ASPEN 3rd Edition Test Your Knowledge Questions

Which of the following incorrectly pairs a metabolic process with its site of occurrence? A. Glycolysis and cytosol B. Tricarboxylic acid (TCA) cycle and mitochondrial membrane C. ATP phosphorylation and cytosol and mitochondria D. Electron transport chain and mitochondrial membrane E. Oxidative decarboxylation of pyruvate and mitochondria

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

Which of the following statements best describes the human gut microbiota? A. The human gut microbiota is established by the age of 3 years and few factors influence it. B. Trillions of bacteria currently compromise the human gut microbiota. C. The human gut microbiota is highly dependent on the host for survival but provides little benefit to the host. D. The human gut microbiota is not influenced by the mode of infant delivery

*B. Trillions of bacteria currently compromise the human gut microbiota* Humans are sterile in utero and are first colonized depending on the mode of delivery. The gut microbiota development increases as the diet increases in complexity. The colonization of gut microbiota is influenced primarily by undigested polysaccharides that ferment to produce SCFAs. The SCFAs serve many biological functions in the host's body. The gut microbiota also has many other positive benefits to the host.

A 19-year-old woman with a history of Crohn's ileitis since the age of 13 years presents for ongoing care. She has been on several medications for Crohn's disease over the course of her diagnosis. Her disease is isolated to the terminal 30 cm of her ileum and ileocecal valve. Despite adequate medication compliance and dosing, her disease remains active. She complains of 4 to 5 loose, watery stools a day, bloating, and mild abdominal pain. She has a microcytic anemia, signs of fat and lean muscle wasting, and osteopenia. She is determined to have failed medical management and undergoes an ileocecectomy. Which of the following vitamins is she most likely to eventually need to take as a supplement? A. Folate B. Vitamin B12 C. Vitamin A D. Vitamin E

*B. Vitamin B12* The terminal ileum is one of the most commonly affected sites in Crohn's disease. As the terminal ileum is the primary site of Vitamin B12 absorption, many Crohn's patients with resection of the terminal ileum will eventually require supplemental Vitamin B12.

Which of the following nutrients does not engage in conversion of homocysteine to methionine? A. Choline B. Vitamin D C. Vitamin B12 D. Folate

*B. Vitamin D* Vitamin B12 and Folate are needed to convert the cardiac risk factor homocysteine back into methionine. Alternatively, choline may be used for this conversion.

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

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

What are the goals for protein support for adults with delayed healing of pressure injuries/ulcers? A. 0.8 g/kg/d B. 1.0 to 1.2 g/kg/d C. 1.25 to 1.5 g/kg/d D. 0.6 g/kg/d

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

A patient is admitted to the medical intensive care unit for sepsis and now requires the use of continuous intravenous insulin infusion for hyperglycemia management. What is the appropriate target glucose range for this patient? A. 80 to 110 mg/dL B. 100 to 150 mg/dL C. 140 to 180 mg/dL D. 150 to 200 mg/dL

*C. 140 to 180 mg/dL* The American Association of Clinical Endocrinologists and The American Diabetes Association (ADA) consensus statement on inpatient glycemic control and ADA standards for Medical Care 2016 recommend 140 to 180 mg/dL as the target glucose range for critically ill patients. In clinical studies, this range has been associated with positive outcomes and limited risk for hypoglycemic complications. This target range is also recommended for the general hospitalized patient population.

What percentage of instilled dextrose is typically absorbed from peritoneal dialysate with a 6-hour dwell time? A. 25% B. 50% C. 75% D. 100%

*C. 75%* In 6 hours, approximately 75% to 80% of the instilled dextrose of the dialysate solution is absorbed. This dextrose can be a significant source of energy.

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, 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 venovenous 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. A formula restricted in fluid but not restricted in protein or electrolytes* 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 phosphorous need only be restricted when serum levels are chronically high.

Enteral nutrition (EN) is an appropriate therapy for which of the following patients? A. A well-nourished patient with colon cancer undergoing chemotherapy B. A severely malnourished gastric cancer patient with nausea and vomiting C. A moderately malnourished patient with head and neck cancer and dysphagia D. A well-nourished recipient of a hematopoietic stem cell transplant (HSCT)

*C. A moderately malnourished patient with head and neck cancer and dysphagia* EN is indicated in patients undergoing anticancer therapies who are malnourished and who have a functional gastrointestinal tract. Nutrition support is not routinely indicated in patients undergoing treatment who are not malnourished. The patient with gastric cancer with nausea and vomiting would have symptoms of gastric outlet obstruction and would require a further evaluation before EN could be initiated.

According to the most recent (2016) ASPEN and Society of Critical Care Medicine (SCCM) guidelines, what is the enteral feeding strategy based on energy requirements for obese patients? A. Hypocaloric with normal protein B. Hypocaloric with low protein C. Hypocaloric with high protein D. Hypercaloric with high protein

*C. Hypocaloric with high protein* The ASPEN/SCCM guidelines recommend high-protein, hypocaloric feeding (grade D). The guidelines suggest that for obese patients (BMI greater than 30), the goal of the EN regimen should not exceed 60% to 70% of target energy requirements. Estimated protein requirements may be 2.0 g/kg IBW/day for patients with class I or II obesity, and 2.5 g/kg IBW/day for patients with class III obesity.

A patient with severe intractable nausea and vomiting is at risk for which of the following acid-base disorders? A. Hypercholremic metabolic alkalosis B. Hypercholremic metabolic acidosis C. Hypocholremic metabolic alkalosis D. Hypocholremic metabolic acidosis

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

Which of the following statements is true regarding parenteral nutrition (PN) in the care of the inpatient with liver disease? A. There is no role for PN in nutrition in liver disease. B. PN should be initiated in all hospitalized patients with liver disease. C. If a patient cannot tolerate enteral feeding, PN can provide necessary nutrition, but it should be discontinued in favor of enteral nutrition as soon as possible. D. When a patient cannot tolerate EN, they should receive PN for the duration of the hospitalization.

*C. If a patient cannot tolerate enteral feeding, PN can provide necessary nutrition, but it should be discontinued in favor of enteral nutrition as soon as possible.* The goal should always be to provide EN to patients with liver disease. In certain patients, such as those without a functional gut, it is necessary to provide PN. PN should be continued for the briefest period possible. EN is always preferred to PN when enteral feeding is possible.

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. Increased amino acid concentration* The higher the concentration of amino acids in the formulation, the less likely precipitation is to occur. Amino acids can form soluble complexes with calcium, which reduce the effective concentrations of free calcium available to form insoluble precipitates with phosphorous 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.

The rate of protein turnover in catabolic, critically ill patients: A. Does not change B. Decreases C. Increases D. Is not affected by nutrition support

*C. Increases* Protein turnover rates increase dramatically in critical illness. Nutrition support will improve protein synthesis somewhat, but it has little effect on protein degredation.

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. Infusing reconstituted powdered formulas or formulas with added modular components in 1 bag for up to 8 hours* A formula prepared from reconstituted powder or with added modular components should be infused for no longer than 4 hours. Infusion times greater than 4 hours are associated with formula contamination. The use of good hand washing 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.

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

Which of the following immunosuppressive agents is nephrotoxic and can cause hyperkalemia, hypomagnesemia and hyperglycemia? A. Sirolimus B. Prednisone C. Tacrolimus D. Mycophenolate mofetil

*C. Tacrolimus* In addition to these side effects, tacrolimus may also cause neurologic symptoms. The main metabolic effect of sirolimus is hyperlipidemia. Corticosteroids, such as prednisone, contribute to hyperglycemia but are not nephrotoxic and do not affect serum magnesium levels. The major nutrition-related side effects of mycophenolate mofetil are gastrointestinal side effects, including nausea, vomiting, and diarrhea.

