Module 3B - Enteral Nutrition Administration, Monitoring, and Clinical Issues (V.6)

Question 1

Which of the following interventions has NOT been proven effective in reducing the risk of aspiration associated with enteral tube feeding in adult patients?
A. Oral care twice a day
B. Motility agents for patients demonstrating intolerance to feeds
C. Post-pyloric tube placement for patients with high risk of aspiration
D. Check of gastric residuals every shift

Answer 1

D. Check of gastric residuals every shift

Research indicates that one key to preventing aspiration in all patients (including those fed enterally) is good oral hygiene, such as brushing teeth and rinsing with mouthwash daily. The ASPEN/SCCM guidelines state “We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastric EN.” Maintaining the head of bed at 30 - 45 degree elevation is desired to reduce the risk of aspiration.

Question 2

During times of tube feeding pump shortages, which of the following patients should be prioritized to receive a pump?
A. A critically ill patient with a nasojejunal tube
B. A patient receiving nocturnal feeding via a gastrostomy tube
C. A patient receiving tube feeding due to severe dysphagia
D. A patient who receives tube feeding at home

Answer 2

A. A critically ill patient with a nasojejunal tube

During times of shortages, tube feeding pumps should first be allocated to patients receiving small bowel tube feeding or who have demonstrated intolerance to gravity or bolus feeding. A critically ill patient with a nasojejunal tube should not receive gravity or bolus feeding, as these approaches may increase the risk of intolerance. A patient receiving nocturnal tube feeding via a gastrostomy should first trial gravity feeding. Although a patient with severe dysphagia is at higher risk for aspiration, a slow gravity feeding or conservative bolus regimen would be appropriate to try. Finally, a patient who receives tube feeding at home does not have a specific indication for a feeding pump; more information is needed regarding this patient’s typical feeding regimen.

Question 3

Which of the following is true regarding infectious complications associated with enteral feedings?
A. Bacterial contamination may originate from the patient’s throat, lung, and stomach
B. Exceeding manufacturer hang-time guidelines is not a risk for bacterial contamination
C. Open systems have less exogenous bacterial contamination
D. The enteral tube site should be routinely cultured

Answer 3

A. Bacterial contamination may originate from the patient’s throat, lung, and stomach

Bacterial contamination may occur both exogenously through the feeding equipment and endogenously through retrograde contamination of the feeding apparatus from the patient’s own infected secretions. There is a correlation between prolonged length of enteral product hang time and bacterial contamination. Open systems provide more opportunity for contamination due to nursing manipulation when adding more formula to the bag. There is no need for routine cultures in the uncomplicated enterally-fed patient.

Question 4

Which type of insulin should be used when initiating enteral nutrition in a hospitalized diabetic patient?
A. Premixed NPH/Regular insulin
B. Regular Insulin
C. NPH Insulin
D. Insulin glargine

Answer 4

B. Regular Insulin

Regular insulin (short acting) may minimize the incidence of hypoglycemia when initiating enteral nutrition as tolerance and titration of enteral delivery may be unpredictable. Longer acting insulins such as intermediate acting (premixed NPH/regular insulin, NPH insulin) and long acting (insulin glargine) could increase the incidence of hypoglycemia due to longer duration of action in the setting of feeding discontinuation or reduction. Once enteral nutrition administration is stable, use of a basal/bolus insulin regimen is recommended to achieve safe, effective glucose control.

Question 5

Which is considered appropriate management of hypergranulation around the PEG site?
A. Keeping the area dry
B. Using a tube stabilizing device
C. Applying an occlusive dressing
D. Cauterization with silver nitrate

Answer 5

D. Cauterization with silver nitrate

Granulation tissue often forms within the tract and may grow out onto the surface of the skin around the PEG tube. Although this does not usually cause excessive exudate and drainage, it is a source of moisture underneath the bolster, which can lead to breakdown of the skin. The hypergranulation tissue may be trimmed with scissors and then treated with silver nitrate sticks or any other cautery device. Topical steroid cream may also be considered as a treatment method.

Question 6

Which of the following is important for an elderly patient who is receiving a high protein enteral formula?
A. Checking weekly weights
B. Providing goal volume of formula each day
C. Providing adequate free water each day
D. Ensuring adequate bowel movements

Answer 6

C. Providing adequate free water each day

Tube feeding syndrome is related to the use of high-protein tube feedings without adequate fluid provision. Inadequate fluid delivery results in an inability to sufficiently excrete the solute load which can lead to the development of azotemia, hypernatremia, and dehydration. Prevention and treatment requires the provisions of adequate fluid (30-40ml/kg/day meets fluid requirements for the average adult). A reduction in protein may be necessary if the ability to excrete byproducts of protein metabolism during adequate fluid provision is compromised.

