Book questions

Question 1

The administration of 1 liter 0.9% sodium chloride (NaCl) to a normonatremic patient will increase the intravascular and interstitial fluid compartments by:

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

Answer 1

4. 250 mL and 750 mL, respectively

A solution of 0.9% NaCl (154 mEq/L) is isotonic and, 4. therefore, does not contribute to an osmotic gradient. Isotonic saline enters and remains in the ECF. Thus, administering
1 liter 0.9% NaCl expands the ECF by 1 liter. The intravascular volume accounts for 25% of the ECF and will expand by 250 mL. The remaining 750 mL will be distributed to the interstitial fluid compartment.

Question 2

Assuming the same weight and serum sodium concentration, which of the following patients has the greatest free water deficit?
1. A 35-year-old man
2. A 75-year-old man
3. A 35-year-old woman
4. A 75-year-old woman

Answer 2

1. A 35-year-old man

The correct answer is 1. Free water deficit is calculated as follows:

Free Water Deficit = TBW × [1 – (140/Serum Sodium)]

where free water deficit and total body water (TBW) are measured in liters and serum sodium is measured in mEq/L. Given the same body weight and serum sodium concentration, the only variable is the percentage of TBW. The percentage of TBW increases as the proportion of lean body mass (LBM) to adipose tissue increases. In general, the percentage of TBW decreases with age and is lower in females than in males. Younger men would be expected to have the highest proportion of LBM and
the highest percentage of TBW and would therefore have the largest free water deficit.

Question 3

A patient with severe intractable nausea and vomiting is at risk for which of the following acid-base disorders?

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

Answer 3

The correct answer is 3. Gastric fluids contain approximately 130 mEq chloride (Cl–) per liter and are very acidic (pH 1 to 2). Losing large amounts of gastric fluids via vomiting, especially for a prolonged period of time, can result in a hypochloremic metabolic alkalosis as the loss of acid from the stomach leaves the body with a relative excess of alkali.

Question 4

Metastatic calcification is a complication of ​

1: hyperkalemia ​
2: hypokalemia​
3: hyperphosphatemia​
4: hypophosphatemia

Answer 4

3: hyperphosphatemia

Question 5

A patient has had a NG tube to suction for 48 hours secondary to a post-operative ileus. Which of the following electrolytes will be lost?

1: Bicarbonate ​
2: Potassium ​
3: Calcium ​
4: Phosphorus

Answer 5

2: Potassium

Question 6

A patient in your intensive care unit has acute severe diarrhea. Which of the following acid-base disorders is likely to occur? ​
​

1: Metabolic acidosis​

2: Metabolic alkalosis​

3: Respiratory acidosis ​

4: Respiratory alkalosis

Answer 6

1: Metabolic acidosis​

Question 7

Which of the following practices is most likely to succeed in improving oral nutrient intake in patients with a prolonged history of weight loss due to poor intake, nausea, and depressed appetite?

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

Answer 7

2. Offering 6 small, low-fat meals daily

When patients experience a prolonged negative B energy balance, the stomach’s adaptive accommodation function declines; therefore, patients may not be able to consume their goal nutrient targets in 3 regular-sized meals because of a feeling of fullness.1 Eating 6 small meals may be a more realistic option. To address nausea, measures should be taken to prevent slowing of gastric emptying, which could potentiate nausea. These measures may include limiting high-fat foods. Providing high-energy or high-fiber supplements initially may not be the best
recommendation because, like fat, energy density and fiber content can slow gastric emptying. Answer D is not a good choice because providing fluids, not limiting them, facilitates gastric
emptying.

Question 8

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

1. Colonic bacteria act on the fiber to produce short-chain fatty acids (SCFAs) that provide an energy source to the intestinal mucosa.
2. Colonic bacteria act on the fiber to produce SCFAs, which, in turn, exert trophic effects on the intestinal mucosa.
3. Fermentable fiber may help control diarrhea by slowing gastric emptying.
4. All of the above.

Answer 8

4. All of the above.

Although more confirming evidence is needed, the addition of fermentable
fibers to enteral formulas likely has multiple beneficial effects, both in the healthy gut and in the malfunctioning gut. Fermentable fibers (eg, pectin, gums, fructooligosaccharides [FOS]) are metabolized by colonic bacteria to produce SCFAs. SCFAs have multiple benefits for the colonic mucosa. These benefits include providing a significant source of energy for and exerting trophic
effects on the intestinal lining. However, fiber is not recommended for patients with diarrhea caused by Clostridium difficile pseudomembranous colitis (PMC) or during low-flow states.

Question 9

Which of the following is the largest component of total energy expenditure (TEE)?

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

Answer 9

1. RMR

The thermogenic effect of digestion is generally thought to contribute no
more than 10% to TEE. Activity contributes 5% to 30% to TEE. With the exceptions of burn and sepsis, metabolic stress contributes less than 50% to TEE. However,min almost all situations, RMR constitutes 60% to 75% of TEE.

Question 10

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

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

Answer 10

2. Predictive equations

Most nutrition support feeding regimens are based on predictive equations used to assess energy expenditure. The measurement of energy expenditure via IC is more accurate
than predictive equations but is underused because the equipment is expensive to purchase and operate, and because some patients cannot be measured for various technical and physiological reasons.

Question 11

Which parameter is measured when using IC?

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

Answer 11

3. Gas exchange

Indirect calorimeters measure respiratory gas exchange (the difference between inspired and expired oxygen and carbon dioxide). If proper testing conditions are observed,
respiratory gas exchange is equivalent to metabolic gas exchange (the consumption of oxygen and production of carbon dioxide [CO2] at the cellular level). Gas exchange data are converted to RMR using the Weir equation

Question 12

You are determining the energy intake target for a 53-year-old, critically ill, male patient who is about to start enteral feeding. He is 170 cm in height and weighs 150 kg. His body mass index (BMI) is 51.9 and his ideal body weight is 70 kg. Body temperature is 37.3 degrees Celsius and minute ventilation
is 12.5 L/min. Based on the 2016 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline for calculating a goal energy intake for such a critically ill patient, 1 what energy value would you use as the basis for the feeding plan?

1. 1750 kcal/d (25 kcal per kg ideal body weight)
2. 1225 kcal/d (70% of the calculated 25 kcal per kg ideal body weight)
3. 2250 kcal/d (25 kcal per kg adjusted body weight)
4. 2615 kcal/d (Penn State equation)

Answer 12

1. 1750 kcal/d (25 kcal per kg ideal body weight)

The ASPEN guideline states that the goal intake for all classes of obesity should not exceed 65% to 70% of target energy expenditure as measured by IC.

For class III obesity (BMI equal to or greater than 40), an intake of 22 to 25 kcal per kg ideal body weight is recommended.
The Penn State equation (answer D) has been validated as being among the most
accurate ways of calculating energy expenditure up to a BMI of at least 80. However answer D is incorrect if following the ASPEN guideline because that guideline emphasizes the kcal/kg method. The patient has class III obesity; therefore, ideal body weight would be used for the calculation,
making answer 3 incorrect because it uses adjusted body weight. Answer B is incorrect because the guideline already factors the 30% reduction in the energy calculation into the standard; therefore, if the energy expenditure were calculated and then multiplied by 70%, the effect would be to reduce the energy intake target to about 50% of expenditure.