Which of the following is true about the mechanisms that promote weight loss and malnutrition in patients with cancer? A. Tumer-induced altered metabolism has been associated with increased energy expenditure B. Inadequate nutrient intake and increased cytokine production can lead to weight loss C. Some cancer patients demonstrate increased glucose turnover compared with non-tumor-bearing patients with simple starvation D. All of the above

*D. All of the above* Early investigations suggested tumor-induced changes in metabolism caused increased energy expenditure and nitrogen loss However, more recent investigations have demonstrated inconsistency with this response across a wide variety of cancer patient populations. Increased glucose turnover has been reported in cancer patients with weight loss, which is in stark contrast to non-tumor-bearing patients with simple starvation, who have decreased glucose turnover. Potential causes of metabolic abnormalities and weight loss in cancer patients include the presence of increased circulating cytokines, changes in hormones and neuropeptide levels, and tumor-derived products.

Which of the following should clinicians do to support patients who are dealing with lifelong dependency on home nutrition support? A. Include the patient in decision-making regarding the choice of access device and administration schedule. B. Recognize symptoms of depression, and refer patients with those symptoms for additional evaluation and care. C. Promote the benefit of patient support groups. D. All of the above

*D. All of the above* Patients who receive long-term HEN or HPN are at high risk depression, social isolation, and poor QOL. Patients and their caregivers should have an active role in determining the appropriate access device and infusion therapy plan to fit their lifestyle. Home care professionals should help patients adapt and cope with the required lifestyle adjustments by painting a realistic picture of what will occur at home, providing education on HEN/HPN procedures and technology, and designing a care plan consistent with the patients' desired goals. Patients should be introduced to the many organizations that provide important outreach services, educational materials, and emotional support.

Which of the following is a primary reason for administering HPN as a cyclic infusion? A. To provide a more normal lifestyle B. To reduce complications of parenteral nutrition-associated liver disease C. Because cyclic infusion allows for administration of intravenous medications that are incompatible with parenteral nutrition (PN) D. All of the above

*D. All of the above* The primary reason to administer HPN using a cyclic or overnight infusion is to allow the patient freedom during the day and thereby improve quality of life. Cyclic infusions allow a period of rest and may decrease the incidence of fatty liver. Off-cycle time allows for administration of other IV medications (i.e. vancomycin) that are incompatible with PN. Cyclic infusions are appropriate if a patient can tolerate the volume of PN over a shorter period of time as evidenced by frequency of urination, blood glucose control, and absence of cardiopulmonary distress.

Patient adherence to the nutrition support regimen is key to achieving goals of therapy. Which of the following are indications of non-adherence? A. Unwillingness to review a product inventory or report of excess supplies B. Unintentional weight loss despite adequate energy being prescribed C. Good communication between the patient and health-care team D. Answers A and B

*D. Answers A and B* The physician managing HEN or HPN patients will need assistance from other providers to monitor patient adherence to therapy. A multidisciplinary approach involving the dietitian, home health nurse, and infusion pharmacist is crucial. Patients or caregivers who are unwilling to review the product inventory or report of excess supplies, or who are not responding appropriately to treatment (i.e. experience unintentional weight loss or unresolved electrolyte imbalances), may not be adhering to the nutrition support plan. Infusion pump reports may be useful for verifying infusion history for patients receiving PN.

Which of the following nutrition interventions have been shown to improve clinical outcomes and quality of life in institutionalized older adults? A. Diet modification and liberalization B. Modification of dining environment C. Provision of aides to improve functional status and increase independence at meals D. Honoring food preferences and providing snacks and fortified foods E. All of the above

*E. All of the above* Many food and dining interventions increase intake and improve nutrition status of older adults. Interventions range from individualizing a diet and liberalizing restrictions or altering food and fluid consistencies where appropriate, to providing food preferences at and between meals and fortifying foods with supplemental protein and energy. Dining-related interventions can include use of a social dining environment, restorative dining, and provision of adaptive feeding aides to increase the older adult's functional independence at meals.

What is the corrected sodium level when blood glucose is 340 mg/dL and current serum sodium is 129 mEq/L? A. 133 mEq/L B. 125 mEq/L C. 130 mEq/L D. 140 mEq/L

*A. 133 mEq/L* Hyperosmolarity from hyperglycemia shifts fluid from the intracellular to extracellular compartments, resulting in a dilutional decrease in sodium levels. Serum sodium concentrations decrease 1.6 mEq/L for every 100 mg/dL increase in serum glucose. Corrected serum sodium = measured serum sodium + (0.016 X Serum glucose -100)

What are some of the possible ramifications of activation of the enzyme phospholipase A2? A. Cyclooxygenase (COX)-dependent, eicosanoid-mediated inflammatory reactions B. Enzymatic degradation of resolvins and protectins C. Desaturation of linoleic acid within lipids D. Chylomicron maturation

*A. Cyclooxygenase (COX)-dependent, eicosanoid-mediated inflammatory resactions* Arachidonic acid (AA), common to membrane phospholipids, usually occupies the sn-2 position within lipids and is almost always found at this position within the important membrane phospholipid phosphatidylinositol. During membrane cell signaling events, a possible outcome is the activation of phospholipase A2, the enzyme that acts on membrane phospholipids to release fatty acids from the sn-2 position. Release of AA sets in motion subsequent intracellular metabolic acitvity via the COX pathway that leads to synthesis of the 2-series of prostaglanidns, including prostaglandin E2 (PGE2), and thromboxanes, including thromboxane A2.

What is the best reason to conservatively prescribe energy in nutrition support regimens? A. Glycemic control B. To facilitate permissive underfeeding C. Cost containment D. To achieve goal infusions more effectively

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

Which of the following statements regarding a subarachnoid hemorrhage is false? A. High doses of folic acid should be administered to reduce the likelihood of a second hemorrhagic stroke. B. Energy expenditure is higher for patients with SAH than for those with ischemic stroke C. Concentrated enteral nutrition may be necessary if fluid intake is restricted to minimize cerebral edema D. Bedside or formal swallow studies should be performed to confirm that the patient does not have dysphagia before an oral diet is initiated.

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

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* 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.

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

Which of the following best describes nutrient requirements during the acute posttransplant phase? A. Moderate energy, high protein B. High energy, low protein C. Moderate energy, low protein D. High energy, high protein

*A. Moderate energy, high protein* Energy needs are only moderately elevated after transplantation unless complications such as sepsis occur. Protein requirements are significantly elevated due to an increased catabolic rate caused by surgery, stress, and corticosteroids.

Which of the following nutrition support interventions has demonstrated the best outcomes in frail, community-dwelling older adults and in postoperative orthopedic surgery populations? A. Oral nutritional supplement B. Intravenous hydration C. EN D. PN

*A. Oral nutritional supplement* Oral nutritional supplements have demonstrated the best outcome in frail, community-dwelling older adults and in post-orthopedic surgery populations. EN, PN, and IV hydration have demonstrated limited success in achieving positive outcomes in older adults.

Which of the following statements regarding the current World Health Organization (WHO) and National Institutes of health (NIH) classification of overweight and obesity is true? A. Overweight is defined as a body mass index (BMI) of 25 to 29.9, and obesity is defined as a BMI equal to or greater than 30. B. Obesity is defined as equal to or greater than 120% ideal body weight (IBW). C. Obesity is defined as body fat equal to or greater than 20% of body weight for men and equal to or greater than 30% for women. D. Obesity is defined as a BMI greater than 25, and morbid obesity is defined as a BMI greater than 30.

*A. Overweight is defined as a BMI of 25 to 29.9, and obesity is defined as a BMI equal to or greater than 30* WHO and NIH currently use BMI to classify overweight and obesity in adults, in contrast to prior use of IBW or percent body fat. Use of BMI is encouraged because it provides a standardized method for expressing weight relatively independent of height and correlates reasonably well with body fat as well as mortality. Although BMI does not always accurately reflect excess body fat (i.e. when ascites or edema is present), it represents a simple and reproducible method for categorizing weight.

Which of the following is one of the best validated screening indicators for malnutrition risk? A. Patient reports a non-volitional 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. Patient reports a non-volitional weight loss.* Of the options provided, the only well-validated indicator to screen for malnutrition risk is a non-volitional weight loss. The other options may be noted in screening and assessment but are not themselves validated measures of malnutrition risk.

