filter. A 0.22 um filter can be used in 2 in 1 mixture but cant be used with ILE as the fat particles would be too big to pass through

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49
Q

Which of the following will increase the solubility if Ca and Phosphate in a PN formulation?

  1. Use of Ca as the chloride salt
  2. Use of Phosphate as the Na salt
  3. Increased AA concentration
  4. Increased Temp
A
  1. Increased AA concentration

The higher concentration of AA in a solution the less precipitate. AA can form soluble complexes with Ca, leading to less free AA to form precipitate.

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50
Q

According to the recs by the National Advisory Group on Standards and Practice guidelines for PN formulation and ASPEN PN safety consensus, the amt of dextrose used in the preparation of a PN formulation is required to appear on the labels as:

  1. The % of original concentration and vol (ex dextrose 50% water, 500mL)
  2. The % of the final concentration after admixture (ex, dextrose 25%)
  3. Gr/L of PN admixed (ex, dextrose 250g/L)
  4. Gr/day (ex, dextrose 250g/day)
A
  1. Gr/day (ex, dextrose 250g/day)
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51
Q

Which of the following is the most appropriate VAD strategy for a pt requiring long term PN therapy?

  1. Use a midclavicular catheter as a cost effective measure.
  2. Place a percutaneous nontunneled catheter to initiate PN and then replace it with an implanted port.
  3. Place a single lumen, tunneled cuffed catheter
  4. Place a triple lumen, antibiotic coated catheter to ensure adequate access for future needs.
A
  1. Place a single lumen, tunneled cuffed catheter

This is the best option for a long term device for PN therapy. Tunneled catheter are safe and effective for long term therapy. A midclavicular catheter is not a central access device. Best to choose optimal device rather than planning for replacement. A percutaneous nontunneled catheter or an antibiotic coated catheter can be used in the hospital setting for short duration

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52
Q

Thrombotic occlusions are most commonly treated with which of the following?

  1. Thrombolytics
  2. Anticoagulants
  3. 10% HCl
  4. Sodium bicarbonate
A
  1. Thrombolytics
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53
Q

Which of the following practices has been shown to reduce the risk of CRBSIs?

  1. Systemic use of antimicrobial prophylaxis at the time of insertion or access.
  2. Routine replacement of central venous access devices
  3. Use of the Central line bundle of insertion and maintenance practices
  4. Selection of an internal jugular site as opposed to a subclavian site
A
  1. Use of the Central line bundle of insertion and maintenance practices

The Central Line Bundle include 1) hand hygiene, 2) maximal barrier precaution, 3) skin antisepsis with CHG, 4) optimal catheter sites election and 5) daily review of line necessity with the prompt removal of unnecessary line.

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54
Q

Which of the following is the most common metabolic complication associated with PN?

  1. Hyperglycemia
  2. EFAD
  3. Azotemia
  4. Hyperammonemia.
A
  1. Hyperglycemia

Hyperglycemia can occur from overfeeding or as part of critical illness d/t insulin suppression, stress and infection.

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55
Q

2 day after initiating PN in a critically ill pt, the pt’s lab values are as follow, serum K: 3.1mEq/L (normal 3.4-4.8). serum Phos 1.6mg/dL (normal 2.5-4.8) and serum Mg normal. The PN regimen is providing protein 90g, dextrose 150g, no lipid, minimum vol, K 80 mEq, Phos 40mmol, and standard doses of Na, mag, Ca, vitamins and trace elements. The pt weighs 60kg, and has a BMI of 18. The most appropriate response to these labs is

  1. Increase K and phos in the PN, and decrease macro doses with tonight PN’s bag
  2. Provide supplemental IV doses of K and Phos today, but dont change the macro doses with tonight’s bag
  3. Increase K and Phos in the PN and increased dextrose to 225g with tonight bag
  4. Provide supplemental IV doses of K and phos today, and advance dextrose to 225g with tonight PN bag.
A
  1. Provide supplemental IV doses of K and Phos today, but dont change the macro doses with tonight’s bag

The pt is experiencing refeeding with low K and Phos. Replace electrolytes separately but dont change macro until the deficiencies are corrected.

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56
Q

Which of the following measures would be considered most beneficial in a pt who develops cholestasis while receiving long term PN that is infused over 12 hours nightly?

  1. Stop all oral and enteral intake
  2. Switch from a cyclic to continuous method of PN admin
  3. Decrease ILE dose from 1.5g/kg/d to 1g/kg twice weekly
  4. Increase protein dose from 1g/kg/d to 2g/kg/d.
A
  1. Decrease ILE dose from 1.5g/kg/d to 1g/kg twice weekly

Cholestasis has been associated with ILE dose of higher than 1g/kg/d and reducing the dose may be beneficial

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57
Q

Which of the following PN modifications is recommended to help prevent and/or treat osteoporosis in a long term PN pt?

  1. Maintain protein intake of at least 2g/kg/d
  2. Provide more than 20 mEq Ca/ d
  3. Add injectable vit D to the PN formulation
  4. Provide 20-40mmol Phos per day
A
  1. Provide 20-40mmol Phos per day

Inadequate Phos intake may increase Ca excretion in the urine. ASPEN recs 20-40mmol of Phos per day to be added to PN formulation.

58
Q

An alert and oriented adult pt is receiving a continuous infusion of a standard, fiber containing EN formulation through a 8 fr NG tube. Drugs administered by bolus administration through the side port of the tube are phenytoin suspension 400mg daily and nizatidine 150mg every 12 hours. The feeding tube becomes occluded and must be removed. A new tube is placed because a long term tube will not be considered until after a swallow study is completed 2.5 weeks from now. Which of the following measures is the most appropriate for preventing occlusion of the new tube?

