Nutrition Support Part 2

Risk factors for aspiration include all of the following except: A. Malnutrition B. Use of naso-/oro-feeding tube C. Bolus EN feeding D. Supine position

A. 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.

Thrombotic occlusions are most commonly treated with which of the following? A. Thrombolytics B. Anticoagulants C. 10% hydrochloric acid D. Sodium bicarbonate

A. Catheter occlusions are often secondary to a thrombotic problem, such as an intraluminal thrombus, an extraluminal fibrin sleeve, or vessel thrombosis. 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.

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

A. Hyperglycemia is the most common metabolic complication 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.

Which of the following is one of the best validated screening indicators for malnutrition risk? A. Patient reports a nonvolitional weight loss. B. Patient reports following a low-carbohydrate, weight loss diet. C. Patient is 2 days status post laparoscopic cholecystectomy. D. Patient reports a recent flu-like febrile illness.

A. 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

What is the optimal nutrition support for a malnourished patient when enteral nutrition (EN) is not feasible for a prolonged period? A. Central parenteral nutrition (CPN) B. Nasogastric enteral tube feedings C. Postpyloric enteral tube feedings D. Peripheral parenteral nutrition (PPN)

A. The benefits of CPN are more closely associated with patients with malnutrition, although those benefits have not been consistently shown. Newer studies of the impact of PN on malnourished cancer patients' body composition (2010) and performance scores (2011) provide a perspective of PN on outcomes not currently considered in American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines (2009) that may expand the role of CPN in clinical practice.

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? A. By the oral route B. As an oral liquid via the feeding tube C. As a crushed tablet via the feeding tube D. By the intravenous (IV) route

A. 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.

CPN is contraindicated in which of the following conditions? A. Do not resuscitate (DNR) status B. Peritonitis C. Intestinal hemorrhage D. High-output fistulas

A. 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.

In which patient condition or treatment could PN elicit an improved patient outcome? A. Cancer chemotherapy B. Preoperative care of surgery patients with upper gastrointestinal (GI) cancer C. Allogeneic bone marrow transplantation D. Critical illness

B. 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.

A 60-year-old, critically ill patient has been tolerating a standard 1 kcal/mL enteral feeding formula well for the past week. She begins having frequent bouts of loose stools, requiring placement of a rectal tube. What should be the clinician's next suggestion? A. Change to a peptide-based formula. B. Determine the cause of diarrhea. C. Add pre- and probiotics to the feeding regimen. D. Change to a fiber-supplemented formula.

B. Determining the cause of acute diarrhea is the correct answer. The feeding formula that she had been tolerating well during the past week is the least likely cause of the diarrhea. Assessment to identify newly ordered medications that can cause diarrhea or possible infections such as Clostridium difficile may help to determine the cause of diarrhea. If no obvious cause of diarrhea can be found, then a different feeding formula may be tried.

Which of the following actions is most appropriate for enhancing gastric emptying during the administration EN? A. Keep the bed in Trendelenburg position. B. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous feeding. C. Switch to an enteral formulation with a higher fat content. D. Switch to an enteral formulation with a higher protein content.

B. Factors that delay gastric emptying include large boluses of fluid given at one time, increased rate of formula infusion, increased fat content of the solution, and infusion of solutions colder than room temperature. Elevation of the head of the bed (HOB) and turning of the patient slightly to the right side allows gravity to help drain the stomach; however, such positions are often difficult to achieve in the hospital environment.

Which of the following is the most appropriate initial action for the management of tube feeding-associated diarrhea? A. Change to an enteral formulation with fiber. B. Review the patient's medication administration record to determine whether hyperosmolar agents are being administered. C. Change to a peptide-based enteral formulation. D. Use an antimotility agent.

B. If clinically significant diarrhea develops during EN, the most appropriate initial action is to evaluate whether hyperosmolar medications that could result in liquid stooling are being administered. If none are in use, testing for the presence of Clostridium difficile; if those results are negative, the addition of fiber from a formulation that contains fiber or supplemental fiber may be beneficial. Adding an antimotility agent or changing to a peptide-based formula should be considered if diarrhea continues despite these initial interventions. PN should be initiated only if the other treatment modalities fail.