Question 7

Which of the following best describes the addition of blue dye to enteral feedings?
A. It prevents aspiration of enteral formula
B. Its use in detection of aspiration is highly sensitive
C. It should be added only in small amounts
D. It is no longer recommended for the detection of aspiration of enteral formula

Answer 7

D. It is no longer recommended for the detection of aspiration of enteral formula

The addition of blue dye to enteral feedings was common practice in the past to help detect aspiration of formula. The use of blue dye in detecting aspiration of formula has a low sensitivity. Several cases of systemic toxicity, some resulting in death, have been reported. As a result the U.S. Food and Drug Administration removed FD&C Blue #1 from the market in 2003. Other blue dyes such as methylene blue and FD&C Blue #2 may have similar or greater toxicity than Blue #1 and are not suitable alternatives.

Question 8

Which of the following is a benefit of closed enteral feeding systems?
A. Decreased risk for microbial contamination
B. Maximum hang time of 8-12 hours
C. Packaging amenable to addition of medication or modular
D. Decreased incidence of gastric intolerance

Answer 8

A. Decreased risk for microbial contamination

Closed enteral feeding system containers are purchased as bags or rigid containers filled with sterile enteral nutrition formula. Minimum manipulation is possible secondary to the design of the containers helping decrease the risk of microbial contamination. Closed system enteral feeding systems have longer hang time (24-48 hours) and requires decreased nursing time for administration.

Question 9

A patient with short bowel and an end-jejunostomy requires the use of an oral rehydration solution (ORS) to help prevent dehydration. Which best describes the preferred composition of the ORS?
A. An iso-osmolar solution such as diluted juice with added sodium
B. A hyper-osmolar solution such as fruit juice or Kool-aid
C. A hypo-osmolar solution such as water
D. A hyper-osmolar solution such as commercially available sports drink

Answer 9

A. An iso-osmolar solution such as diluted juice with added sodium

Use of oral rehydration solutions (ORS) may help to prevent dehydration in patients with short bowel syndrome (SBS) and an End-jejunostomy. Glucose is an important component in ORS as it promotes salt and water absorption. The optimal sodium concentration of ORS to promote jejunal absorption is in the range of 90-120 mEq/L. Hyper- or hypo-tonic solutions are not well absorbed and may increase osmotic diarrhea in patients with SBS. Commercial sports drinks are considerably lower in sodium and higher in carbohydrate content than ORS.

Question 10

Which enteral feeding method provides 240mL of formula via a syringe over as few as 4-10 minutes, three to six feedings daily?
A. Intermittent feeding
B. Cyclic feeding
C. Bolus feeding
D. Continuous feeding

Answer 10

C. Bolus feeding

Bolus feedings provide a set volume of formula at specified time intervals. Feedings are infused over a short period of time, over as few as 4-10 minutes, three to six feedings daily. Intermittent feedings are commonly delivered by enteral pump or gravity drip method over a period of 20-60 minutes, four to six feedings daily. Bolus and intermittent feedings may mimic normal meal times, provide additional flexibility, and be administered at home. Continuous feedings deliver formula via a pump-assisted continuous drip infusion. This is the preferred method for critically ill or mechanically ventilated patients. Cyclic feedings are similar to continuous feedings except the formula delivery rate ranges from 8 hours to < 24 hours. This type of feeding may be used to transition a patient from continuous feedings, or to increase the patient’s volitional intake.

Question 11

Which of the following enteral feeding schedules would be most appropriate for a critically ill patient with poorly controlled blood glucose?
A. Bolus
B. Continuous
C. Gravity drip
D. Nocturnal infusion

Answer 11

B. Continuous

Continuous infusions of enteral feeding and insulin may facilitate more steady and predictable blood glucose concentrations in critically ill patients. Intermittent, cyclic, or bolus feeding schedules may cause fluctuations in blood glucose concentrations, placing patients at risk for hypoglycemic and hyperglycemic complications.