  1. Replace the 8 fr tube with an 18 fr tube
  2. Flush the feeding tube with 15mL of water before and after administering each medication
  3. Discontinue the fiber containing enteral feeding formulation and initiate feeding with a fiber free formulation
  4. Hold the feeding infusion for 2 hours before and after administering phenytoin.
A
  1. Flush the feeding tube with 15mL of water before and after administering each medication

Tubes should be flushed with 15mL of water before and after each meds. 30mL flushes are more common and may be required for longer and larger tube. Switching to a larger diameter tube may not be the best option for an alert and oriented pt. Holding TF for 2 hours prior to phenytoin administration is recommended to enhance drug absorption, not to prevent occlusion.

59
Q

The EN formulation for a home pt receiving EN through a percutaneous gastrostomy was recently changed from a high protein, fiber containing, 1kcal/mL formulation to the only 1.5 kcal/mL formulation available in the local store. The new product is marketed for used in the pt with compromised pulmonary function and contains low amount of CHO, 55% of energy from fat, about 15% less protein /d than the 1kcal/mL, and no fiber. What component of the new formula is most likely to contribute to interactions resulting from slow gastric emptying?

  1. Lower fiber content
  2. Lower protein content
  3. Higher fat content
  4. Higher energy density
A
  1. Higher fat content

High fat intake slow gastric emptying as with higher energy intake and protein content. However the energy and protein may affect gastric emptying to a lesser degree

60
Q

Which of the following is the preferred method of administering a hospitalized pt’s antihypertensive med when TF is started d/t poor oral intake?

  1. By the oral route
  2. As an oral liquid via the feeding tube
  3. As a crushed tablet via the feeding tube
  4. By the IV route
A
  1. By the oral route

The oral route is the preferred method because this the route that oral medication is designed for.

61
Q

A medication that is ordered as a liquid to be administered via the feeding tube is available in the pharmacy in the IC for, as a capsule (powdered drug in a hard gelatin capsule), and as a film coated tablet. What is the most appropriate and cost effective choice for administration of this medication?

  1. Administer the IV form via the IV route
  2. Administer the IV form via the TF
  3. Make a slurry of the capsule’s powder and administer via TF
  4. Crush the tablet to a fine powder and administer via the feeding tube.
A
  1. Make a slurry of the capsule’s powder and administer via TF

The IV form of meds are usually the most expensive. Crushing tablet can leads to a sticky film that stick to the tube. Most hard gelatin capsules can be opened and the powder insider can be combined with water to make a slurry.

62
Q

Which of the following claims for a dietary supplements would most likely cause the FDA to consider that the supplement should be regulated as a drug rather than as a dietary supplement?

  1. Support strong bone and teeth
  2. Treats influenza
  3. Promote urinary health
  4. Improves immune function
A
  1. Treats influenza

Manufacturer of dietary supplements may make “structure-function claims” which are statements about the product’s ability to affect structure and functions of the body, but may not make statement regarding diagnosis, treatment, cure, or prevention of a disease.

63
Q

Which of the following best describes dietary supplement use in the US?

  1. Only a minority of the population uses dietary supplements
  2. Most pt report their dietary supplement use to their PCP
  3. Most pt think that their health care providers are knowledgeable about dietary supplements
  4. Many pt using prescription medicine concomitantly use dietary supplements.
A
  1. Many pt using prescription medicine concomitantly use dietary supplements.

Surveys show that many persons using supplements do not report this to their PCP as they do not think that the supplement can interfere with medication. Most pt also think that their health care providers should be knowledgeable about supplements but only about half of pt in a recent survey reported that providers are actually knowledgeable

64
Q

Even if the Current Good Manufacturing Practices promulgated by the Dietary Supplement Health and Education act of 1994 are properly implemented, which of the following is still likely to occur?

  1. A dietary supplement product adulterated with a prescription drug such as sibutramine is being marketed and sold
  2. A dietary supplement product is analyzed and found to have much less of the active ingredient than what is indicated on the label
  3. A dietary supplement product is analyzed and found to have much more of the active ingredient than what is indicated on the label
  4. A dietary supplement product is marketed and sold but there is no studies to confirm its efficacy for any condition.
A
  1. A dietary supplement product is marketed and sold but there is no studies to confirm its efficacy for any condition.

The DEASHA mandate that CGMPs are set up for the dietary supplement industry. Under these CGMPs, the products would contain the correct amt and ingredients. Unfortunately, this does not guarantee that the product has the research to back it up.

65
Q

Which of the following statement is true regarding the nutrition status of the pregnant woman and its impact on the fetus?

  1. Obese pregnant women should lose wt during pregnancy to improve fetal outcomes
  2. The fetus is a perfect parasite and the nutrition status of the mother is of no consequence.
  3. Appropriate wt gain for women of all BMI ranges is essential for fetal health
  4. Poor maternal health and nutrition status has only short term impact on the fetus.
A
  1. Appropriate wt gain for women of all BMI ranges is essential for fetal health

Inadequate or excess wt gain can lead to poor fetal outcomes.

66
Q

Which of the following statements about energy needs during pregnancy is true?

  1. Energy requirements are the same for pregnant and non pregnant women
  2. Energy needs are increased only during the 2nd and 3rd trimester
  3. Compared with nonobese women, energy requirements are lower for obese women to promote wt loss during pregnancy
  4. Energy goals should only focus on non protein energy intake
A
  1. Energy needs are increased only during the 2nd and 3rd trimester

Most women do not need to increase energy intake in the first trimester, although underwt women may be more encouraged to do so.

