ASPEN CNSC practice

EN should be delayed until these 3 things can be accomplished in order to reduce the risk of intestinal ischemia?

1. patient is fully volume resuscitated 2. hemodynamically stable 3. mesenteric perfusion has been restored

4 strategies to reduce nausea vomiting with enteral feedings?

1. reduction or discontinuation of narcotic medications 2. use of low fat formulas 3. administering enteral formula t room temperature 4. reducing the rate and/or volume of tube feeding infusion

Which nutrition therapy is preferred in early post-transplant hematopoietic cell transplant patients (adult)?

Currently there is insufficient data to establish benefits of enteral nutrition over parenteral nutrition with hematopoietic cell transplants. In one study, parenteral nutrition was found to increase survival in allogeneic patients

What is the current recommendation for initiating enteral feedings in adults and children?

Currently, it is recommended that feedings in adults and children be initiated with full strength formulas at a slow rate and steadily advanced.

How should liquid formulations be administered? Why?

Many liquid medications are hyperosmolar which can lead to diarrhea and/or have high viscosity which can lead to tube clogging, so liquid dosage forms should be diluted with water prior to administration

Do adult enteral products contain lactose?

No

Do electromagnetic NGT placement devices monitor pH?

No

Is evidence of bowel function (bowel sounds) required prior to starting enteral nutrition?

No

Is sorbitol an ingredient in enteral formulas?

No

Is there an indication for routine cultures in the uncomplicated enterally fed patient?

No

What is the most common complication following gastrostomy placement?

peristomal infection

What does the display on an electromagnetic placement device for NGT placement show?

real-time perspective of the tube tip location with a 3D localization

Do liquid medications contain lactose?

the lactose content of most individual dosage forms of medication is too small to result in significant digestive problems

What is the osmolality of a 30 calorie per ounce concentrated standard infant formula?

About 450 mOsm/kg

What was common practice in the past to detect aspiration of enteral feedings?

Addition of blue dye

What population is sarcopenia a common problem for?

Adults over the age of 65 years and increases with age

After 2 weeks of fasting where does most energy come from?

After 2 weeks of fasting, adipose tissue can provide more than 90% of daily energy requirements

What is the role of bile acids secreted by the liver as well as lipase and colipase produced by the pancreas?

Aid in micellar solubilization and absorption of dietary fat

How are hypoalbuminemia and hypocalcemia related?

Although there is a causal relationship between hypoalbuminemia and hypocalcemia a low serum calcium does not cause a low serum albumin

Define ketonemia. What is the cause?

An elevated circulating ketone bodies secondary to increased fatty acid oxidation occurring with starvation, catabolic illness or inadequate dietary carbohydrate intake.

What is galactosemia?

An inborn error of metabolism that affects the body's ability to metabolize galactose

Who should place an NGT if a patient is being transferred to the OR and requires enteral access?

Anesthesia staff or the surgeon after the patient is under sedation

How much TBW is contained in the extracellular fluid?

Approximately 1/3 of total body water

What amino acid is conditionally essential during wound healing?

Arginine

Why are ileal resections generally more poorly tolerated than jejunal resections?

Because adaptive hyperplasia in the remaining jejunum is limited, the ileum is capable of compensation and adaptation

Describe glycogen as a storage method for energy.

Because glycogen is stored with water, this is a somewhat bulky depot and inefficient storage method

What are mid-arm muscle circumference and hand grip strength sensitive markers for?

Body cell mass depletion

List 3 reasons postoperative and critically ill neonates have lower energy needs.

1. Absence of growth 2. Decreased activity 3. Reduction of insensible losses

3 factors that favor continuous infusion feeding in critically ill patients.

1. Accessibility of enteral pumps to control the rate and volume delivered to the patient 2. Better tolerance to tube feeding with fewer gastric complaints 3. Possible lowered risk of aspiration by prevention of gastric distention

Which of the following immunomodulating nutrients may be harmful in patients with severe sepsis? 1. Arginine 2. Glutamine 3. Nucleic acids 4. Omega-3 fatty acids

1. Arginine

List the 3 components of basal-bolus insulin therapy?

1. Basal insulin 2. Nutritional component prior to meals 3. Correctional insulin

What 2 cell types in the body require a constant supply of glucose?

1. Brain 2. Red blood cells

List 2 other factors aside from overfeeding which can increase RQ?

1. CO2 production 2. Administration of excess buffering agents such as sodium bicarbonate

What 2 methods have been used effectively to break down bezoar?

1. Cellulase enzymatic therapy 2. Cola

List 3 possible causes of zinc deficiency.

1. Chronic malnutrition 2. Cirrhosis 3. Chronic stress

What 3 oils are rich in linoleic acid?

1. Corn 2. Soybean 3. Safflower

List 3 responsibilities of home infusion providers.

1. Delivery of nutritional products 2. Appropriate supplies for the delivery of nutrition 3. Nursing care required to educate about and monitor the prescribed therapy

Which of the following diagnoses would meet Medicare Part B coverage criteria to qualify a beneficiary for home enteral nutrition? 1. Dysphagia 2. Aspiration pneumonia 3. Anorexia 4. Malnutrition

1. Dysphagia

2 situations in which hypergranulation develops?

