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CNSC exam > Previous Exam Questions > Flashcards

Previous Exam Questions Flashcards

1
Q

Intracellular ion?

A

Potassium

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2
Q

Extracellular Ion?

A

Sodium (Na)

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3
Q

Osmolarity of dextrose?

A

1g =5 mOsm

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4
Q

Osmolarity of Amino Acids?

A

1g = 10 mOsm

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5
Q

What decreases the GRADE of research articles?

A

Score may be decreased because of problem with Bias, constistency, precision, directness

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6
Q

GRADE I

A

Large randomized trials with clear cut results; low risk of false positive and or false negative error

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7
Q

GRADE II

A

Small randomized trials with uncertain results; moderate risk of false-positive and/or false negative error

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8
Q

Grade III

A

Nonrandomized cohort with contemporaneous controls

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9
Q

Level IV

A

nonrandomized cohort with historical controls

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10
Q

Level V

A

Case series, uncontrolled studies, and expert opinion

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11
Q

Types of research

A

Retrospective, Descriptive, Qualitative, Experimental

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12
Q

Retrosepective research

A

uses information already collected

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13
Q

Descriptive Research

A

analysis of data to make a hypothesis

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14
Q

Qualitative Research

A

Obtaining data through open ended and conversational communication

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15
Q

Experimental Research

A

uses scientific method to determine cause/effect

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16
Q

Insulin Dosing

A

Regular insulin is the only type of insulin added to the TPN bag, Only addd 60-80% of IV insulin needs to PN. If patient is not in the ICU, start with 0.1 unit of insulin/gram of dextrose or 10 units per 100gm of dextrose (ex: for 200gm or dextrose, add only 20units of inuslin), detrose in PN should not ben increased until BG is less than 200. Can increase insulin by adding 2/3 of insulin needed from the day before or adding 5 units per 10 grams of carb.

Insulin function decreases in TPN, will stick to tubing

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17
Q

Respiratory quotient of fat metabolism

A

0.7

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18
Q

Respiratory quotient of protein

A

0.82

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19
Q

Respiratory quotient of mixed

A

0.85

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20
Q

Respiratory quotient of carbohydrate

A

1.0

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21
Q

Respiratory quotient greater than 1.0

A

lipogenesis, overfeeding likely going on

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22
Q

What to do during IV vitamin shortages

A

Reserve for patients receiving soley PN or have a clinical need for IV MVI

Consider using oral MVI if able

Provide x3 week or reduce by 50%

If a 13 vitamin product cannot be obtained, obtain a 12 vitamin product and supplement K outside (150mcg/day or 5-10mg/week)

Give B1 (thiamine), folate (B9), B6, vitamin C daily if absolute shortage

Using pediatric MVI for adults is not recommended because it could lead to shortage of pediatric product

Adult MVI should not be administered to peds

Monitor for signs of deficiency of vitamins

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23
Q

Lipid limit for critical care PN

A

No more than 1gm/kg/day

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24
Q

Phenoytoin requires supplementation of which micronutrient and how long should EN be held?

A

Folate
Can bind to tubing or EN formulation, Hold EN 1 hr before and 2 hrs after dose

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25
Q

Filter size needed for 3:1 TPN formulation

A

1.2-um filter

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26
Q

Filter size needed for a 2:1 TPN formulation?

A

0.22-um filter

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27
Q

Are antibiotics used for line care?

A

Do not use antibiotics for line care as there is concern for multidrug resistance

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28
Q

Line insertion bundle and what it entails

A

Hand hygiene, maximal barrier precautions, (mask, gloves, gown, cap, and body drape), CHG skin antisepsis, optimal catheter site selection and daily review of line necessity with prompt removal of unnecessary lines

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29
Q

Grade level for nutrition support education material

A

5th or 6th grade

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30
Q

Niacin

A

used for cardiovascular disease to treat HLD but can cause flushing

Pellagra = 3 D’s - diarrhea, dermatitis, dementia

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31
Q

Erythromycin can cause which deficiency?

A

Erythromycin can cause hypokalemia and hypomagnesemia

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32
Q

What happens with aging?

A

Functional age-related changes in the GI tract may include an altered GI motility, such as delayed gastric emptying. The changes may include altered sensory response; decreased muscle mass, strength, or pressure; decreased secretions. The absorption of certain nutrients, such as calcium, iron, vitamin D, and others may be reduced. With aging, liver values of vitamin A remain stable, which may mean that, despite decreasing dietary intake, absorption of the vitamin increases.