67
Q

Which of the following parameters is appropriate for monitoring glycemic control of pregnant women receiving nutrition support?

  1. Urine glucose
  2. Urine lactic acid
  3. Serum glucose
  4. Serum insulin
A
  1. Serum glucose
68
Q

What are the goals for protein support for adults with delayed healing of PI?

  1. Provide adequate protein: 0.8g/kg/d
  2. Provide adequate protein: 1-1.2g/kg/d
  3. Provide adequate protein: 1.25-1.5g/kg/d
  4. Provide adequate protein: 0.6g/kg/d
A
  1. Provide adequate protein: 1.25-1.5g/kg/d
69
Q

Which of the following should be offered to provide elemental zinc for PI healing?

  1. Zinc sulfate: 220mg/d
  2. Zinc gluconate: 84mg/d
  3. Daily multivitamin with mineral supplements
  4. Zinc chloride: 170mg/d
A
  1. Daily multivitamin with mineral supplements

Zinc supplementation is only recommended for zinc deficiencies.

70
Q

All wounds begins as acute wounds. Which of the following distinguishes as an acute wound from a chronic wound?

  1. An acute wound will generally heal within 2-3 days
  2. Acute wounds are related to an initial injury, whereas chronic wounds develop d/t an underlying pathological process.
  3. The microenvironments of the 2 types of wounds are different, with acute wounds having fewer inflammatory mediators presents.
  4. Both B&C.
A
  1. Both B&C.

Acute wounds tend to heal within 4 weeks and the microenvironment of the 2 types of wounds can be very different.

71
Q

Which of the following is most strongly correlated with improved mortality in TBI?

  1. Strict avoidance of TPN
  2. Early initiation of nutrition
  3. High protein content in nutrition formula
  4. Supplementation of Vit C and E.
A
  1. Early initiation of nutrition

Early initiation of nutrition is found to help improve outcome in TBI

72
Q

Which of the following commonly used medication in TBI is not associated with a reduction in measured energy expenditure?

  1. Propranolol
  2. Mannitol
  3. Pentobarbital
  4. Rocuronium
A
  1. Mannitol

All the other meds have been shown to reduce energy expenditure, only mannitol doesnt.

73
Q

Metabolic changes following SCIs depend on the level of cord injury and the extent of injuries. Which of the following statement is true?
1. The energy expenditure following SCI is approximately 48% higher than that following TBI.
2 To accurately assess the energy requirements for a pt with SCI, multiply the REE (calculated by Harris Benedict) b an injury factor of 1.6 and then again by an activity factor of 1.2
3. A modified BMI scale has been proposed for individuals with SCIs, with healthy normal categorized a s 18-22.
4. Pt with chronic SCI require approximately 30-33kcal/kg/d depending on their physical activity.

A
  1. A modified BMI scale has been proposed for individuals with SCIs, with healthy normal categorized a s 18-22.

Energy expenditure following SCIs is estimated to be 48% lower than compared to TBI. They generally require about 20-23kcal/kg/d and a modified BMI has been proposed, normal is considered to be btw 18-22

74
Q

Which of the following statements regarding a subarachnoid hemorrhage is false?

  1. High doses of folic acid should be administered to reduce the likelihood of a 2nd hemorrhagic stroke
  2. Energy expenditure is higher for pt with SAH than for those with ischemic stroke
  3. Concentrated EN may be necessary if fluid intake is restricted to minimize cerebral edema
  4. Bedside or formal swallow studies should be performed to confirm that the pt does not have dysphagia before an oral diet is initiated.
A
  1. High doses of folic acid should be administered to reduce the likelihood of a 2nd hemorrhagic stroke

Daily folic acid and B6 and B12 did not reduce the recurrence of ischemic stroke. SAH may require more energy expenditure than ischemic stroke.

75
Q

Which of the following characterizes the current understanding of systemic inflammatory responses?

  1. Overstimulated immune system
  2. Mixture of immune stimulation and suppression
  3. Initial immune suppression followed by stimulation
  4. Immune suppression.
A
  1. Mixture of immune stimulation and suppression

The systematic inflammatory response is a combination of both metabolic and immune response as well as a compensatory reaction causing immune metabolic suppression.

76
Q

Why is hemodynamic stability an important consideration before initiating EN?

  1. To avoid overfeeding
  2. Hemodynamic instability is an indication for PN
  3. GI perfusion maybe compromised
  4. Pt cannot absorb any nutrients when they are under resuscitated
A
  1. GI perfusion maybe compromised

GI perfusion is compromised during the septic state and feeding into the GI can initiate an ischemic event

77
Q

What is the best reason to conservatively prescribe energy in nutrition support regimens?

  1. Glycemic control
  2. To facilitate permissive underfeeding
  3. Cost containment
  4. To achieve goal infusions more efficiently
A
  1. Glycemic control

Hyperglycemia is associated with adverse outcome in clinical care. Therefore conservative energy prescription and gradual increase in infusion rate can help in controlling serum glucose level.

78
Q

Which of the following is the most important benefit to starting early EN after trauma?

  1. Addressing protein energy malnutrition before it is severe
  2. Preventing negative nitrogen balance
  3. Modulating the immune response and supporting the GI tract
  4. Preventing severe hyperglycemia.
A
  1. Modulating the immune response and supporting the GI tract
79
Q

For routine colon surgery, which of the following component of ERAS protocols contributes to the improved outcomes?

  1. Keeping the pt NPO after midnight to avoid aspiration on induction of general anesthesia
  2. Providing glucose rich supplementation 6 and 2 hours prior to surgery
  3. Using high dose oral protein supplements
  4. Using probiotics to restore normal intestinal flora after surgery.
A
  1. Providing glucose rich supplementation 6 and 2 hours prior to surgery

The principles to improve outcome include avoiding starvation, limiting IV and increasing motility.