1. Exit site remains moist 2. Tube is not stabilized

What 2 vitamin deficiencies lead to anemia but not peripheral neuropathy?

1. Iron 2. Folate

Which are the only 2 organs with the necessary enzymes for gluconeogenesis?

1. Kidney 2. Liver

In cirrhotic patients, which of the following should be implemented to assist in avoiding fasting-associated starvation during the night? 1. Late evening snack 2. nocturnal tube feeding 3. branched chain amino acids supplement 4. nocturnal parenteral nutrition

1. Late evening snack

What 5 molecules are proteins involved in the transport of?

1. Lipids 2. Vitamins 3. Minerals 4. Albumin 5. Oxygen

List 5 signs and symptoms of Wernicke's encephalopathy.

1. Mental status changes 2. Confusion 3. Nystagmus 4. Gait ataxia 5. Polyneuritis

List the 3 components of the Resident Assessment Instrument (RAI).

1. Minimum Data Set (MDS) 2. Resident Assessment Protocols (RAPs) 3. Utilization guidelines

List the 5 elements which are excreted at higher rates in the urine during the flow phase following burn injury.

1. Nitrogen 2. Sulphur 3. Magnesium 4. Phosphorus 5. Potassium

Which 5 elements are excreted at higher rates during the flow phase after burns?

1. Nitrogen 2. Sulphur 3. Magnesium 4. Phosphorus 5. Potassium

When used in assessment of critically ill children, how do predictive equations compare to indirect calorimetry? 1. No consistent comparison can be found 2. Equations typically overestimate needs 3. Equations typically underestimate needs 4. Equations correlate well with indirect calorimetry

1. No consistent comparison can be found

Name 2 research based methods utilized to restore patency to clogged feeding tubes.

1. Pancreatic enzyme with sodium bicarbonate 2. Mechanical declogging device

List 10 possible causes of abdominal distention in enteral tube feeding.

1. Rapid administration of feeding (bolus feeds) 2. Use of hyperosmolar solution (concentrated formulas) 3. Medications that slow peristalsis (pain relievers, anticholinergics) 4. Excess air in the stomach or intestines 5. Tube migration from stomach to small intestine 6. Infection 7. Cold formula 8. Inadequate fluid provision leading to constipation 9. Bacterial contamination 10. Fat, fiber or lactose intolerance

List 10 possible reason for abdominal distention upon enteral tube feeding.

1. Rapid administration of feeding (i.e. bolus feeds) 2. Use of hyperosmolar solution (concentrated formulas) 3. Medications that slow peristalsis (pain relievers, anticholinergics) 4. Excess air in the stomach or intestines 5. Tube migration from stomach to small intestine 6. Infection 7. Cold formula 8. Inadequate fluid provision leading to constipation 9. Bacterial contamination 10. Fat, fiber or lactose intolerance

What should be addressed prior to discharge of the HPN patient? (3 things)

1. Reimbursement issues 2. Stability of the patient's electrolyte values 3. Components of the PN formulation

What 2 amino acids are essential in neonates and not in adults? Why?

1. Taurine 2. Tyrosine - Enzyme immaturity

3 factors that may affect the measurement of GRV?

1. Type of feeding tube 2. Body posiiton 3. Location of the tip of the feeding tube

3 advantages of the "teach back" process.

1. Verify understanding 2. Correct inaccurate information 3. Reinforce new home care skills

What 2 nutritionally important things are absorbed in the ileum?

1. Vitamin B12 2. Bile salts

The chronic use of steroids in premature infants has been associated with: 1. osteopenia 2. cholestasis 3. nephrolithiasis 4. hypoglycemia

1. osteopenia

Name 4 situations that result in mucosal atrophy.

1. periods of bowel rest 2. minimal PO intake 3. stress 4. absence of glutamine

2 populations in which carnitine deficiency is a concern?

1. preterm infants 2. chronic renal failure

What is the WHO definition of persistent diarrhea?

14 days or longer in duration

What type of fatty acid is oleic acid?

18 carbons, long chain

What percentage of total calories as fat should be sufficient to prevent EFAD?

2-4% of total calories

Which of the following is a characteristic of acute disease-associated malnutrition? 1. splenomegaly 2. anasarca 3. hypoglycemia 4. anemia

2. Anasarca

Which of the following is NOT a frequently reported concern of caregivers of patients receiving enteral tube feedings? 1. Guilt 2. Causing harm 3. Social embarrassment 4. Fatigue

2. Causing harm

Which protein transports oxygen from the lungs to other parts of the body? 1. Albumin 2. Hemoglobin 3. Lipoprotein 4. Retinol-binding protein

2. Hemoglobin

What trace element should be monitored in a child with chronic diarrhea? 1. Iron 2. Zinc 3. Copper 4. Selenium

2. Zinc

Patients with chronic heart failure are typically on a loop diuretic. These patients are at risk for: 1. hyperkalemia 2. azotemia 3. hypermagnesemia 4. hypoglycemia

2. azotemia

How long does the stress phase of the metabolic response to critical illness usually last?