Question 13

Glucose and galactose gain access to enterocytes via ​

1. Glucose-dependent insulinotropic polypeptide (GIP)​
2. Glucokinase​
3. Enterokinase​
4. Sodium-glucose transporter 1 (SGLT-1)​

​

Answer 13

4. Sodium-glucose transporter 1 (SGLT-1)​

Question 14

The presence of which of the following facilitates the absorption of sodium in the lumen of the small intestine​

​
1. Glucose​

2. Potassium​

3 .Vitamin D​

4. Protein

Answer 14

1. Glucose​

Question 15

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

1. Pyruvate is the final product.
2. Oxygen is required for adenosine triphosphate (ATP) synthesis.
3. Both water and carbon dioxide (CO ) are produced.
4. CO is produced but water is not. 2
5. Water is produced but CO is not

Answer 15

3. Both water and carbon dioxide (CO ) are produced.

The correct answer is 3. Pyruvate is the final product of glycolysis. When pyruvate leaves the cytoplasm and enters the mitochondria, it loses CO2. The acetyl group then transfers to coenzyme A
(CoA) and forms acetyl-CoA. In aerobic conditions, pyruvate can be further oxidized during cell respiration. In anaerobic conditions, pyruvate can be broken down into lactate. Both metabolic
pathways can produce ATP. After all energy has been released from the glucose moiety, CO2 and water are the final products.

Question 16

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

1. Glycolysis and cytosol
2. Tricarboxylic acid (TCA) cycle and mitochondrial membrane
3. ATP phosphorylation and cytosol and mitochondria
4. Electron transport chain and mitochondrial membrane
5. Oxidative decarboxylation of pyruvate and mitochondria

Answer 16

2. Tricarboxylic acid (TCA) cycle and mitochondrial membrane

The correct answer is 2. The TCA cycle is the metabolic reaction of cell respiration, which occurs inside the eukaryotic mitochondrion (not on the mitochondrial membrane). Glycolysis occurs in the cytoplasm. ATP phosphorylation occurs both during glycolysis (in the cytoplasm) and the TCA cycle (in the mitochondrion). The electron transport chain is a carrier mechanism within the inner mitochondrion. The oxidative decarboxylation of pyruvate occurs in the mitochondrion.

Question 17

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

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

Answer 17

2. Buildup of pyruvate

Under anaerobic conditions, pyruvate accepts a hydrogen atom from nicotinamide adenine dinucleotide plus hydrogen (NADH), forming nicotinamide adenine dinucleotide (NAD+) and lactic acid. At physiological pH, lactic acid is dissociated into lactate and
protons. Thus, the local pH decreases. Using this pathway, only 2 ATPs can be generated. A shortage of ATP is possible, leading to muscle fatigue.

Question 18

What are some of the possible ramifications of activation of the enzyme, phospholipase A 2?

1. Cyclooxygenase (COX)–dependent, eicosanoid-mediated inflammatory reactions
2. Enzymatic degradation of resolvins and protectins
3. Desaturation of linoleic acid within lipids
4. Chylomicron maturation

Answer 18

1. Cyclooxygenase (COX)–dependent, eicosanoid-mediated inflammatory reactions

Arachidonic acid (AA), common to membrane phospholipids, usually occupies the sn-2 position within lipids and is almost always found at this position within the important membrane phospholipid phosphatidylinositol. During membrane cell signaling events, a
possible outcome is the activation of phospholipase A2, the enzyme that acts on membrane phospholipids to release fatty acids from the sn-2 position. Release of AA sets in motion subsequent intracellular metabolic activity via the COX pathway that leads to the synthesis of the 2-series of prostaglandins, including prostaglandin E (PGE2), and thromboxanes, including thromboxane A2 .

Question 19

How might propofol, when provided to patients within a 10% (w/v) lipid injectable emulsion (ILE), increase risk of hypertriglyceridemia?

1. Propofol causes acute uptake of triglycerides (TGs) by the microvilli of the small intestine.
2. Propofol is known to activate the release of TGs from adipose tissue.
3. The increased presence of liposomes 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 level of TGs in the blood.

Answer 19

3. The increased presence of liposomes in the propofol ILE may interfere with chylomicron and pseudo-chylomicron metabolism.

Hypertriglyceridemia may be caused by interference with chylomicron and
pseudo-chylomicron metabolism as a result of the presence of liposomes within the ILE. Liposomes are formed during the emulsification process when parenteral ILE is produced. These liposomes are usually metabolized in a manner similar to the metabolism of pseudo-chylomicrons, but their presence may lead to the formation of a spherical bilayer of phospholipid and cholesterol known as lipoprotein-X. This lipoprotein inhibits both lipoprotein lipase and hepatic lipase enzymatic activity, and thus can interfere with the proper metabolism of the TGs that are part of the structure of chylomicrons and pseudo-chylomicrons. This interference and the accumulation of endogenous cholesterol can subsequently lead to an increase in circulating TGs and cholesterol. Because 10%
(w/v) ILE contains a greater number of liposomes relative to 20% (w/v) ILE as a result of the relative ratio of phospholipid emulsifier to oil, the former formulation places the patient at greater risk for hypertriglyceridemia

Question 20

Which ionized form of a short-chain fatty acid (SCFA; up to 6 carbons in length) is thought to be the most important to colonic health and why?

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

Answer 20

3. Butyrate

SCFAs such as acetate, propionate, and butyrate are primarily produced in
the colon by bacteria and can serve as important energy sources for colonic tissue. Butyrate in particular is thought to modify inflammatory activity and promote colon health. For example, when applied directly to the colon, butyrate can attenuate the inflammatory activity seen in ulcerative
colitis. In addition, the fermentation of carbohydrate (fiber) and the production of SCFAs in the colon, especially butyrate production, appear to act as antitumorigenic stimuli.

Question 21

Which of the following statements is true relating to hydrochloric acid (HCl) and protein digestion?

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 proteins.
4. HCl’s release is stimulated by the hormone insulin.

Answer 21

2. HCl denatures protein structures to make them more susceptible to enzymatic action

Denaturing protein structures, making them more susceptible B to enzymatic action, is a primary role of HCl. HCl plays several roles in protein digestion, including conversion of
the proenzyme pepsinogen to its active form pepsin. HCl is secreted by the parietal cells within the stomach, not the duodenum. HCl secretion is stimulated by gastrin, not insulin.

Question 22

Proteins perform all 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

Answer 22

1. Provide a major source of energy

Carbohydrates and fats are the major energy source in the human diet. Protein is not preferentially used as a source of energy in health. Protein is used as the body’s primary
buffer to maintain acid-base balance. All cells of the immune system (ie, white blood cells,
macrophages, and so on) are made up of proteins. Proteins are the primary carriers for substances such as minerals, vitamins, and hormones.