80
Q

Which of the following are not thought to benefit burn wound healing?

  1. Vit C supplementation
  2. Ca
  3. Protein delivery of 1.5-2g/kg/d
  4. Zinc supplementation.
81
Q

The strategy of restricted fluid intake may decrease the number of days that pt require mechanical ventilation for which disease process?

  1. TBI
  2. ARDS
  3. PE
  4. Septic shock secondary to bacteria PNA
A
  1. ARDS

Restricting fluid has decreased the number of ventilation days and the number of ICU days, but does not improve mortality

82
Q

Which of the following does not help reduce VAP?

  1. Elevating the head of the bed at least 45 degrees
  2. Gastric ulcer prophylaxis and early PN
  3. Early mobility and decreased days on a ventilator
  4. Minimizing sedation and a daily sedation vacation.
A
  1. Gastric ulcer prophylaxis and early PN
83
Q

Which of the following should not be supplemented via EN to pt in pulmonary failure?

  1. Phos
  2. Ca
  3. Glutamine
  4. Mag
A
  1. Glutamine

REDOX trial indicated that glutamine may potentially harm pt with pulmonary failure.

84
Q

A 56 y.o man with long standing hx of DMT2 presents with postprandial ab pain, N/V. His DM is uncontrolled despite the use of insulin and his A1C is 10%. He also has painful peripheral neuropathy in his legs as well as DM retinopathy. His GI symptoms have progressed over the past 6m and now he reports eating very little bc he fears the ab pain and vomiting will worsen. The emesis occurs 30m to 2 h after eating and it has the appearance of undigested foods. A diagnostic EGD is normal. Which diagnostic test is the ideal next step in determining the cause of his symptoms?

  1. Mesenteric Doppler ultrasound
  2. Gastric emptying scan
  3. Small bowel series/follow through
  4. Abdominal CT
A
  1. Gastric emptying scan

The pt likely has gastroparesis.

85
Q

A 35 y.o white woman presents to the clinic with D, wt loss and anormal LFTs. Her PCP also noted that the pt was vit D and iron deficient with anemia. On physical exam, the pt 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 2nd portion of the duodenum. Which of the following is likely the cause?

  1. Crohn
  2. Celiac
  3. Whipple
  4. Peptic ulcer disease
86
Q

A 19 yo woman with a hx of Crohn’s ileitis since the age of 13 presents for ongoing care. She has been on several meds for Crohn’s over the course of her dx. Her disease is isolated to the terminal 30cm of her ileum and ileocecal valve. Despite adequate med compliant and dosing, her disease remains active. She complains of 4-5 loose, watery BMs a day, bloating, and mild ab 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 and ileocecectomy. Which of the following vit is she mostly likely to eventually need to take as a supplement?

  1. Folate
  2. B12
  3. A
  4. E
A
  1. B12

Terminal ileum is the absorption site of a B12 and is a common site of Crohn’s.

87
Q

Which of the following is an accurate marker of nutrition status in all pt with chronic live disease with portal HTN?

  1. Serum prealbumin
  2. Retinol binding protein
  3. Anthropometry
  4. None of the above
A
  1. None of the above
    There is no consistent marker of malnutrition in liver disease. Visceral protein can be changed due to the severity of liver disease and anthropometric markers may be masked due to ascites
88
Q

Which of the following statements is false regarding alcoholic hepatitis?

  1. Virtually all pt with alcoholic hepatitis have some degree of malnutrition
  2. The severity of liver disease generally correlated with the degree of malnutrition
  3. Energy intake correlates with mortality
  4. Protein delivery should be reduced to prevent portal systemic encephalopathy.
A
  1. Protein delivery should be reduced to prevent portal systemic encephalopathy.

Protein restriction is rarely required in alcoholic hepatitis and should only be considered in the setting of PSE refractory to medical treatment.

89
Q

Which of the following statements is true regarding PN in the care of the in pt with liver disease?

  1. There is no role for PN in nutrition in liver disease
  2. PN should be initiated in all hospitalized pt with liver disease
  3. If a pt cant tolerate EN, PN can provide necessary nutrition, but it should be d/c in favor of EN ASAP.
  4. When a pt cant tolerate EN, he or she should receive PN for the duration of the hospitalization.
A
  1. If a pt cant tolerate EN, PN can provide necessary nutrition, but it should be d/c in favor of EN ASAP.

EN is always preferred to PN whenever possible.

90
Q

A nutrition support clinician was consulted on the second day of hospitalization about a pt 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?

  1. Continue NPO status with no enteral TF, noting that the necrosis may require surgical intervention
  2. Start the pt on PN bc the pt is vented and has a pseudocyst
  3. Place a nasojejunal tube and begin EN, proving no more than 10-20mL/h
  4. Place a nasojejunal tube, begin TF, and advance to the nutrition goal over the first 24-48 hours.
A
  1. Place a nasojejunal tube, begin TF, and advance to the nutrition goal over the first 24-48 hours.

The presence of ascites, fistula and pseudocysts are part of the disease process of pancreatitis and is not an contraindication for TF. The use of EN may also help resolve these complications.

91
Q

Which of the following nutrition regimen is appropriate for a pt with less than 2 Ranson criteria and an APACHE II score of less than 9 (non severe) who has no pancreatic necrosis on a CT scan?