Question 12

You receive a consult for a patient on EN with abdominal distention, nausea, and vomiting. Monitoring of gastric residual volume (GRV) has been ordered as part of the treatment plan. What intervention can be utilized to prevent feeding tube occlusion associated with GRV assessment in the adult patient?
A. Feeding tube should be flushed with 30mL of water following GRV assessment
B. Place the patient in reverse Trendelenberg position prior to GRV assessment
C. Hold enteral feedings one hour prior to GRV assessment
D. Instill 60 mL of air into the tube prior to GRV assessment

Answer 12

A. Feeding tube should be flushed with 30mL of water following GRV assessment

The Society of Critical Care Medicine (SCCM)/ASPEN 2016 guidelines suggest that GRV should not be used as part of routine care to monitor EN. Gastric tubes are reported to clog more frequently than small bowel tubes secondary to intact protein formulas coming in contact with acidic gastric fluid. Flushing feeding tubes with 30 mL of free water following GRV measurement in adult patients is recommended to prevent tube occlusion associated with GRV measurement. The reverse Trendelenberg position is used when elevated backrest is contraindicated to elevate HOB (head of bed). The instilling of air into gastric feeding tubes is useful for increasing negative pressure when drawing GRV from small bore feeding tubes.

Question 13

The initiation of enteral nutrition (EN) tube feeding should be delayed when the patient is
A. hemodynamically unstable.
B. at a decreased level of consciousness.
C. without bowel sounds.
D. at risk for refeeding syndrome.

Answer 13

A. hemodynamically unstable.

EN initiation should be delayed until the patient is fully volume resuscitated and hemodynamically stable to reduce the risk of intestinal ischemia. Evidence of bowel function, including bowel sounds or bowel movements, is not required prior to the initiation of EN. Patients at risk for developing refeeding syndrome should be identified prior to initiation of nutrition support, but the risk of refeeding should not delay EN initiation. A patient thought to be at refeeding risk should be cautiously advanced toward the energy goal as dictated by clinical status and/or stable electrolyte levels. EN should not be delayed with reduced level of consciousness, but post pyloric enteral access is recommended to decrease the risk of aspiration since this patient population is at increased risk of aspiration.

Question 14

Constipation in the enterally fed patient may be associated with all of the following EXCEPT
A. rapid or bolus infusion.
B. obstruction.
C. lack of adequate hydration.
D. prolonged bed rest.

Answer 14

A. rapid or bolus infusion.

Constipation is a gastrointestinal complication associated with enteral nutrition and may be caused by lack of adequate hydration, long-term fiber-free feedings, prolonged bedrest, impaction, obstruction and narcotics.

Question 15

A patient requiring critical care is receiving tube feeding which seem to be tolerated without gastric distension or emesis. Gastric residual volumes (GRV) are 265 mL, 250 mL, and 330 mL. What is the most appropriate recommendation?
A. Consider adding a promotility agent
B. Change to a lower fat formula
C. Continue infusing tube feeding as ordered
D. Use a smaller bore feeding tube

Answer 15

C. Continue infusing tube feeding as ordered

The significance of GRV is controversial due to the lack of well-powered studies. Because of this, the relationship of GRV and aspiration pneumonia can’t be clarified. The measurement of GRV can be affected by the type of feeding tube, body position, and the location of the tip of the feeding tube. Checking gastric residuals as part of routine care in ICU patients is not recommended. If a patient is showing outward signs of intolerance gastric residuals can be measured. Enteral nutrition should not be held for GRV less than 500 ml.

Question 16

A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue enteral feeding. Which of the following is true regarding the dying patient?
A. Intravenous hydration should be used to reduce symptoms of nausea, vomiting, diarrhea and respiratory distress
B. Dehydration, starvation, and ketosis produces a euphoric state that enhances the perception of hunger
C. The most common symptom when nutrition and hydration are withheld is dry mouth
D. Electrolyte imbalance should be expected and may produce a degree of analgesia

Answer 16

C. The most common symptom when nutrition and hydration are withheld is dry mouth

Enteral feeding and hydration do not always ensure comfort. During starvation, the body begins to use fat as the predominant energy source leading to increased ketone production with a resulting euphoria. Feeding even small amounts can prevent ketonemia and prolong the sense of hunger. The most common symptom when feeding or fluids are witheld is dry mouth, which is easily alleviated with good mouth care. Intravenous hydration in the terminal patient can raise the risk of patient discomfort and respiratory distress.

Question 17

Which of the following is NOT an established risk factor for aspiration in critically ill patients?
A. Gastric residual volume <150 mL
B. Decreased level of consciousness
C. Age > 70 years
D. Gastroesophageal reflux disease

Answer 17

A. Gastric residual volume <150 mL

An association between gastric residual volume amounts and aspiration remains a controversial topic. Decreased level of consciousness is a major risk factor for aspiration. Other risk factors include neurologic defect, delayed gastric emptying, gastroesophageal reflux disease, supine position, vomiting, bolus enteral feedings, mechanical ventilation, age > 70 years, and poor oral care.