Decreased colonic tone
Decreased small intestinal absorption
Decreased absorption of calcium, iron vitamin D
Causes of malnutrition: Chronic disease, poor oral health, loss of taste/smell, polypharmacy, social isolation, dementia, sarcopenia, loss of functional capacity, inability to procure, prepare and consume food

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33
Q

What micronutrients need to be supplemented on dialysis?

A

May need to supplement vitamin C, folic acid, B6 may be needed with HD

Supplementation of water soluble vitamins is recommended for all dialysis patients

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34
Q

What risk is TPN and how long can it be stored in the refrigerator for?

A

TPN is medium risk and can be stored for 9 days in fridge

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35
Q

Hang time for Open EN feeding system?

A

Open container: 8-12hrs

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36
Q

Hang time for Closed EN feeding System?

A

24-48 hrs

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37
Q

Hang time for reconstituted EN feeding system?

A

4 hrs, formula can be refrigerated after opening for 24 hrs, feeding bags changed every 24 hrs

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38
Q

Hang time for breast milk?

A

4 hrs

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39
Q

Best way to prevent calcium oxalate stones?

A

Low fat, oxalate restricted diet, calcium supplementation, adequate hydration

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40
Q

Vitmin A toxicity can cause

A

bone fractures

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41
Q

Diarrhea causes which acid/base disorder?

A

Metabolic acidosis

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42
Q

Symptoms of manganese toxicity

A

parkinson’s like symptoms and tested with MRI

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43
Q

Which micronutrient is not compatible with 3:1 TPN?

A

iron

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44
Q

3:1 TPN cannot see changes due to being

A

opaque

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45
Q

Which micronutrient deficiency causes cardiomyopathy?

A

Selenium

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46
Q

Pediatric Fluid calculation

A

100ml/kg for the 1st 10kg, 50ml/kg for 2nd 10kg, 20ml/kg for the next kg

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47
Q

When to stop EN/PN when taking oral intake (% of calories being met)

A

66% or 3/4 of needs

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48
Q

Home nutrition support requires a ____?

A

telephone

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49
Q

How long should you hold EN for carbamazepine?

A

2 hrs before and after administration

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50
Q

Glucose target for hospitalized patients?

A

140-180

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51
Q

Where is iron and vitamin B12 absorbed

A

Iron = duodenum
B12 = ileum

52
Q

How often should a CMP be checked for a stable TPN patient?

A

Monthly

53
Q

Independent variable

A

what is being studied or able to be changed, the “cause”

54
Q

Dependent variable

A

what is being changed due to the study, the “effect”, this is what is being measured, reaction that is studied

55
Q

4 Principles of Ethics

A

Autonomy, Beneficence, Justice, Maleficence

56
Q

Autonomy:

A

right to self determination (ie with advanced directives this allows the person to maintain autonomy even after they are unable to verbalize their wishes)

57
Q

Beneficence

A

fundamental obligation of healthcare workers to seek good for the patient above all other priorities

58
Q

Justice

A

fairness, access to all resources

59
Q

Maleficence

A

do no harm principle, in medicine we need to minimize and relieve needless suffering and pain

60
Q

DPOA

A

form that lists patient wishes when pt is too sick to speak for themselves

61
Q

Peripheral access is not appropriate for PN solutions that have greater than ___ dextrose and ___ mOsm/L

A

10% ; 900

62
Q

Tunneled cuffed catheter

A

Needs a small procedure to be removed

63
Q

Line that needs needle access

A

port

64
Q

ANH and Terminal Illness

A

is it palliative or painful to not have access to food and water when dying?

A common fallacy in terminally ill patients is that dehydration is thought to be an uncomfortable state. At the end of life, patients rarely complain of thirst, and aggressive artificial nutrition and hydration (ANH) can be more harmful and can produce life-threatening symptoms. Decreased nutritional intake stimulates increased production of endorphins and dehydration leads to increased dynorphin levels. Both endorphins and dynorphins are natural analgesics and may increase comfort levels. Numerous studies report that patients who are dying predominately have electrolyte values that run in the normal range.

65
Q

ANH and Dementia

A

a patient’s expected survival time affects the evaluation of the benefits vs burdons and risks of the procedure. Factors to consider before placement of a long term tube is the patient’s prior wishes for medical therapies (if known before advanced dementia), the length of time the feeding tube may be required, the patient’s medical condition, and expected survival time. There is lack of evidenced that EN improves morbidity and decreases mortality in advanced dementia.