  1. Begin volume resuscitation, provide narcotic analgesia, and advance to an oral diet as soon as it is tolerated.
  2. Begin PN in the first 24 hours of admission bc the pt is in acute pain
  3. Keep the pt NPO for at least 7 days
  4. Use PN in the first 24 hours, and then switch to an oral diet.
A
  1. Begin volume resuscitation, provide narcotic analgesia, and advance to an oral diet as soon as it is tolerated.

Pt with mild to moderate pancreatitis can be supported with IV fluid and analgesia.

92
Q

Which of the following is true?

  1. The immune response of the gut remains intact when a pt is maintained on PN
  2. The immune response of the gut remains intact when a pt is maintained on EN
  3. Loss of gut integrity may allow bacteria of gut origin to infect distant organ sites, but this issues is improved with bowel rest
  4. Enteral feedings should be stopped if the ileus is noted radiographically.
A
  1. The immune response of the gut remains intact when a pt is maintained on EN

PN may lead to loss of gut integrity. Pt on PN over time have shorter villi and ultimately lost.

93
Q

Which of the following metabolic alterations is most commonly observed in AKI?

  1. Decreased energy expenditure
  2. Metabolic acidosis
  3. Decreased serum mag concentration
  4. Metabolic alkalosis.
A
  1. Metabolic acidosis

This is due to accumulation of organic and inorganic acids. Serum K also increased due to renal clearance reduction.

94
Q

Which of the following parenteral AA preparations is most appropriate for a dialysis dependent pt with renal failure?

  1. Essential AA only
  2. Nonessential AA only
  3. Mix of essential and nonessential AA
  4. High BCAAs
A
  1. Mix of essential and nonessential AA

Essential and nonessential AA are lost during dialysis and require replacement of both

95
Q

Which of the following is a measurement of body iron stores?

  1. Total iron binding capacity
  2. Ferritin
  3. Transferrin
  4. Ceruloplasmin
A
  1. Ferritin

Ferritin is the protein that binds with iron and can serve as a reliable marker of body iron store. It is an acute phase protein and increase with inflammation. TIBC is a measure of serum iron and various protein that transport iron within circulation. Transferrin is a iron carrier protein that can be used in hematopoiesis. Ceruloplasmin is a copper transport protein.

96
Q

What % of instilled dextrose is typically absorbed from PD dialysate within a 6 h dwell time?

  1. 25%
  2. 50%
  3. 75%
  4. 100%
A
  1. 75%

In 6 h, about 75-80% of the instilled dextrose in the dialysate is absorbed.

97
Q

Which of the following answers best reflects dietary modifications that may prevent the development of nephrolithiasis related renal failure?

  1. A Ca restricted diet with increased free water intake
  2. A low fat diet with adequate phos repletion and increased free water intake
  3. A low fat, oxalate and ca restricted diet
  4. A low fat, oxalate restricted diet and adequate hydration
A
  1. A low fat, oxalate restricted diet and adequate hydration

SBS pt with fat malabsorption and intact colon are at risk of oxalate kidney stone. This is bc usually Ca binds to oxalate, but in the setting of fat malabsorption, Ca will find with excess fat, leaving oxalate free to be filtered by the kidneys, and forming stones

98
Q

Bc of the malabsorptive process present with SBS, pt have a high risk for micronutrients deficiencies. Which of the following answers is correct regarding the monitoring and repletion of micronutrients in SBS?

  1. If pt are receiving PN, there is no reason to monitor micronutrients bc the PN should satisfy all micronutrients needs
  2. Micronutrients should be checked periodically and can be usually replaced via the oral route
  3. Micronutrients should be checked monthly and repletion should be administered in high doses both IV and orally
  4. Micronutrients should be checked annually and all of them should be replaced IV bc pt with SBS cant absorb micronutrients orally
A
  1. Micronutrients should be checked periodically and can be usually replaced via the oral route
99
Q

Which of the following best describes how a clinician determines the most appropriate feeding routes (oral, EN, PN or combo) for a pt with SBS?

  1. All pt with SBS need lifelong PN, if their energy and protein needs are met with PN, the can eat whatever they want for comfort
  2. To avoid the risk of PN associated complications, PN should always be d/c as soon as oral intake or EN is initiated.
  3. The nutrition regimen should be individualized to meet the needs of the particular pt
  4. Insurance reimbursement plays the major role in deciding the feeding route.
A
  1. The nutrition regimen should be individualized to meet the needs of the particular pt
100
Q

Which of the following characteristics of an initial EN regiment would be most appropriate for a pt with SBS?

  1. A fiber free, energy dense formula administered via bolus infusion
  2. A hydrolyzed elemental formula that is high in MCT oil
  3. An isotonic, polymeric, fiber containing formula administered via continuous gastric infusion
  4. A semi elemental, peptide based formula administered nocturnally.
A
  1. An isotonic, polymeric, fiber containing formula administered via continuous gastric infusion

For SBS pt, an isotonic formula is important and most pt can tolerate polymeric formulas

101
Q

Which of the following is a contraindication for organ transplantation?

  1. DM
  2. End stage organ failure
  3. Active infection
  4. Hx of substance abuse
A
  1. Active infection

Active infection like PNA can significantly worsen after immunosuppression is initiated. Substance active substance abuse is a contraindication, however, transplantation can be considered if pt demonstrate recovery.

102
Q

Which of the following immunosuppressive agents is nephrotoxic and can cause hyperK, hypomag and hyperglycemia?

  1. Sirolimus
  2. Prednisone
  3. Tacrolimus
  4. Mycophenolate mofetil
A
  1. Tacrolimus

In additional to the above symptom, tacrolimus may also cause neurological symptom. Sirolimus cause hyperlipidemia. Prednisone is a corticosteroid that causes hyperglycemia but is not nephrotoxic. Mycophenolate mofetil causes GI symptoms

103
Q

Which of the following best describes nutrient requirements during the acute posttransplant phase?