Question 18

When transitioning from enteral to oral feeding, tube feeding may be discontinued when adequacy of oral intake meets at least
A. 33% of nutrient needs.
B. 50% of nutrient needs.
C. 66% of nutrient needs.
D. 90% of nutrient needs.

Answer 18

C. 66% of nutrient needs.

While there are no clinically proven points at which tube feeding should be discontinued with adequacy of oral intake, a general guideline is that oral intake should meet at least two-thirds to three-quarters of nutrient needs.

Question 19

Which of the following types of feeding delivery methods is most appropriate for patients with a jejunostomy?
A. Bolus
B. Gravity
C. Intermittent
D. Continuous pump

Answer 19

D. Continuous pump

Jejunal feeding is usually delivered continuously via pump. Bolus or gravity feeding via jejunostomy may cause intolerance such as abdominal bloating, diarrhea. Gastric feeding can be given as bolus or intermittent gravity methods since the stomach can hold larger amounts.

Question 20

Which of the following is the most likely cause of watery diarrhea and bloating in the enterally fed adult patient?
A. lactose content of the enteral formula.
B. sorbitol content of liquid medications
C. sorbitol content of the enteral formula
D. lactose content of liquid medications

Answer 20

B. sorbitol content of liquid medications

Although lactose intolerance is known to result in watery diarrhea and bloating, the vast majority of adult enteral products are lactose free. The lactose content of most individual dosage forms of medication is too small to result in significant problems. Sorbitol is not an ingredient of enteral products however the cumulative daily dose of sorbitol from liquid medications can easily equal purgative dosages. As little as 10 to 20 g of sorbitol can lead to GI side effects, including diarrhea.

Question 21

Which of the following tubes requires immediate replacement if it becomes dislodged?
A. Jejunostomy tube
B. Nasogastric tube
C. Nasojejunal tube
D. Nasoduodenal tube

Answer 21

A. Jejunostomy tube

It should be a priority to replace any feeding tube that becomes dislodged so that the patient can continue to receive nutrition support. However, the jejunostomy tube requires immediate replacement since the tract for the jejunostomy tube can close quickly. Replacement of a jejunostomy tube requires radiographic verification with contrast medium. The first replacement of a gastrostomy or percutaneous endoscopic gastrostomy tube should be performed by the physician who inserted the tube. After that, it is appropriate for trained nurses to replace these tubes. A nasogastric or nasoduodenal tube can be replaced by a physician, physician assistant, nurse practitioner, or appropriately trained healthcare provider.

Question 22

An enterally fed patient reports nausea and vomiting. If delayed gastric emptying is suspected as the causative factor, which of the following is LEAST likely to improve the patient’s symptoms?
A. Reduce or discontinue narcotic medications
B. Switch to a low fat enteral formula
C. Reduce the rate of enteral nutrition infusion
D. Use a more concentrated enteral formula

Answer 22

D. Use a more concentrated enteral formula

Although the etiology of nausea and vomiting is multifactorial, delayed gastric emptying is a common source of tube feeding intolerance. Reduction or discontinuation of narcotic meds, use of low fat formulas, administering enteral formula at room temperature and reducing the rate and/or volume of tube feeding infusion may all improve gastric emptying and reduce the symptoms of nausea and vomiting. Concentrated enteral solutions generally contain more fat and can further contribute to enteral intolerance by presenting a higher osmotic load to the GI tract.

Question 23

Which of the following is a best practice recommendation in enteral nutrition (EN) formula safety?
A. Mix or reconstitute enteral formulations at the bedside
B. Change the enteral feeding administration set every 24 hours with open systems
C. Limit hang time of closed-system EN formulas to no more than 12 hours
D. Store powdered formulas reconstituted in advance at room temperature for up to 24 hours

Answer 23

B. Change the enteral feeding administration set every 24 hours with open systems

When possible, enteral formulas should be mixed, reconstituted, or diluted in a sterile centralized location, such as an enteral formulary room or pharmacy, to minimize risk of contamination. The feeding administration set should be changed every 24 hours and disposable feeding administration sets should not be reused. Exceptions include administration sets for human breast milk (change every 4 hours) and closed enteral feeding systems (per manufacturer recommendations). Only an 8 to 12-hour supply of formula should be poured into an open administration set. Hang time of canned, ready-to-use formulas should be no longer than 12 hours. Closed-system EN formulas can be safely used for 24-48 hours after opening, depending on manufacturer’s guidelines. Powdered formulas reconstituted in advance should be refrigerated immediately after preparation and discarded within 24 hours of preparation if not used; they should also be exposed to room temperature for no longer than 4 hours. Use of purified water in formula reconstitution minimizes the potential of tap water as a source of contamination. Adding fresh formula to formula already hanging in the administration set should be avoided. To avoid contamination, hands should be washed thoroughly and gloved before touching any component of the tube feeding system and formula should be transferred without touching the component of the feeding set that comes in contact with the formula.