Proteins perform all the following physiological functions *except*: A. Provide a major source of energy B. Maintain acid-base balance C. Contribute to immune defense D. Serve as a mode of transport for substances

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

Which of the following is the largest component of total energy expenditure (TEE)? A. RMR B. Thermic effect of digestion C. Physical Activity D. Metabolic Stress

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

Which of the following is a criterion for selecting patients to undergo gastric bypass surgery? A. BMI greater than 35 and no history of substance abuse or psychiatric disorders. B. BMI equal to or greater than 35 and obesity-associated comorbidities C. BMI equal to or greater than 30 and obesity-associated comorbidities D. BMI equal to or greater than 30 and inability to achieve weight control with low-calorie diets

*B. BMI equal to or greater than 35 and obesity-associated comorbidities* Patients are candidates for gastric bypass surgery if they have a BMI equal to or greater than 40. Individuals are also candidates if their BMI is equal to or greater than 35 and they have weight-related comorbidities and more conservative efforts have not resulted in adequate weight control. patients without weight-related comorbid conditions may be candidates for surgery; indeed, some advocates of surgical treatment suggest that surgery is best performed before lasting health problems or surgical risks are present. Patients with active bulimia, active substance abuse, or major disturbances of thought or mood should be evaluated carefully and treated for these issues before surgery.

Which of the following is least likely to occur during oxygen debt? A. Buildup of lactic acid B. Buildup of pyruvate C. Decrease in pH D. Increased fatigue E. Shortage of ATP

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

Which of the following are not thought to benefit burn wound healing? A. Vitamin C supplementation B. Calcium C. Protein delivery of 1.5 to 2.0 g/kg/day D. Zinc supplementation

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

A 35-year-old white woman presents to the clinic with diarrhea, weight loss, and abnormal liver function tests. Her primary care physician also noted that the patient was vitamin D and iron deficient with anemia. On physical examination, the patient has a very pruritic maculopapular rash with vesicular eruptions on her lower legs. An EGD is performed, and a mosaic pattern with nodularity is noted in the second portion of the duodenum. Which of the following is most likely the cause of the patient's symptoms? A. Chron's disease B. Celiac disease C. Whipple disease D. Peptic ulcer disease

*B. Celiac disease* The patient has classic celiac disease. In addition to the mosaic pattern seen on endoscopy, the patient has both vitamin D and iron deficiency, findings consistent with celiac disease. The rash on the legs likely represents dermatitis herpetiformis, a finding that is pathognomonic but not always present. Abnormal liver function tests and abdominal pain are also commonly seen in celiac disease.

Which of the following actions is most appropriate for enhancing gastric emptying during the administration of 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 formula with a higher protein content

*B. Decrease the rate of a continuous feeding infusion, or change from bolus to continuous feeding* 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 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.

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. Determine the cause of diarrhea* 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 is most strongly correlated with improved mortality in TBI? A. Strict avoidance of parenteral nutrition B. Early initiation of nutrition C. High protein content in nutrition formula D. Supplementation of vitamins C and E

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

Which of the following statements about energy needs during pregnancy is true? A. Energy requirements are the same for pregnant and non-pregnant women B. Energy needs are increased only during the second and third trimesters of pregnancy C. Compared with non-obese women, energy requirements are lower for obese women to promote weight loss during pregnancy D. Energy goals should only focus on nonprotein energy intake

*B. Energy needs are increased only during the second and third trimesters of pregnancy* Energy requirements in pregnancy increase in the second and third trimesters. Most women do not need to increase energy intake in the first trimester, although underweight women may be encouraged to do so.

Which of the following is a measurement of body iron stores? A. Total iron-binding capacity (TIBC) B. Ferritin C. Transferrin D. Ceruloplasmin

*B. Ferritin* Ferritin is a serum protein that binds iron and serves as a reliable indicator of total iron stores. Low levels of this protein are typically seen with iron deficiency anemia, whereas high values occur with iron overload from an excessive intake of iron or the presence of hemochromatosis. Ferritin is an acute-phase protein and is also increased with acute inflammatory diseases of the liver. In CKD, ferritin should be greater than 100 ng/dL and the transferrin saturation (TSAT) should be greater than 20%. TIBC is a measure of serum iron and various proteins that transport iron within the circulation. A saturation index for these proteins is a measure of the available iron within the bloodstream. Transferrin is a circulating transport protein that carries iron that can be used in hematopoiesis. Ceruloplasmin is a copper transport protein, which possesses ferroxidase activity that is important for binding of recycled and stored iron to transferrin.

An alert and oriented adult patient is receiving a continuous infusion of a standard, fiber-containing EN formulation through an 8-Fr nasogastric tube. Drugs administered by bolus 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 2.5 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. Flush the feeding tube with 15 mL of water before and after administering each medication* The most likely cause of the feeding tube occlusion is improper flushing technique. The tube should be flushed with a minimum of 15 mL of water before and after each medication, but 30 mL is commonly recommended and may be required to properly flush longer or larger tubes. Although the risk of occlusion is potentially greater with an 8-Fr small-bore tube than with an 18-Fr tube, the discomfort associated with such a large-bore tube would make it a poor choice for nasoenteral access in an alert patient, especially when needed for more than 2 weeks. Switching from a fiber-containing to a fiber-free EN formulation would have little influence on risk of tube occlusion. The fiber used in EN formulations has been processed to a degree that makes its viscosity similar to that of polymeric, fiber-free formulations. Holding the feeding infusion for 2 hours before and after phenytoin administration has been recommended as a method to enhance drug absorption; it would not be expected to influence tube occlusion.

You are determining the energy intake target for a 53-year-old, critically ill, male patient who is about to start enteral feeding. He is 170 cm in height and weighs 150 kg. His body mass index is 51.9 and his ideal body weight is 70 kg. Body temperature is 37.3 degrees Celsius and minute ventilation is 12.5 L/min. Based on the 2016 ASPEN guideline for calculating a goal energy intake for such a critically ill patient, what energy value would you use as the basis for the feeding plan? A. 1750 kcal/d (25 kcal per kg ideal body weight) B. 1225 kcal/d (70% of the calculated 25 kcal per kg ideal body weight) C. 2250 kcal/d (25 kcal per kg adjusted body weight) D. 2615 kcal/d (Penn State Equation)

*A. 1750 kcal/d (25 kcal per kg ideal body weight)* The ASPEN guideline states that the goal intake for all classes of obesity should not exceed 65% to 70% of target energy expenditure as measured by IC. For class III obesity, an intake of 22 to 25 kcal per kg ideal body weight is recommended. The Penn State equation has been validated as being among the most accurate ways of calculating energy expenditure up to a BMI of at least 80. However, answer D is incorrect if following the ASPEN guideline because that guideline emphasizes the kcal/kg method. The patient has class III obesity; therefore, ideal body weight would be used for the calculation, making answer C incorrect because it uses adjusted body weight. Answer B is incorrect because the guideline already factors the 30% reduction of the energy calculation into the standard; therefore, if energy expenditure were calculated and then multiplied by 70%, the effect would be to reduce the energy intake to about 50% of expenditure.

What amount of retinol is equivalent to 24 mcg of beta-carotene from food? A. 2 mcg B. 4 mcg C. 10 mcg D. 1 mg

*A. 2 mcg* One mcg retinol has the vitamin A activity of 12 mcg beta-carotene. Therefore, 24 mcg beta-carotene is equivalent to 2 mcg retinol.

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

*A. A 35-year-old man* Free water deficit (FWD) is calculated as follows: FWD = total body weight X [1 - (140/serum sodium)] Where FWD and total body water (TBW) are measured in liters and serum sodium is measured in mEq/L. Given the same body weight and serum sodium concentration, the only variable is the percentage of TBW. The percentage of TBW increases as the proportion of lean body mass to adipose tissue increases. In general, the percentage of TBW decreases with age and is lower in females than in males. Younger men would be expected to have the highest proportion of LBM and the highest percentage of TBW and would therefore have the largest free water deficit.

What is the definition of ANH? A. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth. B. Provision of specialized nutrients orally, enterally, or parenterally with therapeutic intent. C. Nutrition provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity. D. Administration of nutrients and fluid intravenously to maintain the patient's nutrition status during acute illness.