  1. Moderate energy, high protein
  2. High energy, low protein
  3. Moderate energy, low protein
  4. High energy, high protein
A
  1. Moderate energy, high protein

Energy is only moderately elevated, while protein needs are significantly elevated due to catabolism and stress.

104
Q

Which of the following should be part of a nutrition care plan for a pt during an acute rejection episode that is being treated with high dose corticosteroid?

  1. Provide increased amt of dietary CHO and monitor for signs of fluid overload
  2. Provide increased amt of dietary fat and monitor for signs of hyperlipidemia
  3. Provide increased amt of dietary CHO and monitor for signs of azotemia
  4. Provide increased amt of dietary protein and monitor for signs of hyperglycemia.
A
  1. Provide increased amt of dietary protein and monitor for signs of hyperglycemia.

Corticosteroids increase the rate of protein catabolism, therefore, likely to lead to increased protein needs. A common side effect of corticosteroid is hyperglycemia. Hyperlipidemia is a long term side effect of corticosteroid, not short term.

105
Q

HIV infection is prevalent in which of the following populations?

  1. Men who have sex with men
  2. Urban heterosexuals in the lowest income strata
  3. Black and hispanic/latino American
  4. All of the above
A
  1. All of the above
106
Q

Which of the following is the goal of antiretroviral therapy?

  1. To increase CD8+ T lymphocytes and decreased viral load
  2. To increase both CD4+ T lymphocytes and viral loads.
  3. To increase CD4+ T lymphocytes and neutrophils
  4. To increase CD4+ T lymphocytes and decrease viral load
A
  1. To increase CD4+ T lymphocytes and decrease viral load

HIV infection leads to the decrease of CD4+ T lymphocytes

107
Q

Which of the following is predictive of the onset of wasting disease?

  1. Hypogonadism
  2. Hypermetabolism
  3. Decreased food intake
  4. All of the above
A
  1. Decreased food intake

Decreased food intake is predictive of the onset of wasting disease. Hypogonadism is not uniform in all pt

108
Q

Which of the following is a central feature of HIV lipodystrophy?

  1. Abdominal obesity
  2. Increases in specific fat deposits
  3. Subcutaneous adipose tissue loss
  4. All of the above
A
  1. Subcutaneous adipose tissue loss

Lipodystrophy is characterized by subcutaneous adipose tissue loss with visceral adipose tissue sparing or accumulation.

109
Q

Which of the following is true about he mechanisms that promote wt loss and malnutrition in pt with cancer?
1. Tumor induced altered metabolism has been associated with increased energy expenditure
2. Inadequate nutrient intake and increased cytokine production can lead to wt loss
3. Some cancer pt demonstrate increased glucose turn over
compared with non tumor bearing pt with simple starvation
4. All of the above.

A
  1. All of the above.

Potential causes of metabolic abnormalities and wt loss in cancer pt include the presence of increased circulating cytokines, changes in hormones and neuropeptide levels, and tumor derived products.

110
Q

EN is an appropriate therapy for which of the following nutrients?

  1. A well nourished pt with colon cancer undergoing chemo
  2. A severely malnourished gastric cancer pt with N/V
  3. A moderately malnourished pt head and neck cancer with dysphagia
  4. A well nourished recipient of HSCT
A
  1. A moderately malnourished pt head and neck cancer with dysphagia
111
Q

Which of the following is true regarding a pt with newly diagnosed pancreatic cancer awaiting chemo?

  1. A nutrition assessment should be performed
  2. EN should be initiated bc the pt will likely need nutrition support during chemo
  3. PN should be initiated bc the pt will likely need nutrition support during chemo
  4. PN should be initiated if surgical intervention is imminent
A
  1. A nutrition assessment should be performed

Pt with cancer are at nutritional risk and require nutrition screening and assessment. EN and PN are not routinely indicated for pt undergoing anticancer treatment.

112
Q

What is the corrected Na level when blood glucose is 340mg/dL and current serum Na is 129mEq/L

  1. 133mEq/L
  2. 125mEq/L
  3. 130mEq/L
  4. 140mEq/L
A
  1. 133mEq/L

Corrected serum Sodium= Measured serum Na + [0.016x(serum Glucose-100)]

113
Q

A pt is admitted to the medical ICU for sepsis and now require the use of continuous IV insulin infusion for hyperglycemia management. What is the appropriate target glucose range for this pt?

  1. 80-110mg/dL
  2. 100-150mg/dL
  3. 140-180mg/dL
  4. 150-200 mg/dL
A
  1. 140-180mg/dL
114
Q

A pt’s glucose decreased from 180 to 140 mg/dL when given 5 units of insulin lispro. Estimate the total daily insulin dose using the sensitivity factor and the rule of 1800

  1. 8 units
  2. 40 units
  3. 187.5 units
  4. 225 units
A
  1. 225 units

If glucose decrease from 180 to 140 with 5 units of insulin, then the sensitivity factor is 40/5=8. Take 1800 and divide by 8, 225 is the number of units needed for the entire day.

115
Q

Which of the following statements regarding the current WHO and NIH classification of overweight and obesity is true?

  1. Overweight is defined as a BMI of 25-29.9 and obesity is defined as > or = to 30.
  2. Obesity is defined as > or = than 120% of IBW.
  3. Obesity is defined as body fat > or = body fat than 20% of body wt for men and 30% for women
  4. Obesity is defined as BMI > 25 and morbid obesity is defined as BMI>30.
A
  1. Overweight is defined as a BMI of 25-29.9 and obesity is defined as > or = to 30.
116
Q

Which of the following is a criterion for selecting pt to undergo gastric bypass surgery?