Question 23

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

1. Anorexia nervosa with body mass index (BMI) of 15
2. Major depression with compromised dietary intake and 5% loss of body weight
3. Homebound older adult with restricted access to food and 10% loss of body weight
4. Thermal burn injury of second and third degrees covering 15% body surface area

Answer 23

4. Thermal burn injury of second and third degrees covering 15% body surface area

The burn injury is significant and will be associated with D severe systemic inflammatory response. The diagnosis, clinical signs, physical examination data, and laboratory indicators for such a patient will support this conclusion. The other answers describe states of
starvation that are not likely to be associated with severe systemic inflammatory response.

Question 24

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

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

Answer 24

3. Consideration of medical history, clinical diagnosis, and laboratory signs of the inflammatory response would help you interpret these findings.

By themselves, these proteins should be interpreted with caution because they lack specificity and sensitivity as indicators of nutrition status. Both albumin and prealbumin may be reduced by the systemic response to injury, disease, or inflammation. Patients with low
albumin or prealbumin levels may or may not be malnourished. The patient’s medical history, clinical diagnosis, and laboratory signs of the inflammatory response can help clarify whether inflammation is present and whether the patient is malnourished.

Question 25

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

1. Patient reports a nonvolitional weight loss.
2. Patient reports following a low-carbohydrate, weight loss diet.
3. Patient is 2 days status post laparoscopic cholecystectomy.
4. Patient reports a recent flu-like febrile illness.

Answer 25

1. Patient reports a nonvolitional weight loss.

Of the options provided, the only well-validated indicator to screen for
malnutrition risk is a nonvolitional weight loss. The other options might be noted in screening and assessment but are not themselves validated measures of malnutrition risk.

Question 26

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

1.Maintenance of normal gallbladder function
2. Reduced gastrointestinal (GI) bacterial translocation
3. More efficient nutrient metabolism
4. All of the above

Answer 26

4. All of the above

EN provides nutrients to the small intestine, stimulating D the release of
cholecystokinin, which helps maintain normal gallbladder function and reduce the risk of cholecystitis. Luminal nutrients provide GI structural support and help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function. Immunoglobulin A (IgA), which is secreted within the GI tract in response to intraluminal nutrients, can prevent bacterial adherence and translocation. Nutrients from EN more closely mimic normal oral feeding, and undergo first-pass
metabolism, promoting more efficient nutrient utilization

Question 27

High-protein hypocaloric EN feeding providing 65% to 70% of energy needs, as determined by indirect calorimetry (IC), is recommended for intensive care unit (ICU) patients with which of the following conditions?

1. Malnutrition
2. Obesity
3. Liver failure
4. Acute respiratory distress syndrome (ARDS)

Answer 27

2. Obesity

Patients with malnutrition should receive more than 80% of their estimated nutrient needs within 48 to 72 hours of intubation. Delays in initiating and advancing EN result in greater energy and protein deficits, which may contribute to higher infection and mortality rates. Studies indicate obese patients benefit from low-calorie, high-protein feedings to minimize the metabolic complications of feeding, preserve lean body mass (LBM), and mobilize fat stores. In patients with ARDS, studies indicate no difference in outcomes between those receiving eucaloric feedings and those receiving trophic feedings

Question 28

Risk factors for aspiration include all of the following except:

1. Malnutrition
2. Use of naso-/oro-feeding tube
3. Bolus EN feeding
4. Supine position

Answer 28

1. Malnutrition

Although malnutrition may result in generalized weakness and contribute to swallow dysfunction, malnutrition by itself is not recognized as a risk factor for aspiration. Conditions that manipulate or affect the function of the lower esophageal sphincter, such as the
presence of a feeding tube in the esophagus, increase the risk of reflux and thus aspiration. Bolus feedings, which increase the volume of contents in the stomach, and the supine position also increase
the risk of reflux.

Question 29

The use of 0.1N hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of

A.  calcium-phosphate
B.  tobramycin
C.  phenytoin
D.  lipid residue

Answer 29

A.  calcium-phosphate

thrombolyticsare NOT effective against every occlusion

The use of 0.1N hydrochloric acid has been reported effective in clearing catheters with crystalline occlusions because its acidic pH is favorable for calcium and phosphate solubility. Clinicians should be aware, however, that direct infusion of hydrochloric acid into the venous system can be associated with fever, phlebitis, and sepsis. For catheter occlusions due to precipitates associated with medications in the high pH range such as tobramycin and phenytoin, sodium bicarbonate 1 mEq/mL has been anecdotally reported to be effective. Seventy percent ethanol is the most effective solvent to dissolve lipid residue.

Question 30

An alert and oriented adult patient is receiving a continuous infusion of a standard, fiber-containing EN formulation through an 8-Fr nasogastric (NG) tube. Drugs administered by bolus administration
through the side port of the tube are phenytoin suspension 400 mg daily and nizatidine 150 mg 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 2½ weeks from now. Which of the following measures is most appropriate for preventing occlusion of the new tube?

1. Replace the 8-Fr tube with an 18-Fr NG tube.
2. Flush the feeding tube with 15 mL 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.

Answer 30

2. Flush the feeding tube with 15 mL of water before and after administering each medication.

The most likely cause of the feeding tube occlusion is B improper flushing technique. The tube should be flushed with a minimum of 15 mL of water before and after each medication, but 30 mL is commonly recommended and may be required to properly flush longer or larger tubes. Although the risk of occlusion is potentially greater with an
8-Fr small-bore tube than with an 18-Fr tube, the discomfort associated with such a large-bore tube would make it a poor choice for nasoenteral access in an alert patient, especially when needed for more than 2 weeks. Switching from a fiber-containing to a fiber-free EN formulation would have little influence on risk of tube occlusion. The fiber used in EN formulations has been processed to a degree that makes its viscosity similar to that of polymeric, fiber-free formulations. Holding the feeding infusion for 2 hours before and after phenytoin administration has been recommended as a method to enhance drug absorption; it would not be expected to influence tube occlusion.

Question 31

The EN formulation for a home patient receiving EN through a percutaneous gastrostomy was recently changed from a high-protein, fiber-containing, 1 kcal/mL formulation to the only 1.5 kcal/mL formulation available in the local store. The new product is marketed for use in patients with compromised pulmonary function and contains low amounts of carbohydrate, 55% of energy from fat, about 15% less protein per day than the 1 kcal/mL formulation, and no fiber. What component of the new formulation 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

Answer 31

3. Higher fat content

High fat intake slows gastric emptying. High protein intake C and high energy density can also slow gastric emptying but have less effect than high fat. In addition, protein intake will be lower with the new formulation. Low fiber intake has been associated with slow colonic
transit and constipation rather than altered gastric emptying.

Question 32

Which of the following is the preferred method of administering a hospitalized patient’s antihypertensive medication when tube feeding is started due to poor oral intake?