Question 24

Which of the following individuals would most benefit from cyclic nocturnal tube feeding?
A. A patient recovering from a cerebrovascular accident (CVA) who has initiated intensive rehab
B. A septic patient in the ICU who is hemodynamically unstable
C. A critically ill patient with diabetes who has labile blood glucose levels
D. A post-operative bowel surgery patient who has an ileus

Answer 24

A. A patient recovering from a cerebrovascular accident (CVA) who has initiated intensive rehab

Cyclic feedings are generally administered over 8 to 20 hours. Nocturnal feedings are frequently used to supplement oral intake and promote unobstructed activity during the day. A patient recovering from a CVA, who is beginning a rigorous therapy program can benefit from the use of cyclic nocturnal feeding to promote activity during the day. Patients who are hemodynamically unstable should not receive tube feeding until they are fully resuscitated. Critically ill patients with labile blood glucose levels are more likely to require continuous feeding to prevent episodes of extreme hypo- or hyperglycemia. The post-op patient with an ileus may require parenteral nutrition depending upon the length of time without enteral support.

Question 25

What is the optimal sodium concentration of an oral rehydration solution for patients with short bowel syndrome? A. 54 - 80 mEq/ L B. 90 - 120 mEq/L C. 134 - 160 mEq/L D. 170 - 190 mEq/L

Answer 25

B. 90 - 120 mEq/L ## Footnote The ideal sodium concentration for oral rehydration solutions depends on the segment of bowel lost, e.g., jejunum, ileum, or colon. Patients with short bowel syndrome who do not have a colon often require slightly hypoosmotic or isotonic oral rehydration solution to promote maximal fluid absorption and reduce secretion. In contrast, most patients with a colon can maintain adequate hydration without excessive fluid losses by utilizing hypotonic fluids. The optimal sodium concentration of oral rehydration solutions ranges from 90 - 120 mEq/L to promote jejunal absorption.

Question 26

Which of the following is a primary cause of oozing stools in a tube fed patient? A. Fecal impaction B. Fluid restriction C. Physical inactivity D. Narcotic usage

Answer 26

A. Fecal impaction ## Footnote Impaction can be manifested by symptoms of diarrhea. Passage or secretion of fluid around the impaction may be responsible for the loose stool. The patient may intermittently pass small volumes of liquid stool and experience abdominal distention and cramping. Fluid restriction, physical inactivity and narcotic usage lead to constipation.

Question 27

Which of the following should always appear on the label of an enteral feeding product given to a patient in the hospital? A. Product name, rate, volume, additives, caloric density, date and time the formula was prepared and hung B. Patient identification, product name, administration method, route, access device, date and time the formula was prepared and hung C. Patient's name, product name, rate, strength, osmolality, date and time the formula was prepared and hung D. Patient's name, room number, strength, additives, volume, date and time the formula was prepared and hung

Answer 27

B. Patient identification, product name, administration method, route, access device, date and time the formula was prepared and hung ## Footnote The EN formula label should reflect the elements of the EN order form and therefore contain the following: patient identifiers, product name, enteral access delivery site, administration method, and time/date the formula was prepared and hung. The importance of providing this information ensures the patient is receiving the formula ordered and that the infusing formula is not expired or exceeding the recommended hang time.

Question 28

Which of the following patients is at lowest risk of small bore feeding tube misplacement into the respiratory system? A. A patient status post stroke on the inpatient medical unit B. A patient who is alert and cooperative C. A patient with head and neck trauma admitted to the ICU D. A patient status post Roux-en-Y gastric bypass

Answer 28

B. A patient who is alert and cooperative ## Footnote The selection of enteral access device depends on the patient's disease state, anatomy, and expected duration of therapy. An oral or nasoenteric small bore feeding tube is usually indicated when duration of EN therapy is anticipated to be less than 4 weeks. Passage of a feeding tube may be facilitated by concurrent patient swallowing thus decreasing the risk of feeding tube placement into the respiratory system. The procedure is difficult in uncooperative patients, patients with anatomic abnormalities, and in critically ill patients in which swallowing is inhibited.