24 hours

What is the hang time range for closed system enteral feeding containers?

24-48 hours

What is the recommended hang time for closed system enteral feeding containers?

24-48 hours

What is the hang time for closed system enteral feeding? How does this compare to open feeding systems?

24-48 hours, compared to 8-12 hours for open feeding systems

What are fluid requirements for healthy adults > 75 years old?

25 ml/kg

All patients admitted to the home care provider shall undergo nutrition screening using subjective and/or objective criteria within: 1. 24 hours 2. 48 hours 3. 72 hours 4. 96 hours

3. 72 hours

First-line therapy for hyperkalemic emergencies is 1. hemodialysis 2. regular insulin with dextrose 3. calcium gluconate 4. furosemide

3. Calcium gluconate

Pancreatic enzymes supplemented at high doses in children with cystic fibrosis could result in 1. Steatorrhea 2. Meconium ileus 3. Fibrosing colonopathy 4. Cystic fibrosis related diabetes

3. Fibrosing colonopathy

Cheilosis is a physical symptom associated with a deficiency of 1. vitamin D 2. folic acid 3. riboflavin 4. vitamin C

3. Riboflavin

Lactic acidosis can be a result of which vitamin deficiency? 1. folic acid 2. vitamin E 3. Thiamin 4. Vitamin C

3. Thiamin

Arginine supplementation should be used most cautiously in which of the following patients? 1. short bowel 2. cirrhotic patients 3. septic shock patients 4. immunocompromised patients

3. septic shock patients

How many calories are in 1 gram of dextrose?

3.4

What is the most widely used tool to measure generic health-related quality of life? 1. Katz ADL 2. Lawton-Brody IADL 3. FIM 4. SF-36

4. SF-36

Which of the following is recommended to prevent vitamin D deficiency in a 1 month old infant fed human milk? 1. Supplement with 100 IU vitamin D per day 2. Supplement with 200 IU vitamin D per day 3. Supplement with 300 IU vitamin D per day 4. Supplement with 400 IU vitamin D per day

4. Supplement with 400 IU vitamin D per day

Which of the following is recommended to prevent vitamin D deficiency in a 1-month-old infant fed human milk? 1. Supplement with 100 IU vitamin D per day 2. Supplement with 200 IU vitamin D per day 3. Supplement with 300 IU vitamin D per day 4. Supplement with 400 IU vitamin D per day

4. Supplement with 400 IU vitamin D per day

When implementing early enteral nutrition (EN) in critically ill patients, which of the following factors is most likely to increase success in moving patients toward target feeding rate? 1. Degree of adherence to physician's orders 2. Combined use of EN and parenteral nutrition 3. Use of gastric feeding 4. Use of an interdisciplinary EN feeding protocol

4. Use of an interdisciplinary EN feeding protocol

When implementing early enteral nutrition (EN) in critically ill patients, which of the following factors is most likely to increase success in moving patients toward target feeding rate? 1. degree of adherence to physician's orders 2. Combined use of EN and parenteral nutrition 3. Use of gastric feeding 4. Use of an interdisciplinary EN feeding protocol

4. Use of an interdisciplinary EN feeding protocol

What vitamin absorption is most likely to be impaired with chronic use of proton pump inhibitor therapy? 1. Vitamin A 2. Vitamin C 3. Vitamin B6 4. Vitamin B12

4. Vitamin B12

All of the following hydrolyze fat in the small intestine EXCEPT 1. pancreatic lipase 2. cholesterol ester hydrolase 3. phospholipase 4. bile acids

4. bile acids

The majority of fat digestion occurs in the: 1. ileum 2. mouth 3. colon 4. duodenum

4. duodenum

Iron is absorbed in the 1. stomach 2. colon 3. ileum 4. jejunum

4. jejunum

Which of the following types of fistulas will result in the greatest degree of nutritional loss? 1. distal low output 2. distal high output 3. proximal low output 4. proximal high output

4. proximal high output

The use of enteral nutrition formulas enriched with BCAAs is best used for patients with: 1. cirrhosis 2. hepatic failure 3. liver transplantation 4. refractory encephalopathy

4. refractory encephalopathy

What is the macronutrient breakdown for most oral nutrition supplements.

40-60% carbohydrate, 15-25% protein, 15-35% fat

What is the hang time for open system enteral feeding containers at the hospital?

8 hours

What is the half life of transferrin?

8-10 days

Once enteral nutrition administration is stable in the diabetic patient what type of insulin should be used?

A basal/bolus insulin regimen is recommended to achieve safe, effective glucose control

When possible where should enteral formulas be mixed, reconstituted or diluted? Why?

A centralized location, such as an enteral formulary room or pharmacy to minimize the risk of contamination

How is infantile anorexia characterized?