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 intravenous (IV) route

Answer 32

1. By the oral route

The oral route is preferred whenever possible because it is the route by
which oral medications are designed to be administered. If the patient is allowed to take adequate water to swallow the medication, the oral route should be considered. For medications to be taken with food, the patient should have either food from oral ingestion or enteral formulation in the stomach before medication administration by mouth. Medications that are not administered via the feeding tube will not cause tube occlusion, making oral administration a very effective method of preventing tube occlusion caused by medications.

Question 33

A medication that is ordered as a liquid to be administered via the feeding tube is available in the pharmacy in the IV form, as a capsule (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 feeding tube.
3. Make a slurry of the capsule’s powder and administer via the feeding tube.
4. Crush the tablet to a fine powder and administer via the feeding tube.

Answer 33

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

Question 34

The use of 70% ethyl alcohol is most effective for clearing catheter occlusions due to precipitation of:

1: calcium-phosphate.
2: lipid residue.
3: phenytoin.
4: tobramycin.

Answer 34

2:  lipid residue.

The treatment for catheter occlusion depends on whatprecipitate is occluding the catheter. Patients receiving TPNwho have poor flushing habits may encounter lipid sludgeand deposits leading to catheter occlusion. 70% ethyl alcoholassists with lipid deposits as lipids are soluble in alcohol.Precipitation from acidic medications (i.e., vancomycin) orfrom calcium-phosphorous precipitation can be cleared with0.1-N hydrochloric acid (HCl).Occulsionfrom basicmedications (i.e., phenytoin, oxacillin) can be cleared with8.4% sodium bicarbonate or 0.1-N NaOH.

Question 35

Which of the following claims for a dietary supplement would most likely cause the US Food and Drug Administration (FDA) to consider that the supplement should be regulated as a drug rather than as a dietary supplement?

1. Supports strong bones and teeth
2. Treats influenza
3. Promotes urinary health
4. Improves immune function

Answer 35

2. Treats influenza

Under the DSHEA, manufacturers of dietary supplements B may make
statements regarding product ability to affect structure or function of the body. Manufacturers refer to these as “structure-function claims,” which are regulated by the FDA for labeling and the US Federal
Trade Commission (FTC) for merchandizing and marketing. Any claim regarding diagnosis, treatment, cure, or prevention of a disease is disallowed and subject to fines and prosecution. Therefore, a claim to support strong bones and teeth would be allowed as a structure claim, if true. The claims to promote urinary health and support the immune system would be function claims. The claim that a product treats influenza is an obvious claim regarding treatment of disease and would
thus be disallowed.

Question 36

Which of the following best describes dietary supplement use in the United States?

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

Answer 36

4. Many patients using prescription medicines concomitantly use dietary supplements.

Surveys have shown varying percentages of the US population using dietary supplements. Data from a large nationwide survey published in 2016 indicated that the use of dietary supplements remained stable between 1999 and 2012, with 52% of US adults reporting use of any
supplements in 2011–2012.1 Many persons using dietary supplements do not report this use to their allopathic health providers. Patients may not disclose supplement use because they do not think of supplements as products that may interact with their medications or because they believe that the health provider will be judgmental about their use. Abundant data indicate that the latter belief is overwhelmingly the most common reason why patients do not disclose the supplements they use, and there is strong evidence to validate patients’ fear of reprisal. Although most patients think that their healthcare provider should be knowledgeable regarding dietary supplements, only about half of
patients in a recent survey reported that providers actually were knowledgeable. In contrast, surveys of healthcare providers indicate that they are often reluctant to recommend CAM modalities even
though they report having good to excellent awareness of the potential benefit of these modalities. Many patients using dietary supplements also use prescription medications; this concomitant use
could result in supplement interactions with medication or increased incidence of adverse events.

Question 37

Even if Current Good Manufacturing Practices (CGMPs) promulgated by the Dietary Supplement Health and Education Act of 1994 (DSHEA) 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 are no studies to confirm its efficacy for any condition.

Answer 37

4. A dietary supplement product is marketed and sold, but there are no studies to confirm its efficacy for any condition.

The DSHEA mandates that CGMPs be set up for the dietary supplement
industry. Under these CGMPs, process controls are supposed to be in place at each step of manufacturing. Thus, the dietary supplements arriving on the shelf should contain the correct ingredients in the correct amounts and should be free of adulterants. There should be consistency between lots in terms of content. Unfortunately, the FDA does not have sufficient resources to inspect all manufacturing plants and final products. However, examples of random testing of the authenticity
of dietary supplements sold in large national retail chains by New York State agencies caught national attention in 2015 and led to legal action against the retailers, which ultimately paid large settlements. The CGMPs do not address whether there are any data supporting the efficacy of dietary supplements.

Question 38

What is the optimal nutrition support for a malnourished patient when enteral nutrition (EN) is not feasible for a prolonged period?

1. Central parenteral nutrition (CPN)
2. Nasogastric enteral tube feedings
3. Postpyloric enteral tube feedings
4. Peripheral parenteral nutrition (PPN)

Answer 38

1. Central parenteral nutrition (CPN)

The benefits of CPN are more closely associated A with patients with
malnutrition, although those benefits have not been consistently shown.1 Newer studies of the impact of PN on malnourished cancer patients’ body composition and performance scores provide a perspective of PN on outcomes not currently considered in American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines that may expand the role of CPN in clinical practice

Question 39

CPN is contraindicated in which of the following conditions?

1. Do not resuscitate (DNR) status
2. Peritonitis
3. Intestinal hemorrhage
4. High-output fistulas

Answer 39

1. Do not resuscitate (DNR) status

Trujillo and colleagues abstracted indications for PN from the 1993 ASPEN guidelines as peritonitis, intestinal hemorrhage, intestinal obstruction, intractable vomiting, paralytic ileus, severe pancreatitis, stool output greater than 1 L/d, high-output fistulas, short bowel syndrome, and bone marrow recipients. PN therapy was contraindicated for patients who were classified as well
nourished and had inadequate EN for less than 7 days; patients who had a DNR status and were deemed to warrant comfort measures only or were terminally ill; and those receiving adequate EN.

Question 40

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

1. A clear liquid diet is ordered.
2. Tube feeding is initiated at 10% of goal rate.
3. Solid food is well tolerated by mouth.
4. Advancement to a regular diet is poorly tolerated.

Answer 40

3. Solid food is well tolerated by mouth.

The goal of PN therapy is to maintain the nutrition status of the patient until some form of EN is tolerated. Critically ill patients whose therapy is withdrawn during the terminal stages of their disease process are the exception to this goal. In most other situations, GI function returns or appropriate enteral access is obtained, and PN is tapered as the amount of reliable enteral intake increases. PN support may be discontinued when patients can tolerate solid food by mouth, unless advanced age, debilitation, malignancy, or cultural food practices complicate the transition to oral intake. In those circumstances, a detailed transitional feeding plan should be established.