*A. A medical treatment that allows a person to receive nutrition and hydration when he or she is no longer able to consume them by mouth.* ANH involves technology-assisted administration of nutrients when a patient is unable to swallow or unable to absorb nutrients through the GI tract. ANH is considered a medical intervention.

Which of the following is true regarding a patient with newly diagnosed pancreatic cancer awaiting chemotherapy? A. A nutrition assessment should be performed B. EN should be initiated because the patient will likely need nutrition support during chemotherapy C. Parenteral nutrition (PN) should be initiated because the patient will likely need nutrition support during chemotherapy D. PN should be initiated if surgical intervention is imminent

*A. A nutrition assessment should be performed* According to the American Society for Parenteral and Enteral Nutrition guidelines, patients with cancer are nutritionally at risk and should undergo a nutrition screening to identify those who require formal nutrition assessment. Neither EN or PN is routinely indicated in patients undergoing anticancer treatment who are not malnourished. The role of perioperative PN is controversial, and it is not recommended for patients who are not malnourished.

Which of the following nutrition regimens is appropriate for a patient with less than 2 Ransom criteria and an Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score of less than 9 (nonsevere) who has no pancreatic necrosis on a CT scan? A. Begin volume resuscitation, provide narcotic analgesia, and advance to an oral diet as soon as it is tolerated B. Begin PN in the first 24 hours of admission because the patient has acute pain. C. Keep the patient NPO for at least 7 days. D. Use PN in the first 24 hours and then switch to an oral diet.

*A. Begin volume resuscitation, provide narcotic analgesia, and advance to an oral diet as soon as it is tolerated* Patients with mild to moderate pancreatitis may be supported with intravenous fluid resuscitation and analgesia without added specialized nutrition support.

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 route

*A. By the oral route* The oral route is preferred whenever possible because it is the route by which oral medications are designed to be administered. If the patient is allowed to take adequate water to swallow the medication, the oral route should be considered. For medications to be taken with food, the patient should have either food from oral ingestion or enteral formulation in the stomach before medication is administered 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.

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

*A. Central parenteral nutrition* 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 PON on outcomes not currently considered in ASPEN guidelines (2009) that may expand the role of CPN in clinical practice.

Which of the following core ethical principles is the pre-dominant value in American bioethics? A. Respect for autonomy: The patient has a right to self-determination in healthcare decision making. B. Beneficence: The healthcare professional is fundamentally obligated to seek the good of the patient above all other priorities. C. Nonmaleficence: The prime directive of medicine is to prevent, minimize, and relieve needless suffering and pain. D. Justice: When treating patients, healthcare providers should consider only clinically relevant factors and provide equitable care to clinically similar patients.

*A. Respect for autonomy: The patient has a right to self-determination in healthcare decision making.* In the US ethico-legal framework, the primary goal is to provide medical therapies based on the individual's quality-of-life goals, as determined by the patient with decision-making capacity or an authorized surrogate. Completion of advance directives for individuals is encouraged. Beneficence is the fundamental obligation of a healthcare professional to seek the good of the patient above all other priorities, and nonmaleficence addresses the aspect of "do no harm". The justice principle deals with fairness and requires that nutrition support clinicians equitably treat similar patients similarly and consider only clinically relevant information.

For patients with colitis or proctitis after colon resection and proximal diversion of the fecal stream, which of the following represents an effective first-line treatment? A. Short-chain fatty acid enemas B. Hydrocortisone enemas C. Topical 5-aminosalicylic acid D. Fecal microbial transplant

*A. Short-chain fatty acid enemas* SCFAs are the treatment of choice for patients with diversion proctitis or colitis, because a deficiency in SCFAs has been implicated in the etiology of this disease process. Answers B, C, And D represent alternative treatments for patients who have persistent symptoms after 2 - 4 weeks of treatment with SCFAs.

Which of the following nutrients is added to rehydration liquids to promote water absorption in patients with diarrhea? A. Sodium and glucose B. Amino acids C. Long-chain fatty acids D. Alcohol

*A. Sodium and glucose* Sodium is the nutrient that is added to rehydration liquids to promote glucose and water absorption in patients with diarrhea The presence of sodium in the lumen of the small intestine facilitates the absorption of glucose. When more sodium is absorbed, more water from the lumen of the intestines is absorbed. For this reason, oral rehydration fluids used to treat sodium and water losses from diarrhea contain sodium chloride and glucose.

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

*A. Thrombolytics* 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 (i.e. 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.

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/day, 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.

Which of the following statements best describes a probiotic? A. A probiotic is a live organism used to make yogurt B. A probiotic is a "live nonpathogenic organism (bacteria or yeast) which when administered in adequate amounts confers a health benefit on the host" C. Probiotics are on the Generally Recognized As Safe (GRAS) list and therefore can be safely provided to all humans receiving nutrition support therapy D. The mechanisms of probiotics are well known, making probiotic therapy a great addition to nutrition support therapy

*B. A probiotic is a "live nonpathogenic organism (bacteria or yeast) which when administered in adequate amounts confers a health benefit on the host"* While the starter cultures used to make yogurt, Lactobacillus bulgaricus and Streptococcus termophilus are on the GRAS list and therefore considered safe for human consumption, they are not probiotics. There are specific criteria that a bacterium must meet to be considered a probiotic. The mechanisms of action of probiotics are still being researched, but what is known is that each strain of bacteria behaves differently, particularly in different environments. Therefore, a general application of probiotic therapy for nutrition support patients is not recommended.

The strategy of restricted fluid intake may decrease the number of days that patients require mechanical ventilation for which disease process? A. Traumatic brain injury (TBI) B. ARDS C. Pulmonary embolism (PE) D. Septic shock secondary to bacterial pneumonia

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

Which of the following metabolic alterations is most commonly observed in AKI? A. Decreased energy expenditure B. Metabolic acidosis C. Decreased serum magnesium concentration D. Metabolic alkalosis

*B. Metabolic acidosis* In AKI, a metabolic acidosis develops from organic and inorganic acid accumulation. Serum potassium concentrations increase as obligate renal clearance is reduced.

A 56-year-old man with long-standing history of type 2 diabetes mellitus presents with postprandial abdominal pain, nausea, and vomiting. His diabetes is uncontrolled despite the use of insulin, and his glycosylated hemoglobin A1C is 10%. He also has painful peripheral neuropathy in his legs as well as diabetic retinopathy. His GI symptoms have progressed over the past 6 months, and he now reports eating very little because he fears the abdominal pain and vomiting will worsen. The emesis occurs 30 minutes to 2 hours after eating, and it has the appearance of undigested food. A diagnostic upper endoscopy is normal. Which diagnostic test is the ideal next step in determining the cause of his symptoms? A. Mesenteric Doppler ultrasound B. Gastric emptying scan C. Small bowel series/follow-through D. Abdominal computed tomography

*B. Gastric emptying scan* This patient already has signs of end-organ damage from the uncontrolled diabetes (peripheral neuropathy, retinopathy), which means he likely has diabetic gastroparesis. Postprandial abdominal pain, nausea, and vomiting of food that was just consumed are common symptoms of diabetic gastroparesis. All the diagnostic tests listed as options could be reasonable steps in the diagnosis, but a gastric emptying scan is the most valuable initial test as it is used to confirm the presence of delayed gastric emptying.

Which of the following does not help to reduce VAP? A. Elevating the head of the bed to at least 45 degrees B. Gastric ulcer prophylaxis and early PN C. Early mobility and decreased days on a mechanical ventilator D. Minimizing sedation and a daily sedation vacation

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

Which of the following statements is true relating to hydrochloric acid (HCl) and protein digestion? A. HCl Aids in the conversion of pepsin to pepsinogen. B. HCl denatures protein structures to make them more susceptible to enzymatic action C. HCl is secreted by the parietal cells within the duodenum in response to dietary proteins. D. HCl's release is stimulated by the hormone insulin

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

You perform a telephone evaluation of a patient who relates increased redness, pain, and swelling around his existing low-profile gastrostomy 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. If possible, have him come to the clinic or call the clinician managing the tube to rule out buried bumper syndrome* 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 abdominal 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.