66
Q

Vegetative state

A

In early stages, clinicians are cautioned against the premature forgoing of ANH in these patients soley based on neurologic status. Need accurate dx and reassessment of the patient’s neurolog status (Persistent Vegetative State vs Minimally Conscious State). Clinicians need to provide information to surrogate about PEG tube long-term outcomes or a patient in a PVS. Decisions to forgo PEGs in the early vegetative state may be premature, particularly if the dx of PVS is not confirmed. In these cases, a time limited trial of EN may be warranted, along with frank discussions with the surrogate decision maker, other family members, and significant others regarding specific goals and expectations

67
Q

How to best prevent oxalate stones

A

Avoid High protein diet
Avoid High green leafy veg
Calcium supplementation - correct answer
High dose vitamin C—this is def wrong
Include high calcium food or calcium citrate supplement with meals to bind oxalate and alkaliniaxe the urine
Consume a low oxalate diet

68
Q

Biliary draining electrolyte losses

A

Sodium, Potassium, Chloride, Bicarb

69
Q

Respiratory acidosis

A

Increase in CO2, compensatory increase in HCO3

Causes: head injury, pulmonary abnormalities, PNA, Guillian-Barre, hypoventilation, overfeeding, caused by decreased effective alveolar ventilation

70
Q

Respiratory Alkalosis

A

Decrease in CO2, compensatory decrease in HCO3
Causes: anxiety, pain , hyperventilation

71
Q

Metabolic Acidosis

A

Decrease in HCO3, compensatory decreased in CO2

Caused by inability of kidneys to excrete H or the loss of bicarb from diarrhea or fistula, can also happen with SIBO or short gut

Causes: Diarrhea, fistula output

72
Q

Metabolic Alkalosis:

A

Increase in HCO3, compensatory increase in CO2

Caused by loss of gastric acid (HCl) dt vomiting or NG suction or loss of volume/chloride from diuretics, normally kidneys can compensate so for this to happen some degree of renal function is present

Causes: diuretic therapy, NG suctioning, N/V

73
Q

Max LIR

A

0.11 gm/kg/hr

74
Q

DIR caluclation

A

Gm Dextrose / wt in kg/ 1.44

75
Q

Triglyceride level for adults and peds to remove lipids

A

Adults: 400
Peds: 200

76
Q

Six Sigma

A

a process improvement workflow, includes define, measure, analyze, improve, control

Goal is to reduce failure of quality until it is no longer cost-effective to pursue further reduction

Goal is not to fix all failures

77
Q

Plan/Do/Study/Act (PDSA)

A

Quality improvement problem solving model

The Plan/Do/Study/Act (PDSA) cycle is a quality improvement problem-solving model. The process begins with a planning phase, followed by the implementation of a process improvement (the “do” phase). The study process measures the results of the improvement effort. During the “act” phase, the team will determine if changes made should be permanent and includes standardization and documentation of the processes.

Method for improving strategies, defines a problem/barriers to track progress, study the plan and summarize data, act to implement changes

Create a plan, execute the plan and document problems/barriers and track progress, study the plan and summarize data, act to implement changes

78
Q

Prosthetic device act

A

EN/PN may be covered under the prosthetic device act which is a benefit of medicare part B, requires the permanent dysfunction of a body organ and must be needed for 3+ months

79
Q

Vitamin D toxicity can contribute to

A

metabolic bone disease

80
Q

TPN taper 1-2 hrs to prevent

A

hypoglycemia

81
Q

What is a closed feeding system and what are the benefits?

A

Sterile container of prefilled formula that is ready to administer to the patient and is spiked with an administration set

Less manipulation
Less human/environmental contact
Decreased risk of bacterial contamination
Fewer steps in administration, this saving time and resources

82
Q

What is an open feeding system?

A

Involve cartons/cans poured into feeding bags or syringe before delivery to the patient

83
Q

Hang time for lipids

A

Time for lipids in PN
TNA: 24 hrs
Alone 12 hrs
Can store in fridge for 9 days

84
Q

Cracking of lipids

A

Cracking is expiring, bad, dont use, brown and yellow

2: yellow-brown oil droplets at or near the TNA surface.
3: a continuous layer of yellow-brown liquid at the surface of the TNA.
4: marbling or streaking of the oil throughout the TNA.