Question 41

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

1. Cancer chemotherapy
2. Preoperative care of surgery patients with upper gastrointestinal (GI) cancer
3. Allogeneic bone marrow transplantation
4. Critical illness

Answer 41

2. Preoperative care of surgery patients with upper gastrointestinal (GI) cancer

A review of PN literature has reported improved outcomes in patients with upper GI tract malignancies when PN is initiated 7 days before surgery. An early report of a decrease in length of stay and infectious complications in allogeneic bone marrow transplant patients receiving
PN has not been confirmed. A review of published data on the use of PN in cancer chemotherapy, in the perioperative period, and during critical illness reports no positive effect of PN on clinical outcomes and a significant increase in infectious complications in patients randomly assigned to PN therapy as compared with those receiving no nutrition support

Question 42

Which of the following may increase the risk of phlebitis with peripherally administered parenteral nutrition (PPN)?

1. Osmolarity equal to or less than 900 mOsm/L
2. Potassium 100 mEq/L
3. Calcium less than 5 mEq/L
   4 Addition of heparin to the PPN

Answer 42

2. Potassium 100 mEq/L

Potassium can be quite irritating to peripheral veins. Potassium in concentrations less than 60 mEq/L and preferably less than 40 mEq/L is generally suggested for fluids administered via the peripheral vein. All the other choices may actually decrease the risk of phlebitis.

Question 43

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

1. 0.22 m
2. 0.5 m
3. 1.2 m
4. 5 m

Answer 43

3. 1.2 m

The 1.2-m filter is not a sterilizing filter, but it will remove large microorganisms such as Candida albicans and large particles that might otherwise lodge in pulmonary capillaries if allowed to pass through. A 0.22-m filter is used for the 2-in-1 dextrose and
amino acid type of PN, and it does qualify as a sterilizing filter. Because fat particles are generally between 0.1 m and 1 m in size, lipid injectable emulsion (ILE) could occlude 0.22-m and 0.5-m filters, or the emulsion could be destabilized if used with these filters. The 5-m filter removes particulate matter, but it would allow many types of microbial contaminants to pass through

Question 44

Which of the following will increase the solubility of calcium and phosphate in a PN formulation?

1. Use of calcium as the chloride salt
2. Use of phosphate as the sodium salt
3. Increased amino acid concentration
4. Increased temperature

Answer 44

3. Increased amino acid concentration

The higher the concentration of amino acids in the formulation, the less likely precipitation is to occur. Amino acids can form soluble complexes with calcium, which reduce
the effective concentrations of free calcium available to form insoluble precipitates with phosphorus ions. Calcium chloride is more dissociated than calcium gluconate, making the risk of precipitation with phosphate higher. The salt form of phosphate does not affect calcium solubility if the phosphate
amount remains constant; that is, 1 mmol of phosphate as the sodium salt has the same potential to precipitate with calcium as 1 mmol of phosphate as the potassium salt. Precipitation is more likely to occur at warmer temperatures because the dissociation of calcium salts increases as the temperature
rises, promoting the availability of ions to form insoluble complexes with phosphate

Question 45

According to recommendations by the National Advisory Group on Standards and Practice guidelines for parenteral nutrition formulations and the American Society for Parenteral and Enteral Nutrition (ASPEN) parenteral nutrition safety consensus, the amount of dextrose used in 1 preparation of a PN formulation is required to appear on the label as:

1. The percentage of original concentration and volume (eg, dextrose 50% water, 500 mL)
2. The percentage of final concentration after admixture (eg, dextrose 25%)
3. Grams per liter of PN admixed (eg, dextrose 250 g/L)
4. Grams per day (eg, dextrose 250 g/d)

Answer 45

4. Grams per day (eg, dextrose 250 g/d)

Grams of dextrose per day is the information most consistent with that found on a nutrient label, supports the use of the 24-hour nutrient infusion system, and requires the least number of calculations to determine the daily energy amount. The quantity per liter may appear on the label in a second column in parentheses

Question 46

Which of the following is the most appropriate VAD strategy for a patient 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.

Answer 46

3. Place a single-lumen, tunneled cuffed catheter.

A single-lumen tunneled catheter is the preferred device. The tunneled catheter was originally developed for patients with long-term PN.1 Tunneled catheters have been demonstrated to be safe and effective in long-term therapies ranging from months to years. A midclavicular catheter does not provide central access and, therefore, would not be an appropriate catheter choice. Percutaneous nontunneled catheters with additional features of multiple lumens and an antibiotic/antimicrobial coating provide PN access in the acute care setting for a shorter duration of time. It would be best to start with selection of the optimal device for the current therapy rather than a
planned replacement. Ports are an alternative to external-lumen catheters, and patients need to understand that repeated needle sticks will be required for daily therapy.

Question 47

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

1. Thrombolytics
2. Anticoagulants
3. 10% hydrochloric acid
4. Sodium bicarbonate

Answer 47

1. Thrombolytics

Catheter occlusions are often secondary to a thrombotic problem, such as an intraluminal thrombus, an extraluminal fibrin sleeve, or vessel thrombosis.3 The successful use of thrombolytics (eg, streptokinase, urokinase, alteplase) to treat catheters occluded with a thrombus is
well documented. Nonthrombogenic factors in catheter occlusion include intraluminal drug and lipid precipitates. Pharmacological agents that change the pH within the lumen increase the solubility of
the precipitate.

Question 48

Which of the following practices has been shown to reduce the risk for catheter-related bloodstream infections (CRBSIs)?

1. Systemic use of antimicrobial prophylaxis at the time of insertion or access
2. Routine replacement of central venous access devices (CVADs)
3. Use of the “Central Line Bundle” of insertion and maintenance practices
4. Selection of an internal jugular site as opposed to subclavian site

Answer 48

3. Use of the “Central Line Bundle” of insertion and maintenance practices

The Central Line Bundle for insertion and maintenance includes (1) hand
hygiene, (2) maximal barrier precautions, (3) skin antisepsis with chlorhexidine gluconate (CHG), (4) optimal catheter site selection, and (5) daily review of line necessity, with the prompt removal of
unnecessary lines. The use of this bundle has been documented to decrease 4 the incidence of catheter-related infections. The systemic use of antimicrobial prophylaxis at the time of insertion or access is not recommended and may actually promote the resistance of microbial populations associated with catheter infections. The routine replacement of CVADs is not recommended, and catheters should only be removed when clinically indicated. Studies have shown a lower rate of catheter-related infections in line placements via the subclavian site.

Question 49

The clinical presentation of refeeding syndrome includes all of the following EXCEPT

A: Respiratory Failure
B: Seizures
C: Cardiac Arrythmias
D: Dehydration

Answer 49

D: Dehydration

Electrolyte abnormalities that may occur with refeeding syndrome include sodium retention, hypophosphatemia, hypokalemia, and hypomagnesemia. Sodium retention usually occurs in the early phase of the refeeding syndrome and is exacerbated by excessive sodium and fluid intake. This may lead to fluid overload, pulmonary edema, and cardiac decompensation. Severe hypophosphatemia has been reported to cause respiratory failure and seizures. Severe hypokalemia and hypomagnesemia predispose patients to cardiac arrhythmias and neuromuscular adverse effects such as weakness and muscle cramps.