What is the most accurate way to determine energy requirements for obese patients in the ICU requiring EN support? A. The Harris-Benedict Equation B. Indirect Calorimetry (IC) C. The Mifflin-St. Jeor equation D. The Penn State Equation

*B. Indirect Calorimetry* Various equations (Harris-Benedict, Penn State, and Mifflin-St. Jeor) have been widely used to predict resting metabolic rate, but most predictive equations were validated in patients without extremes of weight or age. Overestimation of total energy requirements when using actual body weight (ABW) and underestimation when using IBW lead to inadvertent overfeeding and underfeeding, respectively. Efforts to account for altered body composition with these equations by using corrections for ABW have lead to even more confusion. For these reasons, IC should be used, when available, to determine the energy requirements of critically ill obese patients.

Which of the following commonly used medications in TBI is not associated with a reduction in measured energy expenditure? A. Propranolol B. Mannitol C. Pentobarbital D. Rocuronium

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

Medicare coverage for HPN is possible with adequate documentation in which of the following conditions? A. Anorexia nervosa B. Massive small bowel resection resulting in short bowel syndrome with less than 150 cm bowel remaining C. Six weeks of bowel rest for severe pancreatitis D. Swallowing disorder with history of aspiration pneumonia

*B. Massive small bowel resection resulting in short bowel syndrome with less than 150 cm bowel remaining* Coverage for HPN under Medicare is available for patients who have undergone massive small bowel resection leaving less than 150 cm residual bowel. Operative notes must include documentation of intestinal length. Patients with anorexia nervosa would not meet Medicare criteria for permanent severe pathology of the alimentary tract. A patient requiring bowel rest for 6 weeks for severe acute pancreatitis may have an appropriate clinical indication for HPN; however, per Medicare guidelines, bowel rest must be required for 3 months or longer and the patient must have evidence that EN is contraindicated. A patient who has a swallowing disorder with or without evidence of aspiration pneumonia would be a candidate for EN.

Because of the malabsorptive process present in SBS, patients have a high risk for micronutrient deficiencies. Which of the following answers is correct regarding the monitoring and repletion of micronutrients in SBS? A. If patients are receiving parenteral nutrition, there is no reason to monitor micronutrients because the PN should satisfy all micronutrient needs B. Micronutrients should be checked periodically. Micronutrients can usually be repleted via the oral route. C. Micronutrients should be checked monthly. Repletion should be administered in high doses both intravenously and orally. D. Micronutrients should be checked annually, and all micronutrients should be repleted intravenously because patients with SBS cannot absorb micronutrients administered orally.

*B. Micronutrients should be checked periodically. Micronutrients can usually be repleted via the oral route* Patients with SBS are at risk for deficiencies of micronutrients (vitamins, minerals, trace elements) and essential fatty acids. There are no formal guidelines regarding the monitoring and repletion of micronutrients in this patient population. Nevertheless, micronutrients and an essential fatty acid profile should be checked at least annually, and interventions to replete deficient micronutrients should be done. Abnormal micronutrient levels should be monitored on a quarterly basis. Although some micronutrients can be increased in the PN solution, not all micronutrients will be able to be added to the PN solution because of the formula stability issues or because the nutrient does not come in single unit doses. Fortunately, adequate micronutrient supplementation can be provided orally, although the regimen will need to be tailored to meet the patient's increased needs. Some micronutrients are available for either intramuscular or intravenous administration.

Which of the following characterizes the current understanding of systemic inflammatory response? A. Overstimulated immune system B. Mixture of immune stimulation and suppression C. Initial immune suppression followed by stimulation D. Immune suppression

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

High-protein hypocaloric EN feeding providing 65% to 70% of energy needs, as determined by indirect calorimetry (IC), is recommended for ICU patients with which fo the following conditions? A. Malnutirition B. Obesity C. Liver Failure D. Acute respiratory distress syndrome (ARDS)

*B. Obesity* Patients with malnutrition should receive more than 80% of their estimated nutrient needs within 48 to 72 hours of intubation. Delays in initiating and advancing EN result in greater energy and protein deficits, which may contribute to higher infection and mortality rates. Studies indicate obese patients benefit from low-calorie, high-protein feedings to minimize the metabolic complications of feeding, preserve lean body mass, 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 practices is most likely to succeed in improving oral nutrient intake in patients with a prolonged history of weight loss due to poor intake, nausea, and depressed appetite? A. Providing a high-energy oral liquid supplement 3 times daily B. Offering 6 small, low-fat meals daily C. Ordering fiber-supplemented snacks 3 times daily D. Planning primarily solid meals and limiting fluids

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

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

Which of the following is the most commonly used method for assessing energy expenditure? A. Indirect calorimetry (IC) B. Predictive equations C. The reverse Fick equation D. Doubly labeled water

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

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 cancer C. Allogeneic bone marrow transplantation D. Critical illness

*B. Preoperative care of surgery patients with upper gastrointestinal cancer* A review of PN literature has reported improved outcomes in patients with upper GI tract malignancies when PN is initiated 7 days before surgery. An early report of a decrease in length of stay and infectious complications in allogenic 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.

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 phosphorous 1.6 mg/dL (normal: 2.5 - 4.8 mg/dL); and serum magnesium, normal. The PN regimen is providing protein 90g, dextrose 150g, no lipid, minimum volume, potassium 80 mEq, phosphate 40 mmol, and standard doses of sodium, magnesium, calcium, vitamins, and trace elements. The patient weights 60 kg and has a body mass index 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. Provide supplemental intravenous doses of potassium and phosphate today, but do not change the macronutrient doses with tonight's PN bag* Management and prevention of refeeding syndrome and refeeding hypophosphatemia involve identifying patients at risk, serum electrolyte monitoring with aggressive replacement, and 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.

For routine colon surgery, which of the following components of Enhanced Recovery After Surgery protocols contributes to improved outcomes? A. Keeping the patient nil per os after midnight to avoid aspiration on induction of general anesthesia B. Providing glucose-rich supplementation 6 and 2 hours prior to surgery C. Using high-dose oral protein supplements D. Using probiotics to restore normal intestinal flora after surgery

*B. Providing glucose-rich supplementation 6 and 2 hours prior to surgery* The principles of a perioperative plan to improve outcomes in elective colon surgery have included avoiding starvation, limiting intravenous fluids, and increasing mobility. Providing a carbohydrate enhanced drink preoperatively as part of a complex perioperative plan has improved outcomes. Patients consuming 800 mL of a carbohydrate-rich liquid (100 g carbohydrate) at midnight and 400 mL 2 hours before the surgical intervention demonstrate a faster recovery, fewer infectious complications, and no increased aspirations. By providing this fluid and nutritional supplementation without a preoperative bowel prep, patients received less IV fluid, which improved recovery. In addition, a decrease in insulin resistance has been observed and associated with decreased complications and mortality. While oral nutritional supplements and probiotic use both have potential benefits, neither is currently standard in ERAS protocols.

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 formula D. Use an anti-motility agent

*B. Review the patient's medication administration record to determine whether hyperosmolar agents are being administered* 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 anti-motility 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.

What is the most reasonable justification to initiate enteral nutrition in an individual with advanced dementia? A. Decreased morbidity B. Specific and limited goal C. Improved mortality D. Improved quality of life

*B. Specific and limited goal* EN has not been shown to be an effective intervention to decrease mortality, improve morbidity outcomes, or improve quality of life in patients with advanced dementia. However, according to the Academy of Nutrition and Dietetics, a specific and realistically achievable goal may be a reason to initiate tube feeding in an older adult with advanced dementia.

Which of the following is true? A. The immune response of the gut remains intact when a patient is maintained on PN. B. The immune response of the gut remains intact when a patient is maintained on EN. C. Loss of gut integrity may allow bacteria of gut origin to infect distant organ sites, but this issue is improved with bowel rest. D. Enteral feedings should be stopped if the ileus is noted radiographically.