  1. BMI>35 and no hx of substance abuse of psy disorders
  2. BMI = or > than 35 and obesity related comorbidities
  3. BMI = or >30 and obesity related comorbidities
  4. BMI = or > 30 and inability to achieve wt control with low cal diet.
A
  1. BMI = or > than 35 and obesity related comorbidities

The criteria for gastric bypass surgery are BMI =or> than 40 or BMI = or > than 35 and obesity related comorbidities

117
Q

According to the most recent ASPEN and SCCM guidelines, what is the enteral feeding strategy based on energy requirements for obese pt?

  1. Hypocaloric with normal protein
  2. Hypocaloric with low protein
  3. Hypocaloric with high protein
  4. Hypercaloric with high protein.
A
  1. Hypocaloric with high protein.

ASPEN recommends that the goal of EN should not exceed 65-70% of energy as estimated by IC. BMI 30-50, protein requirement is 2g/kg IBW/d, and for BMI>50, protein requirement is 2.5g/kg IBW

118
Q

What is the most accurate way to determine energy requirements for obese pt in the ICU requiring EN?

  1. The Harris Benedict equation
  2. Indirect Calorimetry
  3. Mifflin St joer
  4. Penn state
A
  1. Indirect Calorimetry
119
Q

Of the following, which is the best currently known nutrition intervention to minimize negative outcomes associated with sarcopenia?

  1. Protein supplementation
  2. Amino acid supplementation
  3. Protein adequacy
  4. Omega 3 acid adequacy.
A
  1. Protein adequacy

Adequacy in protein is the most important in preserving LBM for older adults

120
Q

What is the most reasonable justification to initiate EN in an individual with advanced dementia?

  1. Decreased morbidity
  2. Specific or limited goal
  3. Improved mortality
  4. Improved QOL
A
  1. Specific or limited goal

EN has not been found to improve morbidity, mortality and QOL in older adults with dementia. However, it can be useful for specific and realistically achievable goals

121
Q

Which of the following nutrition support interventions has demonstrated the best outcomes in frail, community dwelling older adults an in postoperative orthopedic surgery population?

  1. Oral nutrition supplements
  2. IV hydration
  3. EN
  4. PN
A
  1. Oral nutrition supplements

Oral nutrition supplements have demonstrated the best outcomes in frail, community dwelling older adults

122
Q

Which of the following nutrition interventions have been shown to improve clinical outcomes and QOL in institutionalized older adults?

  1. Diet modification and liberalization
  2. Modification of dining environment
  3. Provision of aides to improve functional status and increase independence at meals
  4. Honoring food preferences and providing snacks and fortified foods
  5. All of the above.
A
  1. All of the above.
123
Q

Which of the following does not represent a potential complication following gastric resection and anastomosis?

  1. Anastomotic stricture
  2. Anastomotic ulcer
  3. Acid hyposecretion
  4. Biliary limb obstruction.
A
  1. Acid hyposecretion

The remaining parts of the stomach will be sufficient to secrete enough acid.

124
Q

Which of the following is an example of a malabsorptive procedure for wt loss?

  1. Gastric band
  2. Sleeve gastrectomy
  3. Biliopancreatic diversion with duodenal switch
  4. Gastric balloon.
A
  1. Biliopancreatic diversion with duodenal switch

A duodenal switch bypasses the functional small bowel, therefore, leading to malabsorption of water and nutrients of foods by these portions of the small bowel.

125
Q

For pt with colitis or proctitis after colon resection and proximal diversion of the fecal stream, which of the following represents and effective first line treatment?

  1. SCFA enemas
  2. Hydrocortisone enemas
  3. Topical 5-aminosalicylic acid
  4. Fecal microbiota transplant
A
  1. SCFA enemas

This is the treatment of choice for colitis and proctitis because a deficiency of SCFA can cause these conditions.

126
Q

Medicare coverage for HPN is possible with adequate documentation in which of the following conditions?

  1. Anorexia nervosa
  2. Massive small bowel resection resulting in short bowel syndrome with less than 150cm bowel remaining
  3. Six weeks of bowel rest for severe pancreatitis
  4. Swallowing disorder with hx of asp PNA.
A
  1. Massive small bowel resection resulting in short bowel syndrome with less than 150cm bowel remaining

Pt who needs bowel rest may qualify for HPN if the period of bowel rest is at least 3 months and there is evidence that EN is contraindicated.

127
Q

Which of the following is a primary reason for administering HPN as a cyclic infusion?

  1. To provide a more normal lifestyle
  2. To reduce complications of PNALD
  3. Bc cyclic infusion allows for administration of IV meds that are incompatible with PN
  4. All of the above.
A
  1. All of the above.
128
Q

The success of home nutrition support depends on which of the following strategies?

  1. Facilitating insurance reimbursement for nutrition support
  2. Providing individualized care to the pt at home
  3. Educating the pt and/or caregiver in managing EN and PN at home
  4. Providing comfort to the families caring for the pt.
A
  1. Educating the pt and/or caregiver in managing EN and PN at home
129
Q

Which of the following should clinicians do to support pt who are dealing with lifelong dependency on home nutrition support?

  1. Include the pt in decision making regarding the choice of access device and administration schedule.
  2. Recognize symptoms of depression, and refer pt with those symptoms for additional evaluation and care
  3. Promote the benefit of pt support groups
  4. All of the above.
A
  1. All of the above.
130
Q

Pt adherence to the nutrition support regimen is key to achieving goals of therapy. Which of the following are indications of nonadherence?