Question 50

All of the following conditions predispose a patient to the refeeding syndrome EXCEPT:

A: Chronic alcoholism
B: Malabsorptive syndromes
C: Weight loss after bariatric surgery
D: Poor oral intake for 3 days

Answer 50

D: Poor oral intake for 3 days

Conditions that predispose patients to the refeeding syndrome include chronic starvation, prolonged fasting or minimal oral intake (>7 days), chronic alcoholism, anorexia nervosa, malabsorption syndromes, morbid obesity followed by significant weight loss, and wasting diseases such as cancer and AIDS.

Question 51

Which of the following illustrates the most common electrolyte imbalances observed in patients with refeeding syndrome?

A: Hypokalemia, hyperphosphatemia, hypocalcemia
B: Hyperkalemia, hyperphosphatemia, hypocalcemia
C: Hypokalemia, hypophosphatemia, hypermagnesemia
D: Hypokalemia, hypophosphatemia, hypomagnesemia

Answer 51

D: Hypokalemia, hypophosphatemia, hypomagnesemia

Refeeding syndrome is a potentially lethal condition that can result from fluid and electrolyte shifts in malnourished patients undergoing refeeding of oral, enteral, or parenteral nutrition. The syndrome is characterized by alterations in electrolytes and vitamins. Hypokalemia, hypophosphatemia, and hypomagnesemia commonly occur and are associated with significant morbidity and mortality. Identification of patients at high risk for refeeding syndrome is essential in providing nutrition support to malnourished patients.

Question 52

Hypophosphatemia is the hallmark feature of refeeding syndrome (True/False)

A: True
B: False

Answer 52

Answer: B- False

Question 53

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

A- Hyperglycemia
B-Essential fatty acid deficiency (EFAD)
C-Azotemia
D-Hyperammonemia

Answer 53

A- Hyperglycemia

Hyperglycemia is the most common metabolic complication A that
occurs with PN. Hyperglycemia is associated with overfeeding but is also common in appropriately fed patients, where it is attributed to insulin suppression and resistance as well as gluconeogenesis from stress and
infection. Nondiabetic hospitalized patients receiving IV dextrose infusions at rates greater than 4 mg/kg/min have a 50% chance of developing hyperglycemia. EFAD is associated with fat-free PN and can be avoided by administering minimal amounts of ILE. Azotemia is usually associated with renal or hepatic dysfunction or protein overfeeding. Hyperammonemia rarely occurs now that crystalline amino acids are used in PN.

Question 54

One day after initiating PN in a critically ill adult patient, the patient’s laboratory values are as follows: serum potassium, 3.1 mEq/L (normal: 3.4–4.8 mEq/L); serum phosphorus 1.6 mg/dL (normal: 2.5–4.8 mg/dL); and serum magnesium, normal. The PN regimen is providing protein 90 g, dextrose 150 g, no lipid, minimum volume, potassium 80 mEq, phosphate 40 mmol, and standard doses of sodium, magnesium, calcium, vitamins, and trace elements. The patient weighs 60 kg and
has a body mass index (BMI) of 18. The most appropriate response to these laboratory data is:

A. Increase potassium and phosphate in the PN, and decrease macronutrient doses with tonight’s PN bag.

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

C. Increase potassium and phosphate in the PN, and advance dextrose to 225 g with tonight’s PN bag.

D. Provide supplemental IV doses of potassium and phosphate today, and advance dextrose to 225 g with tonight’s PN bag

Answer 54

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

Management and prevention of refeeding syndrome B and refeeding
hypophosphatemia involve (1) identifying patients at risk, (2) serum electrolyte monitoring with aggressive replacement, and (3) slowly increasing energy intake. In this critically ill patient who
experiences hypophosphatemia and hypokalemia after the initiation of PN, the electrolyte abnormalities should be treated quickly with supplemental, IV replacement doses. Energy intake from PN should not be advanced until the electrolyte deficiencies are corrected.

Question 55

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

A. Stop all oral and enteral intake.
B. Switch from a cyclic to continuous method of PN administration.
C. Decrease lipid injectable emulsion (ILE) dose from 1.5 g/kg/d to 1 g/kg twice weekly.
D. Increase protein dose from 1 g/kg/d to 2 g/kg/d.

Answer 55

C. Decrease lipid injectable emulsion (ILE) dose from 1.5 g/kg/d to 1 g/kg twice weekly.

Cholestasis has been associated with ILE doses greater than 1 g/kg/d in adult patients receiving long-term PN, and the patient may therefore benefit from a trial of lowering the ILE dose. Cyclic infusion has been shown to reduce serum liver enzyme and conjugated bilirubin
concentrations when compared with continuous infusion. Enteral feeding should be attempted to promote enterohepatic circulation of bile acids. The protein dose does not seem to play a role in the
development of cholestasis in adults.

Question 56

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

A. Maintain protein intake of at least 2 g/kg/d.
B. Provide more than 20 mEq calcium per day.
C. Add injectable vitamin D to the PN formulation.
D. Provide 20 to 40 mmol phosphorus per day.

Answer 56

D. Provide 20 to 40 mmol phosphorus per day.

An inadequate phosphorus dose may increase urinary calcium excretion; therefore, the American Society for Parenteral and Enteral Nutrition (ASPEN) recommends that phosphorus doses of 20 to 40 mmol/d be added to the PN formulation. Although patients receiving
PN are vulnerable to a negative calcium balance, calcium supplementation in the PN formulation is limited by calcium’s physical compatibility with phosphorus, and higher calcium doses are offset by
higher urinary losses. ASPEN recommends that calcium gluconate 10 to 15 mEq/d be added to the PN formulation. High protein doses (2 g/kg/d vs 1 g/kg/d) in PN formulations have been associated
with increased urinary calcium excretion in adult patients. Excessive vitamin D doses can be detrimental to the bone because they can suppress parathyroid hormone (PTH) and promote bone
resorption, and individual forms of parenteral ergocalciferol or cholecalciferol are not available.

Question 57

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

A. Obese pregnant women should lose weight during pregnancy to improve fetal outcomes.

B. The fetus is a “perfect parasite,” and the nutrition status of the mother is of no consequence.

C. Appropriate weight gain for women of all body mass index (BMI) ranges is essential to fetal health.

d. Poor maternal health and nutrition status has only short-term impact on the fetus.