*B. The immune response of the gut remains intact when a patient is maintained on EN.* Loss of gut integrity has been demonstrated in patients hospitalized for pancreatitis who are maintained on PN and gut disuse while awaiting surgery. Over time, the villi in these patients become shortened, then lost. In contrast to pancreatitis patients who receive enteral tube feeding, pancreatitis patients placed on PN with gut disuse have greater exposure to endotoxins and greater oxidant stress. Clinicians should assess clinical signs of feeding intolerance because radiographic information on ileus may be misleading.

Which of the following claims for a dietary supplement would most likely cause the US Food and Drug Administration 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. Treats influenza* 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 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 a disease and thus would be disallowed.

Metabolic changes following SCIs depend on the level of cord injury and the extent of injuries. Which of the following statements is true? A. The energy expenditures following SCI is approximately 48% higher than that following TBI. B. To accurately assess the energy requirements for a patient with SCI, multiply the resting energy expenditure (calculated with the Harris-Benedict equation) by an injury factor of 1.6 and then again by activity factor of 1.2 C. A modified body mass index scale has been proposed for individuals with SCI, with healthy normal categorized as BMI 18 to 22. D. Patients with chronic SCI require approximately 30 to 33 kcal/kg/d depending on their physical activity.

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

Which of the following does not represent a potential complication following gastric resection and anastomosis? A. Anastomotic stricture B. Anastomotic ulcer C. Acid hyposecretion D. Biliary limb obstruction

*C. Acid hyposecretion* The remnant stomach continues to secrete acid in sufficient amounts to maintain an acidic stomach pH. Persistent secretion of acid is one of the contributing factors to development of anastomotic ulcers, and, ultimately, anastomotic strictures. Biliary limb obstruction can occur for a number of reasons, including torsion of said limb around adhesive bands or at the point of its distal anastomosis to the jejunum.

Which of the following is a contraindication for organ transplantation? A. Diabetes mellitus B. End-stage organ failure C. Active infection D. History of substance abuse

*C. Active infection* A significant, active infection such as pneumonia is likely to worsen after transplantation once immunosuppression is initiated. Diabetes mellitus is not by itself a contraindication for transplantation. In fact, diabetes mellitus is the indication for pancreas transplantation. However, if a potential transplant candidate has diabetes that is not well controlled, transplantation could be denied based on the transplant selection committee's criteria until glucose control is improved. End-stage organ failure that is not amenable to further medical or surgical treatment is an indication for transplantation. Finally, although active substance abuse is a contraindication for transplantation, transplantation may be considered if a candidate has demonstrated recovery.

Which of the following characteristics of an initial enteral feeding regimen would be most appropriate for a patient with SBS? A. A fiber-free, energy-dense formula administered via bolus infusion B. A hydrolyzed, elemental formula that is nigh in medium-chain triglyceride (MCT) oil C. An isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion D. A semi-elemental, peptide-based formula administered nocturnally

*C. An isotonic, polymeric, fiber-containing formula administered via continuous gastric infusion* When initiating enteral feedings in a patient with SBS, it is important that the formula be isotonic. Polymeric formulas are generally well tolerated. Gastric feeding may result in less diarrhea than small bowel feeding. The inclusion of soluble fiber may also be beneficial because it can slow gastric emptying, enhance adaptation, and provide an energy source in those patients who have a colon. Slow initiation of feedings administered via continuous gastric infusion as opposed to bolus administration may be better tolerated.

Which of the following statements is true regarding the nutrition status of the pregnant woman and its impact on the fetus? A. Obese pregnant women should lose weight during pregnancy to improve fetal outcomes B. The fetus is a "perfect parasite", and the nutrition status of the mother is of no consequence C. Appropriate weight gain for women of all body mass index ranges is essential to fetal health D. Poor maternal health and nutrition status has only short-term impact on the fetus

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

Which of the following is an example of a malabsorptive procedure for weight loss? A. Gastric band B. Sleeve gastrectomy C. Biliopancreatic diversion with duodenal switch D. Gastric balloon

*C. Biliopancreatic diversion with duodenal switch* A duodenal bypasses the functional small bowel (duodenum and a portion of the jejunum), thereby inhibiting absorption of water and nutrients from an ingested food bolus by these portions of the small bowel. Answers A, B, and D represent restrictive procedures for weight loss.

Which of the following is true about the net chemical reaction of glucose catabolism? A. Pyruvate is the final product B. Oxygen is required for Adenosine Triphosphate (ATP) synthesis C. Both water and carbon dioxide (CO2) are produced D. CO2 is produced but water is not E. Water is produced but CO2 is not

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

Which ionized form of SCFA (up to 6 carbons in length) is thought to be the most important to colonic health and why? A. Myristate B. Caproate C. Butyrate D. Valerate

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

A physician informs you that a patient has a serum albumin of 2.8 mg/dL, and a 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 indicated 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. Consideration of medical history, clinical diagnosis, and laboratory signs of the inflammatory response would help you interpret these findings* By themselves, these proteins should be interpreted with caution because they lack specificity and sensitivity as indicators of nutrition status. Both albumin and prealbumin may be reduced by the systemic response to injury, disease, or inflammation. Patients with low albumin or prealbumin levels may or may not be malnourished. The patient's medical history, clinical diagnosis, and laboratory signs of the inflammatory response can help clarify whether inflammation is present and whether the patient is malnourished.

Which of the following should be offered to provide elemental zinc for pressure injuries/ulcers healing? A. Zinc sulfate: 220 mg/d B. Zinc gluconate: 84 mg/d C. Daily multivitamin with minerals supplement D. Zinc chloride: 170 mg/d

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

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 does from 1.5 g/kg/d to 1 g/kg twice weekly. D. Increase protein does from 1 g/kg/d to 2 g/kg/d

*C. Decrease lipid injectable emulsion does from 1.5 g/kg/d to 1 g/kg twice weekly* Cholestasis has been associated with ILE doses greater than 1 g/kg/d in adult patients receiving long-term PN, and the patient may therefore benefit from a trial of lowering the ILE dose. Cyclic infusion has been shown to reduce serum liver enzyme and conjugated bilirubin concentrations when compared with continuous infusion. Enteral feeding should be attempted to promote enterohepatic circulation of bile acids. The protein dose does not seem to play a role in the development of cholestasis in adults.

The success of home nutrition support depends on which of the following strategies? A. Facilitating insurance reimbursement for nutrition support B. Providing individualized care to the patient at home C. Educating the patient and/or caregiver in managing enteral nutrition or PN at home D. Providing comfort to the families caring for the patient

*C. Educating the patient and/or caregiver in managing enteral nutrition or PN at home* Home nutrition support uses complex technical equipment. Ensuring that the patient or caregiver is willing and able to safely manage this equipment as well as all related procedures reduces the risk for complications. Short-term goals for the new home nutrition support patient or caregiver are to optimize the organization and safety of the home environment and identify risks related to potential complications. Long-term goals are to promote patient independence and adherence, and prevent hospital readmission.

Which parameter is measured when using IC? A. Heat loss B. Catabolic rate C. Gas exchange D. Free energy balance

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

Why is hemodynamic stability an important consideration before initiating enteral nutrition? A. To avoid overfeeding B. Hemodynamic instability is an indication for parenteral nutrition C. Gastrointestinal perfusion may be compromised D. Patients cannot absorb any nutrients when they are under-resuscitated

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

Which of the following should not be supplemented via EN to patients in pulmonary failure? A. Phosphorous B. Calcium C. Glutamine D. Magnesium

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

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 formula 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. Higher fat content* 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 table. 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. Make a slurry of the capsule's powder and administer via the feeding tube* IV administration is generally the most expensive method and requires IV access. Use of IV dosage forms via the gastrointestinal tract is not usually recommended because these dosage forms are not designed to withstand the environment of the GI tract (i.e. gastric acid), and adequate amounts may not reach the blood-stream after presystemic metabolism in the GI tract mucosa (i.e. cytochrome P450 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 can be combined with water to make a slurry for administration via a feeding tube.