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.

B. Management and prevention of refeeding syndrome 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.

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? A. Malnutrition B. Obesity C. Liver failure D. Acute respiratory distress syndrome (ARDS)

B. 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.

Which of the following may increase the risk of phlebitis with peripherally administered parenteral nutrition (PPN)? A. Osmolarity equal to or less than 900 mOsm/L B. Potassium 100 mEq/L C. Calcium less than 5 mEq/L D. Addition of heparin to the PPN

B. 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.

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? A. Replace the 8-Fr tube with an 18-Fr NG tube. B. Flush the feeding tube with 15 mL of water before and after administering each medication. C. Discontinue the fiber-containing enteral feeding formulation, and initiate feeding with a fiber-free formulation. D. Hold the feeding infusion for 2 hours before and after administering phenytoin.

B. The most likely cause of the feeding tube occlusion is improper flushing technique (see Chapters 12 and 13). 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.

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? A. Supports strong bones and teeth B. Treats influenza C. Promotes urinary health D. Improves immune function

B. Under the DSHEA, manufacturers of dietary supplements 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.

You perform a telephone evaluation of a patient who relates increased redness, pain, and swelling around his existing low-profile gastrostomy tube (G-tube). He has not been seen in the clinic for more than 6 months and, when asked, states that he has been doing quite well on his enteral tube feeds. In fact, the patient states he has gained over 20 pounds. You would proceed as follows: A. Congratulate him on gaining the weight and tell him to continue his present tube feeding plan. B. If possible, have him come to the clinic or call the clinician managing the tube to rule out buried bumper syndrome. C. Direct him to put some triple antibiotic around the site and call back in a couple of weeks if the discomfort continues. D. Tell him to put hot packs on it, take acetaminophen, and rest for a few days.

B. Whenever a patient with a low-profile feeding tube gains or loses a significant amount of weight, there is a risk that the tube is no longer sized correctly. This risk is greatest with weight gain, because that can cause abnormal internal pressure from the bolster or balloon (one that has deflated enough to be pulled into the abdominal wall), which can erode the gastric mucosa. If this process continues, buried bumper syndrome may develop. It results from growth of the gastric mucosa partially or completely over the internal bumper, or excess pressure on the tissues in-between the abdominal wall and gastric mucosa, usually because of excessive tension between the internal and external bumpers or a partially deflated balloon. Poor wound healing, significant weight gain without adjusting the external bumper or changing to a longer, low-profile feeding tube, or lack of routine changes with a balloon tube can contribute as well. Patients are often unaware of this problem until the tube site becomes extremely painful. As the skin becomes irritated and swells, it magnifies the problem. This patient needs to be evaluated soon and have the feeding tube exchanged for either a longer, low-profile tube or a standard tube. If the process has progressed too far, infection may also occur and more intensive treatment with antibiotics and tube removal may be required.

Which of the following methods is not recommended to minimize contamination of enteral feeding formula? A. Washing hands and donning clean gloves before preparing enteral formula. B. Immediate use of enteral formula from a newly opened container. C. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours. D. Changing an "open" feeding container every 24 hours.

C. A formula prepared from reconstituted powder or with added modular components should be infused for no more than 4 hours. Infusion times greater than 4 hours are associated with formula contamination. The use of good handwashing technique and clean gloves and immediately using a newly opened formula container will minimize contamination. Changing an "open" feeding container every 24 hours will minimize bacterial growth that can contaminate formula.

Which of the following is the most appropriate VAD strategy for a patient requiring long-term PN therapy? A. Use a midclavicular catheter as a cost-effective measure. B. Place a percutaneous nontunneled catheter to initiate PN and then replace it with an implanted port. C. Place a single-lumen, tunneled cuffed catheter. D. Place a triple-lumen, antibiotic-coated catheter to ensure adequate access for future needs.

C. A single-lumen tunneled catheter is the preferred device. The tunneled catheter was originally developed for patients with long-term PN. 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.

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

C. 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.

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.