A child's refusal to eat adequate amounts of food for at least 1 month. The disorder is not due to an associated gastrointestinal disorder or other medical condition and does not follow a traumatic event

What is mixed state malnutrition?

A combination of marasmus and kwashiorkor

What should be recommended for a child with a suspected cow's milk protein allergy?

A correct initial response would be to switch to a protein hydrolysate or free amino acid formula. Since a percentage of children who are allergic to cow's milk protein will also be allergic to soy protein, the American Academy of Pediatrics now recommends a trial use of either a hydrolyzed or free amino acid containing formula

What is the major advantage of the Fenton growth chart?

A major advantage is that it allows for tracking of growth from 22 weeks gestational age up through 10 weeks post term age

What is the current evidence based recommendation for lactobacillus GG usage?

A meta-analysis of randomized controlled studies concluded that Lactobacillus GG is a safe and effective treatment for children with acute infectious diarrhea. Current research does not support use of Lactobacillus GG as therapy for treatment of NEC, Crohn's or heliobacter pylori in infants or children (research has been done with other strains of probiotics in these conditions)

What type of calcium balance can be expected in cyclic TPN patients?

A negative calcium balance with an 80% increase in urinary calcium excretion has been reported in cyclic patients

When would port placement for PN be indicated?

A port would require surgical implantation and is generally indicated for long term use (greater than 6 weeks)

What does fluoroscopy require?

A radiologist to be in attendance

What is the preferred treatment for an otherwise healthy infant with acute dehydration?

A short course of oral rehydration therapy followed by returning to an age-appropriate and healthy diet early in the course of diarrheal illness is superior to providing diluted formula or clear liquids.

An infant who is mildly dehydrated from diarrhea is likely suffering from what?

A viral gastroenteritis that will resolve in 72-96 hours

Where is iron primarily absorbed?

duodenum and jejunum

When are cyclic feedings typically given?

overnight

Is pH monitored in electromagnetic placement for NGT placement?

pH is not monitored in this placement technique

When can soft tissue and vascular calcification be expected to occur?

Calcification occurs when the product of calcium x phosphorus exceeds 55

What should be supplemented in patients on long-term steroids?

Calcium and Vitamin D to reduce ostepenia

At what level of IV Mn administration can brain deposition of maganese develop?

Can occur with IV Mn administration of 1.1 mg/day

What can be done if granulation tissue is excessive?

Cauterized with silver nitrate sticks or other cauterizing devices

What population should the BSA method for calculating fluid needs not be used?

Children < 10 kg

What is the final digestive process for nucleosides?

Cleaved into purines and pyrimidines and the absorbed by active transport

What is Mosteller's formula used for?

Commonly used equation to calculate body surface area

What is the electrolyte content of normal saline (0.9% sodium chloride)?

Contains only sodium: 154 mEq/L and chloride: 154 mEq/L

Where does Crohn's disease impact the GI tract?

Crohn's disease can appear anywhere from the mouth to the most distal bowel

Define cyclic feeding.

Cyclic feedings are generally administered over 8-16 hours per day, depending on the patients volume tolerance

When do post procedural complications present after PEG tube placement?

Days to months after placement

What was found to be the most common problem in a group of elderly patients receiving home enteral nutrition? What is the etiology?

Decreased urination Relates to inadequate fluid intake while on enteral feeding and the potential for dehydration

Define continuous feedings.

Delivered at a prescribed rate without interruption

Why does cyclosporine lead to hyperkalemia? What education should be provided to patients?

Direct effect on the renin-angiotensin-aldosterone system contributing to altered potassium homeostasis. Cyclosporine also affects the renal tubular excretion of potassium. Patients taking cyclosporine should be educated on dietary potassium intake and should have serum potassium levels monitored on a regular basis

Are dressings necessary for feeding tube site care?

Dressings at the tube insertion site are not necessary unless there is drainage

How does fluorosis develop?

During normal enamel maturation, the increased mineralization int eh developing tooth is accompanied by the loss of matrix proteins that are secreted early in development. Sufficiently high levels of fluoride can disrupt this process and increase enamel porosity. The greater the amount of fluoride intake during development the greater the prevalence of enamel fluorosis

What happens to the body during starvation?

During starvation the body begins to use fat as the predominant energy source leading to increased ketone production with a resulting euphoria

How is EFA status usually evaluated?

EFA status is usually evaluated by measuring the triene:tetraene ratio

When should EN be initiated in the hemodynamically unstable patient?

EN should be delayed until fluid resuscitation is complete

What reduces morbidity and mortality with exit site infections?

Early recognition

What is the upper limit for pancreatic enzyme usage?

Enzymes should be used at less than 10,000 units of lipase/kg/day

How does excess protein intake impact calcium?

Excessive protein is known to enhance calcium excretion leading to negative calcium balance

What is the recommended blood glucose level for critically ill patients?

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

What does FiO2 stand for?

Fraction of inspired oxygen

Define cyclic feedings

Generally administered over 8-16 hours per day

What is the purpose of glutamine supplementation?