Question 29

What is the maximum hang time for human breast milk (HBM)? A. 4 hours B. 8 hours C. 12 hours D. 24 hours

Answer 29

A. 4 hours ## Footnote Human breast milk (HBM) should have a hang time of no longer than 4 hours. In addition, the tubing and syringe should be changed every 4 hours. Administration sets used for HBM should be di(2-ethylhexyl) phthalate (DEHP) free and bisphenol A (BPA) free. HBM for hospitalized neonates, infants, and children should be prepared in a clean environment using aseptic technique by specially trained personnel. Current recommendations also support the use of gloves during HBM administration.

Question 30

A home enteral nutrition patient recently treated for pneumonia is noted to have new onset diarrhea. Of the following, the first intervention should be to A. change to an elemental feeding. B. obtain an order for a bile-sequestering agent. C. obtain a Clostridium difficile toxin stool assay. D. obtain an order for an antidiarrheal medication.

Answer 30

C. obtain a Clostridium difficile toxin stool assay. ## Footnote There are many causes of diarrhea in the tube fed patient including the patient's underlying medical condition, tube feeding intolerance, medication effects, and infectious causes including bacterial contamination of enteral tube feeding formula or equipment and Clostridium difficile. Clostridium difficile should be ruled out in any patient recently receiving antibiotic therapy. This should be done prior to ordering antidiarrheal medication since antidiarrheal medications are not indicated in those with Clostridium difficile. There is no need to change to an elemental formula if there are no other indications for an elemental diet.

Question 31

In critically ill patients receiving early enteral nutrition (EN), which is most likely to improve nutrient delivery? A. Use of small bowel feeding B. Use of a standard EN feeding protocol C. Use of gastric feeding D. Use of a volume-based EN feeding protocol

Answer 31

D. Use of a volume-based EN feeding protocol ## Footnote Volume-based EN feeding protocols prescribe EN in terms of the goal per day vs. goal per hour. The use of such protocols, including FEED ME (FeedEarly Enteral Diet Adequately for Maximum Effect? And PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) have been found to significantly improve delivery of nutrients. Standard EN protocols begin full strength feeds at an hourly rate and advance to goal within 24 to 48 hours. While small bowel feeding is superior to gastric feeding in terms of nutrient delivery, it can be interrupted during the day and is therefore likely not as effective as volume-based protocols.

Question 32

Which of the following is the first line method to restore patency to clogged enteral access devices (EADs)? A. Water B. Cranberry juice C. Mechanical declogging device D. Pancreatic enzyme solution

Answer 32

A. Water ## Footnote The use of cranberry juice and carbonated beverages may worsen occlusions because of the acidic pH of these fluids. Acid can cause proteins in enteral formulae to precipitate within the tube, making the clog worse or leading to more clogging later on. If water does not work, a pancreatic enzyme solution, an enzymatic declogging kit, or mechanical devices for clearing feeding tubes are second-line options. Water is the fluid of choice.

Question 33

Which of the following is most likely to improve tolerance of enteral feeding in a postoperative patient with documented high gastric residual volume (GRV) receiving bolus tube feedings? A. Provide intermittent feeding B. Provide continuous enteral feeding C. Initiate levofloxacin to aid with motility D. Invert the patient to a prone position

Answer 33

B. Provide continuous enteral feeding ## Footnote Recovery of gastric emptying may be slower than return of small bowel motility in postoperative patients. Small bowel feeding may increase the amount of feeding delivered in patients with high GRVs. Continuous feeding is the preferred method as bolus and gravity feeding are poorly tolerated in the small bowel. Holding of feedings should be avoided when possible to optimize meeting calorie and protein needs. Prone positioning in a patient with elevated GRVs may increase the risk of aspiration. Prokinetic agents such as metoclopramide and erythromycin are used to increase motility and may be of benefit in this situation. Levofloxacin is an antibiotic and does not help with GI motility.