85
Q

Creaming of lipids

A

translucent layer on top

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

86
Q

Common cause of N/V in long term EN

A

Gastic outlet obstruction

87
Q

Manganese toxicity

A
  • Long term TPN patients are high risk
  • Manganese can cause parkinson like symptoms, affects the brain
  • Can be monitored with MRI
88
Q

Iron in regards to PN

A
  • Not added to TPN due to compatability concerns, deficiency is common
  • Iron dextran can be added to 2:1 solutions but cannot be added to TNA
89
Q

Which trace elements should be removed in liver disease or hyperbilirubinemia?

A

Manganese and copper

90
Q

Fluid needs for different age groups

A

18-55: 35 ml/kg
55-75: 30ml/kg
>75: 25 ml/kg

91
Q

Enteral formula free water estimations

A

1 kcal/ml: 85% free water
1.5 kcal/ml: 78% free water
2 kcal/ml: 69-72% free water

92
Q

ASPEN feeding guidelines: BMI 30-50

A

11-14 kcal/kg ABW
>2gm/kg IBW

93
Q

Aspen Feeding guidelines: BMI >50

A

22-25 kcal/kg IBW
Protein 2-2.5 kgm/kg IBW

94
Q

When should PN be discontined?

A

when pt has reliable EN intake, can tolerate solid foods. Consider reduction to 50% and continue to increase EN/PO intake to “acceptable” limit before DC

95
Q

Nitrogen Balance

A

Gold standard to determine if protein intake is adequate

80% of nitrogen is lost to urine

Nitrogen Output (g/day)= [Urinary Urea nitrogen (mg/100mL) x Urinary volume (L/day)] x .2(urine nitrogen) + 2 g

Nitrogen is 16% of protein losses

Nitrogen output (g/day) = urinary urea nitrogen (gm/100mL) x urinary volume (L/day) / 100 + 20% of urinary losses + 2g (estimated other nitrogen from skin, GI losses)

I.e.: Enteral nutrition provides 136gm protein (21.8g Nitrogen), Urine output was 2920ml, and urine nitrogen was 16g. Therefore 21.8 - [16 +3.2 (20% for other urinary losses) + 2] = 0.6 nitrogen equilibrium

To get the gm Nitrogen multiply the gm protein from EN by 0.16 (ie 136 x 0.16 = 21.8 g Nitrogen)

96
Q

Majority of fat digestion occurs in the

A

Duodenum - due to excretion of pancreatic lipase

97
Q

What is the best intervention for a community dwelling elderly patient who is homebound?

A

Meals on Wheels

98
Q

What is the hallmark sign of frailty?

A

Sarcopenia

99
Q

An older adult without IV access requires strict bowel rest and PN for 6 weeks. Which of the following vascular access devices should be employed?

A

A . PICC

100
Q

75 year old man is admitted tot he hospital with aspiration PNA, was deemed unsafe for an oral diet, and is now experiencing aspiration while receiving continues EN via NGT. Which of the following long term feeding options would be most appropriate?

A

PEJ

101
Q

An older adult nursing home resident with a history of constipation has a newly placed PEG tube. Which of the following formulas would most likely be the best choice?

A

Standard 1kcal/ml formula with fiber

102
Q

Enteral nutrition formulas supplemented with fiber are often used in the older adult patient population to prevent constipation. Which of the following considerations is most important it this type of formula is chosen?

A

Provision of adequate water

103
Q

Patient receiving PN has HIgh ileostomy output. Which of the following changes to the PN prescription is most appropriate?

A

Increase sodium and increase fluid volume

104
Q

Subjective Global assessment

A

Method of assessing nutritional status in a variety of patient populations. It intigrates 5 historical (weight, dietary intake, GI symptoms, functional status, metabolic demand) and four physical exam parameters (subcutaneous fat loss, muscle wasting, edema, ascites) to define nutrition status.

105
Q

Which of the following are examples of conditionally indispensable amino acids?

A

Glutamine and arginine - conditionally indispensable amino acids are synthesized from other amino acids under normal conditions but require dietary source in order to meet increase needs by metabolic stress

106
Q

Best method for energy requirements in the critically ill

A

Indirect calorimetry (IC)

107
Q

Respiratory Quotient calculation

A

CO2 produced / O2 consumed

108
Q

Primary fuel for colonocytes

A

Short Chain Fatty Acids

109
Q

Which of the following is associated with adaption to starvation?