Glutamine supplementation is supposed to reduce mortality and nosocomial infections in critically ill patients

Define marasmus.

Gradual wasting of body fat and somatic muscle with preservation of visceral proteins

What is the objective measure used to assess functional status?

Handgrip strength is a measurement that may indicate functional ability

What is the hang time for human breast milk (HBM) decanted into an open delivery system for use in neonates and immunocompromised pediatric patients?

Hang time no longer than 4 hours

What is Hartnup's Syndrome?

Hartnup's syndrome is an autosomal recessive disorder i which basic amino acids are not absorbed and may present as a pellagra-like syndrome. Pellagra-like symptoms include dermatitis, diarrhea and dementia

How does pediatric disease impact children?

Has an adverse effect on growth and nutritional status

How does hemodialysis impact copper levels?

Hemodialysis increases copper losses

Can hypermaganesemia occur in PN patients with normal liver function?

Hypermaganesemia can occur in all patients on long-term PN, regardless of liver function

When is dumping syndrome most likely to develop?

If all or part of the stomach has been removed

What is the fluid provision recommendation when using a fiber containing enteral regimen?

If fiber is added to the enteral regimen, patients must receive a minimum of 1 mL of fluid per kcal to prevent solidification of waste in the colon and constipation

What is the role of the ileocecal valve in nutrient absorption?

Ileocecal valve slows intestinal transit allowing for greater absorption of nutrients

What is the evidence for albumin as a significant independent predictor of morbidity and mortality in ICU patients?

In a study including 1023 critically ill patients, albumin was a significant independent predictor of morbidity and mortality. ICU and hospital length of stay, ventilator days, risk of infection and mortality were significantly greater for patients with a serum albumin < 2.6 g/dL

What percentage of ingested glucose is converted into glycogen?

In general only about 5% of ingested glucose is polymerized into glycogen, with the majority being oxidized

Describe the accuracy of predictive equations in pediatric intensive care patients.

In pediatric intensive care patients, predictive equations for energy expenditure yield results that are not consistent with measured energy expenditure. Provision of nutrition support based on inaccurately estimated energy requirements has been shown to result in significant under or overfeeding

How does steatorrhea impact nephrolithiasis from calcium oxalate stones?

In the setting of steatorrhea calcium binds to fatty acids, leaving oxalate free to pass into the colon to be absorbed and then filtered by the kidney. In the kidney oxalate binds to calcium resulting in oxalate nephropathy

How does volume depletion impact nephrolithiasis?

Increases risk

What method of feeding uses enteral pump or gravity drip method over a period of 20-60 minutes 4-6xs/daily?

Intermittent feedings

What form is iron absorbed in? Why? What is important for its absorption?

Iron is absorbed in the ferrous state rather than the ferric state. The ferric form of iron is insoluble in aqueous solutions and, therefore, not absorbed. Gastric acid is very important in maintaining dietary iron in the ferrous state

What is the iron supplement protocol for infants exclusively fed human milk?

Iron supplement starting at 4-6 months of age

Where is Lactobacillus GG normally found?

It is a component of normal human intestinal flora

What may be done to treat excessive hypergranulation tissue?

It may be cauterized with silver nitrate sticks or other cauterizing devices

Where is the primary site of most nutrients (including water soluble vitamins)?

Jejunum

What form of glutamine is used in oral nutrition supplements?

L-glutamine powder

What is sarcopenia?

Loss of muscle mass and strength, it is the hallmark of frailty

How is maganese deficiency detected?

MRI can detect Mn toxicity but the procedure is expensive. The best method of monitoring Mn status is with whole blood Mn levels as they correlate well with MRI abnormalities

How is manganese (Mn) eliminated normally?

Manganese is almost exclusively excreted via the hepatobiliary system

What is the predicted length of usage for a midline catheter?

Midline catheters are short-term vascular access devices (VADs) typically used for therapies lasting 2-4 weeks

What does an RQ of 0.85 indicate?

Mixed substrate utilization or appropriate nutrient delivery

How do predictive equations compare with actual measurements using indirect calorimetry when predicting energy expenditure in children?

Most equations are significantly different both overestimating and underestimating, no consistent comparison can be found

What does NEC stand for?

Necrotizing enterocolitis (NEC)

Who is the Holliday-Segar method not suitable for?

Neonates < 14 days old

Is prone positioning recommended in patients with elevated GRVs? Why?

No as it may increase the risk of aspiration

Is supplemental HPN covered at home by Medicare?

No supplemental HPN is rarely covered at home by Medicare

Would prone position be recommended in a patient with elevated GRVs?

No, may increase the risk of aspiration

How is copper homeostasis normally maintained?

Normal copper homeostasis is maintained via biliary excretion

What is the normal mechanism for oxalate excretion?

Normally dietary oxalate binds to calcium and is excreted in the stool

How do nutrition interventions impact frailty?

Nutrition interventions have not improved outcomes in frailty

What is the SF-36?

One of the most widely used tools to measure health-related quality of life

What could hyperglycemia, weight gain, accumulation of carbon dioxide and hepatobiliary effects indicate in an adult receiving enteral nutrition?