Question 34

A patient suffered from a stroke two weeks ago and has significant dysphagia. An isotonic enteral formula has been infusing continuously at goal rate for two days along with an ordered 30 mL water flush per hour. The patient begins to complain of bloating and is mildly distended (to 4 cm from baseline) upon examination. He denies nausea, abdominal cramping or abdominal pain. His last 2 gastric residual volume checks were measured at 100mLs. Which of the following interventions would be the best initial strategy to reduce his unpleasant symptoms? A. Determine last bowel movement and initiate a bowel regimen if constipation suspected B. Hold enteral nutrition C. Initiate a pain reliever D. Switch to a semi-elemental formula

Answer 34

A. Determine last bowel movement and initiate a bowel regimen if constipation suspected ## Footnote Abdominal distention while receiving enteral nutrition may result from many different reasons: rapid administration of feeding (i.e. bolus feeds); use of hyperosmolar solution (i.e. concentrated formulas); medications that slow peristalsis (i.e. pain relievers, anticholinergics); excess air in the stomach or intestines; tube migration from stomach to small intestine; infection; cold formula; inadequate fluid provision leading to constipation; bacterial contamination; and, fat, fiber or lactose intolerance. Aggressive bowel regimens need to be considered in these patients to reduce distention and prevent impaction. Holding enteral feedings is generally not indicated unless abdominal girth exceeds the baseline measurement by at least 8 to 10 cm. Agents such as narcotics or diphenhydramine have well documented anticholinergic effects often resulting in constipation. Fiber may help to promote regular bowel movements in patients receiving enteral nutrition, but may also lead to excess gas production and increased abdominal distention. Providing additional free water flushes may help to decrease constipation.

Question 35

A patient was cleared to eat orally by the speech language pathologist; however the diet is still restrictive in nature. To ensure the patient meets their nutritional requirements, tube feeding is required during the night at a rate of 75 mL per hour over 10 hours. The night feeding is an example of A. bolus feeding. B. intermittent feeding. C. cyclic feeding. D. continuous feeding.

Answer 35

C. cyclic feeding. ## Footnote Cyclic feeding provides tube feeds via pump in less than a 24-hour time period. They are generally administered over 8-20 hours per day, depending on the patient's tolerance. Cyclic feedings during the night are frequently used as patients are transitioning from enteral feeds to oral intake. Time off of tube feeding during the day often increases appetite.

Question 36

Which of the following tube feeding orders best reflects the use of an intermittent schedule? A. 240 mL administered over 45 minutes, five times per day B. 50 mL/hr over 24 hours C. 100 mL/hr over 12 hours D. 240 to 480 mL administered over 15 minutes every eight hours

Answer 36

A. 240 mL administered over 45 minutes, five times per day ## Footnote Intermittent feedings are generally an amount of 240 to 720 mL administered over 20 to 60 minutes several times daily with or without a feeding pump, whereas continuous feedings are delivered at a prescribed rate without interruption. Cyclic feedings are generally administered over 8 to 16 hours per day, depending on the patient's volume tolerance. Bolus feedings are generally an amount of 240 to 480 mL delivered by gravity or a syringe over 15 minutes into the stomach.

Question 37

One method of minimizing the complications associated with refeeding syndrome is to initiate an electrolyte replacement protocol before nutrition therapy begins. Which of the following is true regarding such a plan? A. Potassium, magnesium, and calcium are the most important electrolytes to closely monitor B. Patients considered not at risk should also be included in the protocol C. The protocol should replete all electrolytes only via the feeding tube D. Feeding should be delayed until the risk of electrolyte imbalance is eliminated

Answer 37

B. Patients considered not at risk should also be included in the protocol ## Footnote Refeeding syndrome describes the occurrence of electrolyte disturbances when attempting to initially feed the undernourished patient. Although hypokalemia, hypomagnesemia, and hypocalcemia may occur in refeeding syndrome, hypophosphatemia is more prevalent. Patients considered not at risk should also be included since methods for screening at risk are inadequate. The protocol should replete all electrolytes via the intravenous, oral or enteral route depending on the condition of the patient and ability to tolerate oral repletion. Feeding should not be delayed but instead initiated slowly and then advanced based on electrolyte levels and clinical response.

Question 38

In a patient with a newly placed gastrostomy or jejunostomy tube, observation of which of the following conditions at the tube exit site would signal concern for infection? A. Serosanguineous drainage B. Foul-smelling drainage C. Coffee-ground drainage D. Bile-colored drainage

Answer 38

B. Foul-smelling drainage ## Footnote Peristomal infection is the most common complication following gastrostomy placement. Foul-smelling drainage around the tube exit site is a sign of infection. Early recognition and treatment of exit site infections reduces morbidity and mortality. Leakage around the gastrostomy site is another common complication. Exit site care, proper outer bumper placement and prevention of tension on the tube help reduce gastrostomy exit site leakage.

Question 39

Most enteral formulas designed for oral consumption are composed primarily of A. carbohydrates. B. protein. C. fat. D. vitamins.