C. 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.

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? A. Lower fiber content B. Lower protein content C. Higher fat content D. Higher energy density

C. High fat intake slows gastric emptying. - High protein intake 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.

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? A. Administer the IV form via the IV route. B. Administer the IV form via the feeding tube. C. Make a slurry of the capsule's powder and administer via the feeding tube. D. Crush the tablet to a fine powder and administer via the feeding tube.

C. IV administration is generally the most expensive method and requires IV access. Use of IV dosage forms via the gastrointestinal (GI) tract is not usually recommended because these dosage forms are not designed to withstand the environment of the GI tract (gastric acid), and adequate amounts may not reach the bloodstream after presystemic metabolism in the GI tract mucosa (eg, cytochrome P450 [CYP450] metabolism) and first-pass metabolism in the liver. - Crushing a film-coated tablet can be difficult because the film coating tends to remain intact and can become sticky when wetted with water. That makes administration via a feeding tube challenging. - Most hard gelatin capsules can be opened and the powder inside combined with water to make a slurry for administration via a feeding tube.

A 55-year-old man presented to the hospital after a traumatic fall from a ladder while working at home. A computed tomography (CT) scan of the head showed significant subdural hematoma with midline shift. After admission to the intensive care unit (ICU), the patient was intubated and sedated, with an orogastric tube to suction and removal of 200 mL gastric content. The patient's abdomen was soft and nondistended. Nephrology was consulted, and the patient was started on continuous veno-venous hemodialysis. What type of enteral formula would best meet his needs? A. A formula restricted in fluid, protein, and electrolytes B. A formula not restricted in protein but restricted in fluid and electrolytes C. A formula restricted in fluid but not restricted in protein or electrolytes D. A formula not restricted in fluid or protein but restricted in electrolytes

C. Not all patients with acute renal failure require fluid restrictions, but, of the answers provided, a formula restricted in fluid but not protein or electrolytes is the best option. There is no need to restrict protein in patients that are dialyzed. Additionally, electrolytes such as potassium and phosphorus need only be restricted when serum levels are chronically high.

What is the smallest pore size filter that recommended for TNA? A. 0.22 μm B. 0.5 μm C. 1.2 μm D. 5 μm

C. The 1.2-μm 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-μm 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 μm and 1 μm in size, lipid injectable emulsion (ILE) could occlude 0.22-μm and 0.5-μm filters, or the emulsion could be destabilized if used with these filters. The 5-μm filter removes particulate matter, but it would allow many types of microbial contaminants to pass through.

Which of the following practices has been shown to reduce the risk for catheter-related bloodstream infections (CRBSIs)? A. Systemic use of antimicrobial prophylaxis at the time of insertion or access B. Routine replacement of central venous access devices (CVADs) C. Use of the "Central Line Bundle" of insertion and maintenance practices D. Selection of an internal jugular site as opposed to subclavian site

C. 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 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.

PN should be discontinued when which of the following criteria are met? A. A clear liquid diet is ordered. B. Tube feeding is initiated at 10% of goal rate. C. Solid food is well tolerated by mouth. D. Advancement to a regular diet is poorly tolerated.

C. 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.

Which of the following will increase the solubility of calcium and phosphate in a PN formulation? A. Use of calcium as the chloride salt B. Use of phosphate as the sodium salt C. Increased amino acid concentration D. Increased temperature

C. 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.

An 18-year-old female patient with cystic fibrosis had a standard-profile, solid internal bolster, 20-Fr percutaneous endoscopic gastrostomy (PEG) tube placed 1 year ago because of her inability to take in enough energy orally and weight loss. She has done very well, with her weight stabilizing and no complications of the PEG. The original tube is now getting stiff and cracking, and the patient wants a replacement tube. The patient has a very supportive family environment, is very active, and is concerned about the cosmetic appearance of the tube itself. What type of replacement tube would you recommend? A. Standard-profile, 20-Fr percutaneous G-tube with solid internal bolster B. Standard-profile, 20-Fr percutaneous G-tube with balloon internal bolster C. Low-profile, 20-Fr percutaneous G-tube with solid internal bolster D. Low-profile, 20-Fr percutaneous G-tube with balloon internal bolster

D. A low-profile, 20-Fr percutaneous G-tube with balloon internal bolster is appropriate for this patient. Because she is very active, standard-profile tubes are less appealing than low-profile, skin-level tubes. Because the patient is concerned about her appearance, a low-profile tube is also a better option. Solid internal bolsters last longer, but they cause significant discomfort when removed and therefore require a clinic or hospital visit to be replaced. Therefore, a low-profile, balloon internal bolster, percutaneous G-tube is the best replacement option. Because the patient and her family are so involved in her care and supportive, they can likely be trained to exchange a low-profile, balloon-type replacement PEG on their own, thus further minimizing future office visits to exchange the feeding tube.