Overfeeding

When is parenteral iron considered for iron deficiency?

Parenteral iron should be considered in conditions of iron deficiency when the oral route is ineffective or not tolerated

Is patient harm typically a significant concern in EN?

Patient harm is not typically a significant concern in EN since administration and care are relatively simple

Which type of formula should be used in exclusive enteral nutrition when administered as front-line therapy for pediatric Crohn's disease? Give 3 reasons why?

Polymeric formula, both elemental and polymeric enteral formulas have been for EEN, but no advantage to elemental formula has been noted 1. Polymeric formulas are typically less expensive 2. Have better tolerance for oral administration 3. Research suggests that use of polymeric formula rather than elemental may promote higher weight gain

What physiological condition requires adjustment of selenium supplementation?

Presence of renal dysfunction

What is the AAP recommendation for preterm infants iron intake?

Preterm infants receive at least 2 mg/kg/day of elemental iron from 1-12 months of age

What should be considered in adult patients with persistently elevated GRVs?

Pro-motility agents

Where is folic acid absorbed?

Proximal jejunum

What type of water is used to reconstitute enteral formula?

Purified water

What is the range for sodium concentrations of homemade or commercial oral rehydration solutions?

Ranges from 60-90 mmol/L

When does infant regurgitation usually resolve? Why?

Regurgitation usually will resolve around 7-12 months of age with maturation of the lower esophageal sphincter

What is the metabolic role of choline?

Required for lipid transport and metabolism

How are biochemical findings impacted by osteogenesis imperfecta?

Routine lab studies are usually within reference ranges

How are iron labs impacted in the acute phase response?

Serum iron levels are depressed and serum ferritin levels are increased

Why are neurologically impaired children (cerebral palsy) at risk for aspiration pneumonia?

Severe gastroesophageal reflux

How any grams of glycogen are stored in the skeletal muscle?

Skeletal muscle stores of 300-400 grams yield approximately 1560 kcal

How does soluble fiber intake impact cholesterol levels?

Soluble dietary fiber lowers total cholesterol and LDL cholesterol without changing or lowering HDL cholesterol levels

What specific area is required for home parenteral nutrition patients?

Supply storage area is required

What is a source of cosmetic concern for most HPN patients?

The cosmetic effect of the catheter

Describe electromagnetic placement device for NGT placement.

The display shows a real-time perspective of the tube tip location with a 3-dimensional localization

What provides the energy for glucose transport?

The energy for glucose transport is provided for by the active transport of sodium out of the cell. The transport of sodium out of the cell maintains the concentration gradient needed for sodium to shuttle more glucose into the mucosal cells

How does the SGA determine malnutrition?

The historical and physical examination data are subjectively weighted to classify the patient as well nourished, moderately malnourished or severely malnourished

Even if HPN is cycled at night what can impact the social quality of life?

The inability to eat

Why has valproic acid been shown to induce carnitine deficiency?

The mechanism of valproic acid induced carnitine deficiency or changes of each acylcarnitine are still under investigation. Impaired renal handling may be involved.

What is the one advantage of open enteral feeding systems?

The potential for less formula wastage due to the ability to customize preparation

Where and how does carbohydrate digestion begin?

The salivary gland releases an enzyme called alpha amylase that initiates hydrolysis of carbohydrate when food enters the mouth. The degree of hydrolysis depends on the time that food is chewed and the nature of the food that enters the stomach

What does the ideal sodium concentration for oral rehydration solution depend on?

The segment of bowel function lost (jejunum, colon, ileum)

What is the ideal sodium concentration for oral rehydration solutions dependent on?

The segment of bowel function lost (jejunum, ileum, colon)

What physiological impairment can lead to copper toxicity?

Toxicity can occur with impaired biliary excretion

What are the consequences of aluminum toxicity?

Toxicity occurs upon accumulation and can result in abnormalities of hematopoietic, bone and neurologic function

When does the adaptive phase of the flow response occur?

Transition from acute to adaptive phase is gradual

What is the treatment for infantile anorexia? (3 things)

Treatment includes 1. Understanding the child's temperament and level of arousal 2. Establishing a regular feeding schedule 3. Incorporation of behavioral techniques and feeding guidelines

Should papain be used to break down bezoar? Why?

Treatment with papain should be avoided because it breaks down normal tissue and is associated with peptic ulcer disease, esophagitis and gastritis

What measurement is used to determine nitrogen balance?

Urine urea

What is the most abundant substance in the body?

Water

What was found to be superior to cranberry juice as an irrigant to maintain feeding tube patency in several clinical trials?

Water

In what situation would essential fatty acid deficiency be associated with biliary atresia?

When an MCT oil predominant without adequate LCT formula was used in dietary management

When should promotility agents be considered in adult patients?

When there are persistently elevated GRVs

How will the addition of a carbohydrate modular impact osmolality?

Will increase osmolality

What mineral deficiency can present with skin rashes, hair loss and loss of taste?