Answer 39

A. carbohydrates. ## Footnote Generally, enteral products designed for oral use contain more sucrose to improve palatability. This translates into a higher carbohydrate to protein and fat ratio. Most enteral products for oral use provide approximately 40% to 60% of total calories from carbohydrate, 15% to 25% from protein, and 15% to 35% from fat. The Daily Reference Intakes (DRIs) for vitamins and minerals may be met by ingesting a portion of oral supplements daily. A blend of soluble and insoluble fibers are also typically found in the oral formulas.

Question 40

When administering multiple medications via enteral feeding tubes, medications should be A. administered separately, followed by a 15-30 ml water flush. B. mixed together in a 30 mL slurry and administered together. C. delivered in liquid form without water flushes. D. mixed directly into the feeding formulations for administration.

Answer 40

A. administered separately, followed by a 15-30 ml water flush. ## Footnote Once an enteral feeding tube is placed, conversion of intravenous medications to the enteral route may be undertaken. Many factors dictate whether it is appropriate to administer medications enterally and include: tube size, tube tip location, and site of medication absorption. Each medication should be given separately flushing with at least 15-30 mL of water prior to, between, and after administration. There is a potential for drug-drug interaction if two or more drugs are crushed and/or diluted together. Medications should not be mixed into the feeding formulation or given through the tube without proper flushing in order to avoid tube obstruction and drug-nutrient interactions. Enteric-coated, controlled-release, and sustained release medications should not be crushed and given through feeding tube.

Question 41

Which is a benefit of using an electromagnetic placement device for nasogastric tube placement? A. pH can be monitored B. Checks the tip position relative to the pylorus C. Provides a 3-dimensional localization D. Shows a time-delayed perspective of the tube tip location

Answer 41

C. Provides a 3-dimensional localization ## Footnote The display shows a real-time perspective of the tube tip location with a 3-dimensional localization. pH is not monitored in this placement technique. The receiver is placed on the patient at the xiphoid process, therefore the magnet follows the tip placement relative to the lower esophageal sphincter, not the pylorus.

Question 42

When initiating and advancing enteral feedings in the hospitalized patient, which of the following is most appropriate? A. 1/2 strength formula at 25 mL/hr, advance to goal rate at full strength over 5-7 days B. 240 mL bolus feedings of full strength hypertonic formulas every 4 hours C. full strength formula at 10-40 mL/hr and advance to goal rate within 1 -2 days D. 1/4 strength formula at goal rate. Advance to full strength over 3-5 days

Answer 42

C. full strength formula at 10-40 mL/hr and advance to goal rate within 1 -2 days ## Footnote Currently it is recommended that tube feedings in adults and children be initiated with full strength formulas at a slow rate and steadily advanced. This approach allows goal rates to be achieved earlier and reduces the risk for microbial contamination by minimizing the number of times the formulas is manipulated. This regimen has been noted to be well tolerated.

Question 43

A patient with oral cancer, who has gained 10 pounds since starting home bolus enteral feedings via gastrostomy tube complains of pain and pressure on the " inside of his stomach" but no redness or drainage at the exterior gastrostomy site. Which of the following is the most appropriate response for the clinician? A. Tell the patient to take over the counter pain medication and rotate the G tube 180 degrees each day. B. Refer the patient to the gastroenterologist or enterostomal nurse. C. Decrease the infusion volume of the formula in half to avoid excessive distention of the stomach. D. Change to a slower tube feed infusion by using a gravity bag for feedings.

Answer 43

B. Refer the patient to the gastroenterologist or enterostomal nurse. ## Footnote Tube complications can be serious if not managed in a timely manner. Any new occurrence of pain at or near the tube site should be promptly evaluated by the patient's gastroenterologist or enterostomal nurse. Buried bumper syndrome results from erosion of the internal bolster into the gastric mucosa and/or wall and occurs in 0.3%–2.4% of patients. Excessive traction on the internal bolster slowly pulls it into the gastric wall as the mucosa grows over it. Pain may indicate the presence of infection or pressure necrosis. Weight gain after tube placement places a patient at greater risk for pressure necrosis and ulceration at the tube site due to increase in abdominal girth.

Question 44

Which formula is most likely to cause an occluded feeding tube? A. Low fat formula B. High fiber formula C. Peptide based formula D. Elemental formula

Answer 44

B. High fiber formula ## Footnote The viscosity of an enteral formula depends on the concentration and characteristics of the macronutrients and fiber. An increase in the accumulation of formula sediment in the inner lumen of the enteral access device (EAD) is seen more often when a high fiber or high protein formula is used.