Which of the following parenteral amino acid preparations is most appropriate for a dialysis-dependent patient with renal failure? A. Essential amino acids only B. Nonessential amino acids only C. Mixtures of essential and nonessential amino acids D. High branched-chain amino acids (BCAAs)

*C. Mixtures of essential and nonessential amino acids* Essential and nonessential amino acids are lost via dialysis solutions used for hemodialysis (HD) and peritoneal dialysis (PD). The ability to synthesize nonessential amino acids is reduced in patients with acute renal insufficiency. Therefore, a solution containing both essential and nonessential amino acids is preferred in this clinical setting. Enriched BCAA solutions have been studied in AKI and have not been shown to improve clinical outcomes.

Which of the following is the most important benefit to starting early enteral nutrition after trauma? A. Addressing protein-energy malnutrition before it is severe B. Preventing negative nitrogen balance C. Modulating the immune process and supporting the gastrointestinal tract D. Preventing severe hyperglycemia

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

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 non-tunneled 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. Place a single-lumen, tunneled cuffed catheter* A single-lumen tunneled catheter is the preferred device. The tunneled catheter was originally developed for patients with long-term PN. 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.

Which of the following statements best describes a prebiotic? A. All fibers are considered prebiotics B. Prebiotics are synthetic compounds C. Prebiotics are dietary polysaccharides that escape digestion by the host enzymes, are fermented by the gut microbiota, and influence the gut microbiota pattern in a beneficial manner D. All prebiotics are fermented to yield the same short chain fatty acids (SCFAs)

*C. Prebiotics are dietary polysaccharides that escape digestion by the host enzymes, are fermented by the gut microbiota, and influence the gut microbiota pattern in a beneficial manner.* Prebiotics are naturally occurring substances, predominantly dietary polysaccharides, which escape digestion by the host enzymes. They reach the distal biota to yield SCFAs and beneficially influence the gut dietary fiber; however, not all fibers are fermentable, and not all fermentable polysaccharides yield the same molar ratios of SCFAs.

Of the following, which is the best currently known nutrition intervention to minimize negative outcomes associated with sarcopenia? A. Protein supplementation B. Amino acid supplementation C. Protein adequacy D. omega-3 fatty acid adequacy

*C. Protein adequacy* Adequacy of protein intake seems to be the most important nutrition-related factor in preserving lean body mass in older adults. The type of protein, essential amino acid supplementation, and omega-3 fatty acid supplementation may all play roles in preventing sarcopenia.

Which of the following parameters is appropriate for monitoring glycemic control of pregnant women receiving nutrition support? A. Urine glucose B. Urine lactic acid C. Serum glucose D. Serum insulin

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

How might propofol, when provided to patients within a 10% (w/v) lipid injectable emulsion (ILE, aka intravenous fat emulsion IVFE) increase the risk of hypertriglyceridemia? A. Propofol causes acute uptake of triglycerides (TGs) by the microvilli of the small intestine B. Propofol is known to activate the release of TGs from adipose tissue C. The increased presence of liposomes in the propofol ILE may interfere with chylomircon and pseudochylomicron metabolism D. The presence of sedative in the ILE prevents phospholipid formation, which results in an increased level of TGs in the blood

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

Which of the following answers best describes how a clinician determines the most appropriate feeding route (i.e. oral, enteral, parenteral, or combination) for a patient with SBS? A. All patients with SBS need lifeline PN; if their energy and protein needs are met with PN, they can eat whatever they want for comfort B. To avoid the risk of PN-associated complications, PN should always be discontinued as soon as oral intake or enteral nutrition is initiated C. The nutrition regimen should be individualized to meet the needs of the particular person D. Insurance reimbursement plays the major role in deciding the feeding route

*C. The nutrition regimen should be individualized to meet the needs of the particular person* Many nutrition support options are available. The best option will depend on the patient's bowel anatomy, length of time since surgery, current weight, laboratory test data, and hydration status. The most appropriate nutrition regimen should be individualized to meet the needs of the particular person. As the adaptation process progresses and the patient becomes more stable, nutrition support may be decreased as tolerated.

Which of the following would be a reason to not place a long-term feeding tube in a patient with advanced dementia? A. A swallow evaluation was not recently completed. B. During the hospitalization, the healthcare team did not have a meeting where the family could ask questions about the rationale for the tube placement. C. The patient's expected survival post feeding tube placement is less than 30 days D. The patient does not have an advance directive indicating a designated decision maker and specific healthcare wishes.

*C. The patient's expected survival post feeding tube placement is less than 30 days* A patient's expected survival time affects the evaluation of the benefits vs. burdens and risks of the procedure. A swallow evaluation, family meeting, and presence of an advance directive are not limiting factors for placement of a long-term feeding tube.

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. Use of the "Central Line Bundle" of insertion and maintenance practices* The Central Line Bundle for insertion and maintenance includes hand hygiene, maximal barrier precautions, skin antisepsis with chlorhexidine gluconate, optimal catheter site selection, and 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 not be removed when clinically indicated. Studies have shown a lower rate of catheter-related infections in line placements via the subclavian site.

A patient's glucose decreased from 180 mg/dL to 140 mg/dL when given 5 units of insulin lispro. Estimate the total daily insulin dose using the sensitivity factor and the rule of 1800. A. 8 units B. 40 units C. 187.5 units D. 225 units

*D. 225 units* To arrive at this answer, first calculate the sensitivity factor (the decline in blood glucose in mg/dL per unit of regular or rapid-acting insulin). If the glucose decreased 40 mg/dL following an injection of 5 units, the sensitivity factor is 8 (40/5 = 8). Since insulin lispro, a rapid-acting insulin, was used, the total daily dose may then be estimated using the rule of 1800: divide 1800 by the sensitivity factor. The patient will need a total daily insulin dose of 225 units (1800/8 = 225).

The administration of 1 liter of 0.9% sodium chloride (NaCl) to a normonatremic patient will increase the intravascular and interstitial fluid compartments by: A. 1000 mL and 0 mL, respectively B. 0 mL and 1000 mL, respectively C. 750 mL and 250 mL, respectively D. 250 mL and 750 mL, respectively

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

Which of the following should be part of a nutrition care plan for a patient during an acute rejection episode that is being treated with high-dose corticosteroids? A. Provide increased amounts of dietary carbohydrate and monitor for signs of fluid overload B. Provide increased amounts of dietary fat and monitor for signs of hyperlipidemia. C. Provide increased amounts of dietary carbohydrate and monitor for signs of azotemia. D. Provide increased amounts of dietary protein and monitor for signs of hyperglycemia.

*D. Provide increased amounts of dietary protein and monitor for signs of hyperglycemia.* Because corticosteroids accelerate the rate of protein catabolism, it is essential to provide adequate protein to reduce nitrogen loss. Hyperglycemia is also a common side effect of high-dose corticosteroids. Hyperlipidemia is a long-term side effect of corticosteroids but is not usually a short-term complication.

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. A dietary supplement product is marketed and sold, but there are no studies to confirm its efficacy for any condition* The DSHEA mandates that CGMPs be set up for the dietary supplement industry. Under these CGMPs, process controls are supposed to be in place at each step of manufacturing. Thus, the dietary supplements arriving on the shelf should contain the correct ingredients in the correct amounts and should be free of adulterants. There should be consistency between lots in terms of content. Unfortunately, the FDA does not have sufficient resources to inspect all manufacturing plants and final products. However, examples of random testing of the authenticity of dietary supplements sold in large national retail chains by New York State agencies caught national attention in 2015 and led to legal action against the retailers, which ultimately paid large settlements. The CGMPs do not address whether there are any data supporting the efficacy of dietary supplements.

Which of the following answers best reflects dietary modifications that may prevent the development of nephrolithiasis-related renal failure? A. A calcium-restricted diet with increased free-water intake B. A low-fat diet with adequate phosphorous repletion and increased free-water intake C. A low-fat and oxalate- and calcium-restricted diet D. A low-fat, oxalate-restricted diet with adequate hydration

*D. A low-fat, oxalate-restricted diet with adequate hydration* Patients with SBS who have fat malabsorption and an intact colon are at risk for oxalate kidney stones. Calcium normally binds oxalate - a substance found naturally in many foods - in the colon, thus preventing oxalate's absorption. In the setting of fat malabsorption, calcium will bind to excess fat entering the colon, leaving the oxalates free to be absorbed into the bloodstream and excreted via the kidney, thus forming oxalate kidney stones. A low-fat, oxalate-restricted diet plays a key role in the prevention of oxalate kidney stones. The use of a calcium supplement or consumption of food that is high in calcium may also help to bind the oxalate and facilitate its excretion in the feces.