Zinc deficiency

What is one of the most useful diagnostic tests in assessing a child with abnormal growth?

bone age

How do critically ill and postoperative neonates compare to healthy neonates?

Critically ill and postoperative neonates have significantly lower energy needs compared with healthy neonates due to absence of growth, decreased activity and reduction in insensible losses during stress states

How do the energy needs of critically ill and postoperative neonates compare with healthy neonates? Why?

Critically ill and postoperative neonates have significantly lower energy needs compared with healthy neonates. This is due to the absence of growth, decreased activity and reduction in insensible losses during stress states.

Why are modified release dosage medication forms (XL, XR, SR, CD, etc.) inappropriate to crush for administration via enteral feeding?

Crushing these dosage forms destroys their modified releasing properties. This may lead to an excessive dose of the drug being released at one time (instead of slowly over a longer period of time), which can lead to adverse effects and has even been reported as a cause of death

Describe the manganese content of current trace element additives for PN?

Current trace element additives for PN contain greater than five times the current estimated requirement for manganese

What is the current recommendation for initiating feedings in adults and children? Why?

Currently it is recommended that feedings in adults and children be initiated with full strength formulas at a slow rate and steadily advanced. This approach allows goal rates to be achieved earlier and reduces the risk for microbial contamination by minimizing the number of times the formulas is manipulated. This regimen has been noted to be well tolerated.

What is the current evidence for enteral nutrition vs. parenteral nutrition in patients with hematopoietic stem cell transplants?

Currently there is insufficient data to establish benefits of enteral nutrition over parenteral nutrition with hematopoietic cell transplants. In one study, parenteral nutrition was found to increase survival in allogeneic patients.

What method is similar to continuous infusion method except that the rate of formula delivery increases allowing patients to meet nutrient goals with an infusion period less than 24 hours down to as few as 8 hours?

Cyclic feeding

Why is cysteine not considered an essential amino acids in adults? Why is it essential in preterm infants?

Cysteine can be synthesized from methionine via a liver-specific trans-sulfuration pathway. The enzyme necessary for this synthesis is not present in adequate amounts in preterm infants. Therefore, cysteine is considered likely to be an essential amino acid in preterm infants

How does cystic fibrosis related diabetes occur?

Cystic fibrosis related diabetes is secondary to mucus obstruction of pancreatic beta cells, which prevents insulin secretion and may lead to beta cell distruction

What is the incidence of gastric ulceration with PEG tube placement?

0.3-2.5% of cases

What amount of IVFE in grams/kg/day should be provided to prevent essential fatty acid deficiency (EFAD) in pediatric patients on parenteral nutrition?

0.5-1.0 g/kg/day

How much formula is provided in a ready to feed bag?

1 Liter

What is the main biochemical finding difference between Vitamin D deficient rickets and Vitamin D dependent type 2 rickets?

1,25 (OH) Vitamin D levels will be elevated in Vitamin D dependent type 2 rickets

What are the 3 quoted conditions for EN and PN to be covered under the "prosthetic device" benefit under the Medicare Part B program?

1. "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body part" 2. "provision of sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status" 3. "permanent impairment of long and indefinite duration" (of at least 3 months)

Glycogen stores can sustain normal activities in a healthy 70 kg man for approximately 1. 1 day 2. 3 days 3. 7 days 4. 14 days

1. 1 day

A parenteral nutrition (PN) formulation contains 95 grams of protein. How many grams of nitrogen are in the PN formulation? 1. 15 grams 2. 75 grams 3. 95 grams 4. 105 grams

1. 15 grams

12 components of the PN label?

1. 2 patient identifiers 2. Patient location and address 3. Dosing weight in metric units 4. Administration date and time 5. Route of administration (central vs. peripheral) 6. Prescribed volume and overfill volume 7. Infusion rate in mL/h 8. Duration of infusion (continuous versus cyclic) 9. Size of in-line filter (1.2 or 0.22 micron) 10. Completer name of all ingredients 11. Barcode 12. Name of institution or pharmacy and institution or pharmacy contact information (including telephone number)

If IVFE is to be infused separately what should the IVFE label include? (13)

1. 2 patient identifiers 2. Patient location or address 3. Dosing weight 4. Administration date and time 5. Route of administration (central vs. peripheral) 6. Prescribed amount of IVFE 7. Volume required to deliver that amount 8. Infusion rate in mL/hour 9. Duration of infusion (not longer than 12 hours) 10. Complete name of IVFE 11. Beyond use date and time 12. Name of institution or pharmacy 13. Institution or pharmacy telephone number

Which of the following tube feeding orders best reflects the use of an intermittent schedule? 1. 240 mL administered over 45 minutes, five times per day 2. 50 mL/hr over 24 hours 3. 100 mL/hr over 12 hours 4. 120 mL administered over 15 minutes one time per day

1. 240 mL administered over 45 minutes, five times per day

What is the maximum hang time for human breast milk (HBM)? 1. 4 hours 2. 8 hours 3. 12 hours 4. 24 hours