Answer 57

C. Appropriate weight gain for women of all body mass index (BMI) ranges is essential to fetal health

Appropriate weight gain for women of all BMI ranges is C essential to fetal health. Inadequate or excessive maternal weight gain can lead to poor fetal outcomes. Weight gain below recommended targets set by the Institute of Medicine (IOM; now the Health and Medicine
Division of the National Academies of Science, Engineering, and Medicine) in 2009 has been associated with low birth weight (LBW) infants. Obese women who lost weight during pregnancy
had twofold greater odds of LBW infants and 1.8 greater odds of small-for-gestational age (SGA) infants. Excessive weight gain increases the odds of gestational hypertension or preeclampsia, macrosomia, and a decrease in the infant’s 5-minute appearance, pulse, grimace, activity, and respiration (APGAR) scores

Question 58

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

A. Energy requirements are the same for pregnant and nonpregnant women.

B. Energy needs are increased only during the second and third trimesters of pregnancy.

C. Compared with nonobese women, energy requirements are lower for obese women to promote weight loss during pregnancy.

D. Energy goals should only focus on nonprotein energy intake.

Answer 58

B. Energy needs are increased only during the second and third trimesters of pregnancy.

Energy requirements in pregnancy increase in the second and third
trimesters. Most women do not need to increase energy intake in the first trimester, although underweight women may be encouraged to do so

Question 59

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

A. Urine glucose
B. Urine lactic acid
C. Serum glucose
D. Serum insulin

Answer 59

C. Serum glucose

Serum glucose levels must be strictly monitored during C pregnancy to avoid the possible detrimental effects of neonatal hyperglycemia and hyperinsulinemia. The presence of glucose in a pregnant woman’s urine is not abnormal and therefore does not necessarily indicate the
presence of maternal diabetes. The presence of lactic acid in the urine is typically observed during strenuous exercise and has no value in terms of monitoring glycemic control.

Question 60

What are the goals for protein support for adults with delayed healing of pressure injuries/ulcers?

A. Provide adequate protein: 0.8 g/kg/d
B. Provide adequate protein: 1.0 to 1.2 g/kg/d
C. Provide adequate protein: 1.25 to 1.5 g/kg/d
D. Provide adequate protein: 0.6 g/kg/d

Answer 60

C. Provide adequate protein: 1.25 to 1.5 g/kg/d

The goal for protein support for patients with pressure injuries/C ulcers is 1.25
to 1.5 g protein per kg body weight per day.

Question 61

Which of the following should be offered to provide elemental zinc for pressure injuries/ulcers healing?

A. Zinc sulfate: 220 mg/d
B. Zinc gluconate: 84 mg/d
C. Daily multivitamin with minerals supplement
D. Zinc chloride: 170 mg/d

Answer 61

C. Daily multivitamin with minerals supplement

Zinc supplementation is recommended only for patients with confirmed zinc
deficiencies, and adequate levels can be achieved with a daily multivitamin with minerals supplement. For patients with normal levels of zinc, supplementation offers no benefit and may result
in zinc toxicity.

Question 62

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

A. An acute wound will generally heal within 2 to 3 days, whereas a chronic wound will likely take 7 to 10 days to heal.

B. Acute wounds are related to an initial injury, whereas chronic wounds develop due to an underlying pathological process.

C. The microenvironments of the 2 types of wounds are different, with acute wounds having fewer inflammatory mediators present.

D. Both B and C.

Answer 62

D. Both B and C.

Wound healing progresses in a predictable series of events. However, when disruptions in the healing process occur, they lead to poor wound healing and the presence of a
chronic wound. An acute wound tends to heal within 4 weeks, although there is no strict timetable for when a wound will heal. Acute wounds occur due to an initial insult but can become chronic, typically because of abnormalities in underlying pathophysiology. The microenvironment is very different between acute and chronic wounds. Chronic wounds are characterized by a disruption in the sequence of expected healing events or prolonged inflammatory metabolism. There are also distinct differences at the molecular level of chronic wounds; increased levels of inflammatory cytokines, such as tumor necrosis factor-, interleukin-1, and interleukin-6, and proteases, such as matrix
metalloproteinases (particularly matrix metalloproteinase-2 and matrix metalloproteinase-9), are evident in chronic wound fluid. This results in an inhibition of fibroblast and endothelial cell
proliferation and function, as well as decreased levels of tissue inhibitors of metalloproteinases. Increased bacterial burden (tissue bacterial levels exceed 100,000 CFU per gram of tissue) and altered
keratinocyte function as well as extracellular matrix degradation have also been implicated in chronic wounds

Question 63

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

1. Strict avoidance of parenteral nutrition (PN)
2. Early initiation of nutrition
3. High protein content in nutrition formula
4. Supplementation of vitamins C and E

Answer 63

2. Early initiation of nutrition

Of the choices, only early initiation of nutrition has been associated with improved outcomes. EN is preferred in patients with TBI because of the general benefits associated with it, but available evidence does not suggest a strong correlation between PN provision and
worsened outcome in TBI (answer A is incorrect). Protein needs are increased after trauma, but provision of high-protein nutrition is not directly correlated with outcomes in TBI (answer C is incorrect). While supplementation of antioxidants is likely beneficial for neurologic recovery after TBI, vitamin replacement has not changed mortality (answer D is incorrect).

Question 64

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

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

Answer 64

2. Mannitol

Propranolol, pentobarbital, and all neuromuscular antagonists have been
shown to reduce energy expenditure after administration (answers A, C, and D are incorrect).
Mannitol does not affect energy expenditure.

Question 65

Metabolic changes following SCIs depend on the level of cord injury and the extent of injuries. Which of the following statements 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 patient with SCI, multiply the resting energy expenditure (calculated with the Harris-Benedict equation) by an injury factor of 1.6 and then again by an activity factor of 1.2.
3. A modified body mass index (BMI) scale has been proposed for individuals with SCI, with
   healthy normal categorized as BMI 18 to 22.
4. Patients with chronic SCI require approximately 30 to 33 kcal/kg/d depending on their physical activity.

Answer 65

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

Energy expenditure following SCI has been repeatedly reported to be almost
48% lower than following TBI. Most patients with SCI will expend 5% to 15% more energy than estimated with the Harris-Benedict equation, and, therefore, Harris-Benedict equation should not be multiplied by extreme injury or activity factors. In the chronic phase, patients with SCI are at risk for obesity and related disorders such as diabetes and cardiovascular disease. Generally, these patients require approximately 20 to 23 kcal/kg/d, depending on their physical activity. A modified proposed BMI scale suggests a normal healthy BMI be 18 to 22.

Question 66

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

1. High doses of folic acid should be administered to reduce the likelihood of a second hemorrhagic stroke.
2. Energy expenditure is higher for patients with SAH than for those with ischemic stroke.
3. Concentrated enteral nutrition (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 patient does not have dysphagia before an oral diet is initiated.

Answer 66

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

The VITATOPS study concluded that daily folic acid and vitamin B6 and B12 supplements did not reduce the recurrence of an ischemic stroke. Recent studies show the SAH is likely more hypermetabolic than the ischemic stroke. Concentrated enteral formulas may be indicated if the patient has a free water or total fluid restriction to minimize cerebral edema. The Joint Commission dropped mandatory dysphagia screening from their core measures as of January 2010, but such screening remains part of many stroke quality programs to ensure that no dysphagia is present prior to advancing an oral diet

Question 67

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

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

Answer 67

2. Mixture of immune stimulation and suppression

Current understanding of systemic inflammatory response has evolved from
interpreting the condition as one of an overstimulated immune system and altered metabolic reaction to infection and trauma to a combination, depending on clinical and individual attributes, of both overstimulation of metabolic and immune responses as well as a compensatory reaction causing immune metabolic suppression. In fact, decreased immunity may predominate, depending on the
source of inflammation, the timing, and the clinical status of the patient.