  1. Unwillingness to review a product inventory or report of excess supplies.
  2. Unintentional wt loss despite adequate energy being prescribed.
  3. Good communication btw the pt and health care team
  4. Both 1&2
131
Q

What is the definition of ANH?

  1. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume the by mouth
  2. Provision of specialized nutrients orally, enterally, or parenterally with therapeutic intent
  3. Nutrition provided through the GI tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity.
  4. Administration of nutrients and fluid intravenously to maintain the pt’s nutrition status during acute illness.
A
  1. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume the by mouth

AND is a medical treatment. It also involves technology assisted delivery of nutrients

132
Q

Which of the following core ethical principles is the predominant value in American bioethics?

  1. Respect for autonomy: the pt has the right to self determination in health care decision making
  2. Beneficence: The healthcare professional is fundamentally obligated to seek the good of the pt above all other priorities.
  3. Nonmaleficence: The prime directive of medicine is to prevent, minimize, and relieve needless suffering and pain.
  4. Justice: when treating pt, healthcare providers should consider only clinically relevant factors and provide equitable care to clinically similar pt
A
  1. Respect for autonomy: the pt has the right to self determination in health care decision making
133
Q

Which of the following statement is true about the decision to withhold and withdraw ANH?

  1. There is an ethical distinction btw withholding and withdrawing treatment.
  2. Decisions to withhold ANH tend to be more psychologically and emotionally charged for families than decisions to withdraw ANH
  3. There is a legal distinction btw withholding and withdrawing any treatment.
  4. The term forgoing refers to both withholding and withdrawing ANH
A
  1. The term forgoing refers to both withholding and withdrawing ANH
    There is no ethical or legal distinction btw withholding and withdrawing ANH
134
Q

Which of the following would be a reason to not place a long term feeding tube in a pt with advanced dementia?

  1. A swallow evaluation was not recently completed
  2. During the hospitalization, the health care team did not have meeting where the family could ask questions about the rationale for the tube placement
  3. The pt’s expected survival post feeding tube placement is less than 30 days.
  4. The pt does not have an advance directive indicating a designated decision maker and specific healthcare wishes.
A
  1. The pt’s expected survival post feeding tube placement is less than 30 days.
    The pt’s expected survival affects the evaluation of the burdens vs benefits and risks of the procedure.
135
Q

What is the main difference btw a QI project and a clinical outcomes research project?

  1. QI intends to improve generalizable knowledge, whereas outcomes research aims to improve clinical performance.
  2. QI intends to answer a clinical question, whereas outcome research aims to improve a procedure.
  3. QI intends to improve a process, whereas outcomes research aims to test a hypothesis.
  4. QI intends to produce a publishable manuscript, whereas outcomes research aims to improve system performance
A
  1. QI intends to improve a process, whereas outcomes research aims to test a hypothesis.

The goal of QI is to improve a process, a program, a system, or the performance of an individual practitioner by comparing current programs, processes, systems or performances with a set of published standards for use within that facility or system.

136
Q

Which of the following is the best example of a QI project?

  1. A RCT to evaluate the impact of EN protocol
  2. A clinical audit to asses the appropriateness of PN ordering.
  3. A needs assessment of pt’s compliance with home PN guidelines
  4. A prospective study to assess hold times for EN caused by high gastric residual volumes in enterally fed pt.
A
  1. A clinical audit to asses the appropriateness of PN ordering.

RCT and prospective studies aim to test hypothesis. A need assessment can be a quality or research project. A clinical audit may be completed during or before a QI project to assess the baseline and progress with change

137
Q

Which of the following best represents a quality indicator for assessing the appropriateness of ordering PN?

  1. The prevalence of central line infections in the study population
  2. The total number of pt who receive PN
  3. The mortality rate in the population
  4. The proportion of pt with a contraindication to EN.
A
  1. The proportion of pt with a contraindication to EN.

Quality indicators are objective metrics by which quality of care and professional performance can be assessed. Nutrition indicators can be derived from published guidelines and standards. In this case, the best indicators for PN appropriateness would be to align with the guidelines stating when PN is indicated if EN is contraindicated.

138
Q

Which of the following represents the highest grade of evidence of interpreting clinical trials in the literature?

  1. A well written editorial piece by a recognized expert in the field
  2. A large observational trial of critically ill pt in hospital around the world
  3. A prospective cohort study with nonrandomized contemporaneous controls.
  4. A large, multicenter RCT.
A
  1. A large, multicenter RCT.
139
Q

Which of the following best descries clinical guidelines issues by a scientific or medical society?
1. Clinical recommendations to guide clinicians
2. Medical legal benchmarks by which to gauge clinical competency
3. Practice parameters to guarantee the best pt outcomes in clinical practices.
4 A well organized list of clinical topics that can be used to gauge future research.

A
  1. Clinical recommendations to guide clinicians
    A clinical guidelines represent a set of recommendations for practicing clinicians that are derived from a vigorous review of the literature.
140
Q

Which of the following is true concerning the Forest plots from a meta analysis?

  1. The test of heterogeneity evaluates similarity btw pt in a study.
  2. The test of overall treatment effect indicates whether the quality of the meta analysis is high or low
  3. Relative risk tend to overestimate the treatment effect
  4. Absolute risk reduction is determined by counting the number of positive studies divided by the total number of studies in the meta analysis
A
  1. Relative risk tend to overestimate the treatment effect

The absolute risk reduction is calculated by the number of events in both the treatment and control groups divided by the denominator in each group. The absolute risk reduction is usually lower than the relative risk reduction.

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