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.

D. 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.

Which of the following is a benefit of EN compared with parenteral nutrition (PN) or no nutrition? A. Maintenance of normal gallbladder function B. Reduced gastrointestinal (GI) bacterial translocation C. More efficient nutrient metabolism D. All of the above

D. EN provides nutrients to the small intestine, stimulating 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.

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 preparation of a PN formulation is required to appear on the label as: A. The percentage of original concentration and volume (eg, dextrose 50% water, 500 mL) B. The percentage of final concentration after admixture (eg, dextrose 25%) C. Grams per liter of PN admixed (eg, dextrose 250 g/L) D. Grams per day (eg, dextrose 250 g/d)

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.

If a nasoenteric feeding tube cannot be unclogged using water flushes, what is the next most reliable method for unclogging the tube before it is replaced? A. Administer cola through the tube, and let it sit for a few hours. B. Administer Clog Zapper (CORPAK MedSystems, Buffalo Grove, IL), and flush within 30 to 60 minutes. C. Wait a few hours to see whether the clog dissolves spontaneously. D. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1 to 2 hours (or longer), and then flush with warm water.

D. Pancreatic enzyme solutions have been studied, and, in one report, this method of unclogging tubes had a 90% success rate when the tube was allowed to sit for 2 hours. The mixture of 1 tablet of a pancreatic enzyme (pancrelipase [Viokase] 6000 units, protease 19,000 units, amylase 30,000 units) and 325 mg sodium bicarbonate (half of a 650-mg tablet) is crushed and mixed with 5 mL of warm water and instilled into the feeding tube for 30 minutes to 2 hours. This method can be tried an additional time (for up to 24 hours), if the shorter waiting period is ineffective. However, if the clog is from a medication and does not clear the first time, the tube should be replaced. Answer A is a common misconception. Administering an acidic solution can actually worsen formula and many medication clogs. Clog Zapper is a commercial mixture of papain, α-amylase, and citric acid solution. It has a lower success rate than pancreatic enzyme solutions. Waiting longer will not help a tube become unclogged.

What should a clinician do when considering the use of enteral formulas marketed for specific disease conditions? A. Use formulas as indicated by the product manufacturer to meet patient's needs. B. Use standard polymeric formulas for all patients. C. Use specialty formulas only when patients exhibit signs and symptoms of intolerance to standard polymeric formulations. D. Evaluate the studies used to support the use of specialty formulas and apply clinical judgment to select the appropriate enteral product for the individual patient.

D. Standard polymeric formulas are indicated for most patients requiring enteral nutrition (EN) support. When considering the use of specialty products, the clinician must use clinical judgment regarding the efficacy, tolerance, and benefit of these formulas and specifically evaluate the studies used to support these formulas, paying close attention to the quality, patient population, and clinical outcomes of the studies that are used to support their use.

Which of the following best describes dietary supplement use in the United States? A. Only a minority of the population uses dietary supplements. B. Most patients report their dietary supplement use to their primary care providers. C. Most patients think that their health care providers are knowledgeable about dietary supplements. D. Many patients using prescription medicines concomitantly use dietary supplements.

D. 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. - 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.

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

D. 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.

Which of the following is an example of a patient condition anticipated to manifest with a severe systemic inflammatory response? A. Anorexia nervosa with body mass index (BMI) of 15 B. Major depression with compromised dietary intake and 5% loss of body weight C. Homebound older adult with restricted access to food and 10% loss of body weight D. Thermal burn injury of second and third degrees covering 15% body surface area

D. The burn injury is significant and will be associated with 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.