A

Increased lipid oxidation and Decrease in urinary nitrogen losses

110
Q

How much vitamin K is in the standard IV MVI

A

150 mcg

111
Q

Glycemic target for critically ill patient?

A

140-180

112
Q

In patients with severe acute pancreatitis, the use of enteral nutrition via NJT rather than PN is associated with

A

Decreased risk of infectious complications, maintained equal nitrogen balance, and had reduced incidence of hyperglycemia

113
Q

What medications can be infused with PN?

A

H2 antagonist

114
Q

Fibrin sheath

A

a layer of fibrin that develops around the outside of a central venous catheter secondary to aggregation of fibrin from the presence of a central venous catheter within a vein

115
Q

Mural thrombus

A

develops when fibrin build up inside the vein causes the vascular access device to adhere to the vessel wall

116
Q

Intraluminal thrombus

A

a clot within the catheter lumen and is caused by inadequate flushing and blood reflux

117
Q

Fibrin tail

A

fibrin build up on the CVC tip that will allow for infusion through the CVC but will inhibit withdrawal of blood

118
Q

0.1N Hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of

A

Calcium- phosphate

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 and acidic medications such as vancomycin

119
Q

Sodium bicarbonate 1 mEq/ml has been anecdotally effective for

A

Occlusions due to precipitates associated with medications in the high pH range such as tobramycin and phenytoin

120
Q

70% ethanol is the most effective solvent for

A

lipid residue

121
Q

Thrombotic catheter occlusion

A

Related to fibrin sheath of fibrin sleeve, develops when fibrin adheres to the external surfaces of the catheter

122
Q

Nonthrombotic catheter occlusion

A

result from mechanical obstructions (catheter migration or malpositioning), drug or mineral precipitates, or lipid deposits

123
Q

Evidenced based intervention for reducing the risk of central venous catheter related infections?

A

Research supports the following recommendations a primary interventions for reducing the risks of CVC-related infections
- Using maximal barrier technique during catheter insertion
- Cleansing insertion sites with 2% chlorhexidine preparation
- Education and training of health care personnel
*** Administering antibiotics has NOT been shown to be effective in reducing the rates of CVC-related infections

124
Q

How to calculate osmolarity

A

Add the mOsm of Amino acids and dextrose. Divide the total mOsm by the volume of PPN

125
Q

ASPEN PN Safety Consensus Recommendations for the inpatient PN label EXCEPT

A

The PN label should include the following:
- Two patient identifiers
- patient location or address
- dosing weight in metric units,
- administration date and time,
- beyond use date and time,
- route of administration (central versus peripheral),
- prescribed volume and overfill volume,
- infusion rate in mL/h, duration of infusion (continuous versus cyclic),
- size of in-line filter (1.2 or 0.22 micron),
- completer name of all ingredients, barcode,
- all ingredients shall be listed in the same sequence and same units of measure as PN order, name of institution or pharmacy, and institution or pharmacy contact information (including telephone number).
- If ILE is to be infused separately, the ILE label should include: two patient identifiers, patient location or address, dosing weight, administration date and time, route of administration (central versus peripheral), prescribed about of ILE and volume required to deliver that amount, infusion rate in mL/h, duration of infusion (not longer than 12 hours), complete name of ILE, beyond use date and time, name of institution or pharmacy, and institution or pharmacy telephone number.

126
Q

What metabolic changes are caused by starvation?

A

Lipolysis

Catabolism of endogenous substrate including fat stored in adipose tissue (lypolysis) is common in stress and starvation related malnutrition. Hypoglycemia and ketosis are also seen in starvation related malnutrition. Hypermetabolism and hyperglycmia are signs of stress related malnutrition.

127
Q

Which of the following is NOT appropriate to tell a family regarding nutrition at the end of life?

1: Dying patients rarely feel hungry or thirsty
2: Fewer calories are needed at the end of life
3: The experience of eating remains unchanged at the end of life
4: Patients should not be made to feel guilty if they do not wish to eat

A

3: The experience of eating remains unchanged at the end of life

It is important for family members to be educated regarding the process of decreased food/fluid intake during the dying process. As illness advances, nutritional needs change and fewer calories are needed. The experience of eating can change from a pleasant one to a distressing one for a patient as the disease process alters the patient’s desire to eat. Dying patients rarely feel hungry or thirsty because the natural process of dying shuts down normal functions. Patients should not be made to feel guilty if they do not try to eat. Diminished food and fluid intake are natural parts of the dying process.

CNSC exam (11 decks)

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