Question 68

Why is hemodynamic stability an important consideration before initiating enteral nutrition (EN)?

A. To avoid overfeeding.
B. Hemodynamic instability is an indication for parenteral nutrition (PN).
C. Gastrointestinal (GI) perfusion may be compromised.
D. Patients cannot absorb any nutrients when they are underresuscitated.

Answer 68

C. Gastrointestinal (GI) perfusion may be compromised.

GI perfusion is compromised during septic states, particularly in conditions of hemodynamic instability. Feeding into the GI tract may initiate an ischemic event. Once
adequately resuscitated, enteral feeding may help preserve GI perfusion. In any case, EN should be started as early as possible under conditions of hemodynamic stability.

Question 69

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

A. Glycemic control
B. To facilitate permissive underfeeding
C. Cost containment
D. To achieve goal infusions more efficiently

Answer 69

A. Glycemic control

In critical care populations, hyperglycemia is associated with adverse
outcomes, including increased incidence of infections. Conservative energy prescription, including a gradual increase of infusion rates to goal energy requirements, assists in controlling serum glucose.

Question 70

Which of the following is the most important benefit to starting early enteral nutrition (EN) after trauma?

1. Addressing protein-energy malnutrition before it is severe
2. Preventing negative nitrogen balance
3. Modulating the immune process and supporting the gastrointestinal (GI) tract
4. Preventing severe hyperglycemia

Answer 70

3. Modulating the immune process and supporting the gastrointestinal (GI) tract

Negative nitrogen balance frequently occurs despite adequate energy provision because of the counterregulatory hormone and cytokine changes that occur from traumatic insult. Epinephrine, glucagon, and growth hormones are elevated, resulting in increased lipolysis and
increased glycerol and free fatty release. Circulating levels of insulin are elevated in most
metabolically stressed patients, but the responsiveness of tissues, especially skeletal muscle, to insulin is severely blunted. Insulin resistance is believed to be caused by the effects of the counterregulatory hormones and causes hyperglycemia regardless of nutrition provision. The hormonal milieu normalizes only after the injury or metabolic stress has resolved. By providing early EN, the cytokine
storm and counterregulatory hormone secretion are attenuated. As a result, critically ill patients experience fewer infections despite not obtaining protein and energy goals within the first few days of nutrition provision

Question 71

For routine colon surgery, which of the following components of Enhanced Recovery After Surgery (ERAS) protocols contributes to the improved outcomes?

1. Keeping the patient nil per os (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

Answer 71

2. Providing glucose-rich supplementation 6 and 2 hours prior to surgery

The principles of a perioperative plan to improve outcomes in elective colon
surgery have included avoiding starvation, limiting intravenous (IV) fluids, and increasing mobility. Providing a carbohydrate-enhanced drink preoperatively as part of a complex perioperative plan has improved outcomes. Patients consuming 800 mL of a carbohydrate-rich liquid (100 g carbohydrate) at midnight and 400 mL 2 hours before the surgical intervention demonstrate a faster recovery, fewer infectious complications, and no increased aspirations. By providing this fluid and nutritional supplementation without a preoperative bowel prep, patients received less IV fluid, which improved recovery. In addition, a decrease in insulin resistance has been observed and associated with decreased complications and mortality. While oral nutritional supplements and probiotic use both have potential benefits, neither is currently standard in ERAS protocols

Question 72

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

1. Vitamin C supplementation
2. Calcium
3. Protein delivery of 1.5 to 2 g/kg/d
4. Zinc supplementation

Answer 72

2. Calcium

Numerous studies have evaluated nutrients in the critically ill; however, few have focused on burn patients. Vitamin C and zinc have been demonstrated to promote healing in burn patients. Protein delivery to maintain positive nitrogen balance is crucial to burn wound healing.

Question 73

Which of the following are counter-regulatory hormones responsible for the hypercatabolism observed in critically ill trauma patients?

A:Glycogen, insulin, norepinephrine
B:Glucagon, epinephrine, cortisol
C:Glycerol, serotonin, thymoglobulin D:Glycerin, leptin, adenosine

Answer 73

B:Glucagon, epinephrine, cortisol

The inflammation following a traumatic injury provokes a release of systemic catabolic hormones including epinephrine, glucagon, and cortisol. These hormones are responsible for glycogenolysis, gluconeogenesis, proteolysis, and free fatty acid release. The goal of this metabolic response by the patient is to maintain survival and homeostasis, and to promote recovery. Therapeutic intervention is geared toward blunting the inflammatory response without making the patient susceptible to immunosuppression. Timely resuscitation, including restoration of perfusion, oxygenation, and hemodynamic stability, is the top priority. The early initiation of nutrition is an important component of supportive therapy in the care of the trauma patient.

Question 74

Which of the following is the inpatient glycemic target for critically ill patients?

A:80-110 mg/dL
B:140-180 mg/dL
C:181-210 mg/dL
D:211-240 mg/dL

Answer 74

B:140-180 mg/dL

For the critically ill patient, blood glucose levels should be maintained between 140-180mg/dL. Lower glucose targets may be appropriate for selected patients, but targets <110mg/dL are not recommended.

Question 75

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

1. Traumatic brain injury (TBI)
2. ARDS
3. Pulmonary embolism (PE)
4. Septic shock secondary to bacterial pneumonia

Answer 75

2. ARDS

Restricted fluid intake has decreased the number of days that patients with ARDS require mechanical ventilation and decreased the overall number of days in intensive care unit (ICU) for patients with ARDS. However, fluid restriction did not improve mortality for patients with
ARDS. Evidence-based treatment for ARDS includes permissive hypercapnia as necessary to reduce the lung barotrauma, fluid restriction, early paralytics, and prone positioning. Fluid restriction has not been shown to make a clinically significant difference in patients with TBI or PE. Fluids should not be restricted in patients with septic shock; instead, these patients should be given aggressive fluid resuscitation.

Question 76

Which of the following does not help reduce VAP?

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

Answer 76

2. Gastric ulcer prophylaxis and early PN

VAP is a preventable disease in the ICU. Strategies to prevent or reduce the incidence of VAP include limiting mechanical ventilator time, sedation, and minimizing aspiration risk. Components of VAP “bundles” are typically implemented in the ICU setting and include elevating the head of the bed, early mobilization, minimal sedation, limiting mechanical ventilator time, and minimizing pooling of oral secretions. Early PN and gastric ulcer prophylaxis do not seem to decrease incidence of VAP

Question 77

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

1. Phosphorus
2. Calcium
3. Glutamine
4. Magnesium

Answer 77

3. Glutamine

Initial studies showed promising results regarding enteral glutamine
supplementation and reduced mortality, but REDOX, a large randomized controlled trial (RCT), indicated that glutamine may potentially harm patients with pulmonary failure. The most recent guidelines (2016) from the Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (ASPEN) do not recommend the use of glutamine supplementation in general critical care patients. Electrolytes should be monitored and replaced as necessary to maintain normal serum levels