If a nasogastric 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. 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* 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, alpha-amylase, and citric acid solution. It has a lower success rate than pancreatic enzyme solutions. Waiting longer will not help a tube become unclogged.

Which of the following statements explains why fermentable fiber is a beneficial addition to enteral formulas? A. Colonic bacteria act on the fiber to produce short-chain fatty acids (SCFAs) that provide an energy source to the intestinal mucosa. B. Colonic bacteria act on the fiber to produce SCFAs, which, in turn, exert trophic effects on the intestinal mucosa C. Fermentable fiber may help control diarrhea by slowing gastric emptying D. All of the above

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

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

*D. All of the above* 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.

Which of the following statements is true about the decision to withhold or withdraw ANH? A. There is an ethical distinction between withholding and withdrawing treatment. B. Decisions to withhold ANH tend to be more psychologically and emotionally charged for families than decisions to withdraw ANH. C. There is a legal distinction between withholding and withdrawing any treatment. D. The term forgoing refers to both withholding and withdrawing ANH.

*D. The term forgoing refers to both withholding and withdrawing ANH.* There is no ethical or legal distinction between withholding or withdrawing treatment. However, decisions to withdraw ANH may be more psychologically and emotionally charged for clinicians, patients, and families than decisions to withhold intervention.

All wounds begin as acute wounds. Which of the following distinguishes an acute wound from a chronic wound? A. An acute wound will generally heal within 2 to 3 days, whereas a chronic wound will likely take 7 to 10 days to heal B. Acute wounds are related to an initial injury, whereas chronic wounds develop due to an underlying pathological process C. The micro-environments of the 2 types of wounds are different, with acute wounds having fewer inflammatory mediators present D. Both B and C

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

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. 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.* Standard polymeric formulas are indicated for most patients requiring enteral nutrition 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.

According to recommendations by the National Advisory Group on Standards and Practice guidelines for parenteral nutrition formulations and the 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 (i.e. dextrose 50% water, 500 mL) B. The percentage of final concentration after admixture (i.e. dextrose 25%) C. Grams per liter of PN admixed (i.e. dextrose 250 g/L) D. Grams per day (i.e. dextrose 250 g/d)

*D. Grams per day (i.e. dextrose 250 g/d)* Grams of dextrose per day is the information most consistent with that found on a nutrient label, supports the use of the 24-hour nutrient infusion system, and requires the least number of calculations to determine the daily energy amount. The quantity per liter may appear on the label in a second column in parentheses.

Which of the following trace elements is regulated at the level of absorption but not excretion? A. Zinc B. Copper C. Manganese D. Iron

*D. Iron* The control mechanisms that keep iron levels stable in the body occur at the absorption phase. It is very difficult to eliminate iron except in conditions of blood loss (i.e. blood donation or menstruation).

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. Low-profile, 20-Fr percutaneous G-tube with balloon internal bolster* 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 the 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 is an example of a patient condition anticipated to manifest with a severe systemic inflammatory response? A. Anorexia nervosa with body mass index 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. Thermal burn injury of second and third degrees covering 15% body surface area* 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.

The first B vitamin deficiency to manifest in people with alcoholism is usually: A. Niacin B. Pantothenic acid C. Vitamin B6 D. Thiamin

*D. Thiamin* Very small amounts of thiamin are stored in the liver. Therefore, this B vitamin tends to be the first to become deficient in malabsorptive or inadequate intake situations.

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 their health care providers are knowledgable about dietary supplements D. Many patients using prescription medicines concomitantly use dietary supplements

*D. Many patients using prescription medicines concomitantly use dietary supplements* Surveys have shown varying percentages of the US population using dietary supplements. Data from a large nationwide survey published in 2016 indicated that the use of dietary supplements remained stable between 1999 and 2012, with 52% of US adults reporting use of any supplements in 2011-2012. Many persons using dietary supplements to 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 their health provider will be judgmental about their use. Abundant data indicate that the latter belief is overwhelmingly the most common reason why patients to 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 knowledgable regarding dietary supplements, only about half of patients in a recent survey reported that providers actually were knowledgable. 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.

Which of the following is an accurate marker of nutrition status in all patients with chronic liver disease with portal hypertension? A. Serum prealbumin B. Retinol-binding protein C. Anthropometry D. None of the above

*D. None of the above* There are no consistently accurate measures of malnutrition in patients with significant liver disease. Visceral proteins such as albumin, prealbumin, and retinol-binding protein are made in the liver and better correlate with the severity of liver disease rather than the degree of malnutrition. Anthropometry can be inaccurate in the setting of edema and/or ascites.

A nutrition support clinician was consulted on the second day of hospitalization about a patient who presented with severe acute pancreatitis and required mechanical ventilation. A recent, dynamic contrast-enhanced computed tomography (CT) scan revealed necrosis involving 30% of the pancreatic gland and a small (4 cm) pseudocyst in the tail of the gland. Which of the following should the clinician recommend? A. Continue NPO status with no enteral tube feeding, noting that the necrosis may require surgical intervention B. Start the patient on PN because the patient is mechanically ventilated and has a pseudocyst. C. Place a nasojejunal tube and begin enteral tube feeding providing no more than 20 ml/hr. D. Place a nasojejunal tube, begin tube feeding, and advance to the nutrition goal over the first 24 to 48 hours.

*D. Plase a nasojejunal tube, begin tube feeding, and advance to the nutrition goal over the first 24 to 48 hours.* Complications such as pancreatic ascites, fistulas, and pseudocysts are part of the natural disease course of acute pancreatitis. Information mostly from retrospective case series indicates that the use of enteral route is safe and allows for the resolution of these complications in most circumstances. The patient has severe pancreatitis and should therefore benefit from EN.

During protein metabolism, branched-chain amino acids (BCAAs): A. Are extracted primarily by the liver after a protein-containing meal B. Are released by the skeletal muscle at a higher rate than other amino acids C. Serve as the primary fuel sources for the enterocytes. D. Produce oxidative wastes during metabolism within the skeletal muscle, which are removed by alanine and glutamine.

*D. Produce oxidative wastes during metabolism within the skeletal muscle, which are removed by alanine and glutamine* Nitrogen end products produced during BCAA oxidation within the skeletal muscle are removed extracted primarily by the skeletal muscle, with minimal extraction by the liver. BCAAs are primarily oxidized in the skeletal muscle (not the enterocytes) and are released from the muscle at a lower rate than other amino acids.

Which of the following statements is false regarding alcoholic hepatitis? A. Virtually all patients with alcoholic hepatitis have some degree of malnutrition B. The severity of liver disease generally correlates with the degree of malnutrition. C. Energy intake correlates with mortality. D. Protein delivery should be reduced to prevent portal systemic encephalopathy.

*D. Protein delivery should be reduced to prevent portal systemic encephalopathy* The Veterans Health Administration (VA) Cooperative Studies Program demonstrated that virtually all patients with alcoholic hepatitis have some degree of malnutrition. In addition, the severity of liver disease generally correlated with the degree of malnutrition. Study subjects consuming more than 3000 kcal/day had almost no mortality, whereas those consuming less than 1000 kcal/day had greater than 80% mortality. Thus, food intake correlated with 6-month mortality. Protein requirements in patients with alcoholic hepatitis are increased, and the delivery of protein is not a significant precipitant of PSE. Protein restriction is rarely required in alcoholic hepatitis (or any other liver disease, for that matter) and should only be considered in the setting of PSE refractory to medical treatment.

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 phosphorous per day

*D. Provide 20 to 40 mmol phosphorous per day* An inadequate phosphorous dose may increase urinary calcium excretion; therefore, ASPEN recommends that phosphorous 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 phosphorous, 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.