1. 4 hours

Which of the following concentrations is considered to be an upper limit for the osmolality of infant formulas to avoid tolerance issues? 1. 460 mOsm/kg 2. 360 mOsm/kg 3. 260 mOsm/kg 4. 560 mOsm/kg

1. 460 mOsm/kg

50 year-old male weighs 80 kg. Calculate the estimated volume of his intravascular space. 1. 4L 2. 8L 3. 12 L 4. 16 L

1. 4L

Following initial certification of parenteral nutrition by Medicare, after what length of time is recertification required? 1. 6 months 2. 1 year 3. 1 month 4. Never

1. 6 months

Patient education material for home enteral and parenteral nutrition patients should be written at what grade level? 1. 6th 2. 9th 3. 10th 4. 12th

1. 6th

Patient education materials for home enteral and parenteral patients should be written at what grade level? 1. 6th 2. 9th 3. 10th 4. 12th

1. 6th

Which of the following vitamins requires bile salts for emulsification and integration into the micelle for intestinal absorption? 1. A 2. B1 3. B12 4. C

1. A

Under Medicare coverage guidelines for HEN the beneficiary must meet one of two criteria, list the 2 criteria.

1. A permanent non-function or disease of the structures that normally permit food to reach the small bowel 2. A disease of the small bowel that impairs digestion and absorption of an oral diet

Under Medicare coverage guidelines for home enteral nutrition (HEN), the beneficiary must meet one of two criteria, name the 2 criteria.

1. A permanent non-function or disease of the structures that normally permit food to reach the small bowel 2. A disease of the small bowel that impairs digestion and absorption of an oral diet

List the 4 Medicare and Medicaid guidelines under the prosthetic device act that qualify a patient for home enteral nutrition (HEN).

1. A permanent non-function or disease of the structures that normally permit food to reach the small bowel 2. A disease of the small bowel that impairs digestion and absorption of an oral diet 3. The beneficiary must also meet the test of permanence, which is based on the judgement of the attending physician and is substantiated int eh medical record. "Permanence" means that the condition is of indefinite duration, 90 days or greater. Permanence does not exclude the possibility of improvement. 4. The beneficiary must require tube feeding to maintain weight and strength commensurate with overall health status, and adequate nutrition must not be possible by dietary adjustment and/or oral supplements

What are the main pathophysiologic features of refeeding syndrome?

1. Abnormalities of fluid balance 2. Abnormal glucose metabolism 3. Vitamin deficiency 4. Electrolyte imbalances

Name 3 reasons critically ill and postoperative neonates have significantly lower energy needs than healthy neonates.

1. Absence of growth 2. Decreased activity 3. Reduction in insensible losses during stress state

When evaluating the home environment for a patient receiving parenteral nutrition, which of the following is required? 1. Access to telephone 2. Isolated infusion area 3. Back-up electrical generator 4. Dedicated refrigerator

1. Access to telephone

When evaluating the home environment for a patient receiving parenteral nutrition, which of the following is required? 1. access to telephone 2. isolated infusion area 3. back-up electrical generator 4. dedicated refrigerator

1. Access to telephone

Name the 3 short chain fatty acids.

1. Acetate 2. Propionate 3. Butyrate

List 3 complications persistent diarrhea can lead to.

1. Acute and chronic undernutrition 2. Micronutrient deficiencies 3. Persistent diarrhea-associated infections

In patients with liver disease a low protein restriction may be recommended for patients with which of the following conditions? 1. Acute hepatic encephalopathy until cause is diagnosed and eliminated 2. chronic alcoholic liver disease with cirrhosis 3. hepatocellular carcinoma preparing for hepatectomy 4. Primary sclerosing cholangitis awaiting transplantation

1. Acute hepatic encephalopathy until cause is diagnosed and eliminated

2 nutrition interventions to reduce the risk of nephrolithiasis from calcium-oxalate stones in SBS?

1. Adequate hydration to support a urine output > 1200 mL/day 2. Oral calcium supplements 800-1200 mg/day in divided doses not exceeding 500 mg

When administering multiple medications via enteral feeding tubes, medications should be 1. Administered separately, followed by a 15-30 mL water flush 2. Mixed together in a 30 mL slurry and administered together 3. Delivered in liquid form without water flushes 4. Mixed directly into the feeding formulations for administration

1. Administered separately, followed by a 15-30 mL water flush

What 2 parenteral nutrition products provide Vitamin K?

1. Adult multivitamin formulations 2. Lipid emulsions

What populations are more prone to lactase deficiency? (4)

1. African Americans 2. Native Americans 3. Asians 4. Mediterranean descendents

What is are 2 additional factors (not considered major) that may increase the risk of aspiration?

1. Age 2. Large diameter feeding tubes

What 2 patient populations may require thiamin supplementation.

1. Alcoholic 2. Malnourished

List the 4 steps in nutrition screening for the home care patient.

1. All patients accepted by a home care provider should undergo nutrition screening using subjective and/or objective criteria within 72 hours of acceptance or on the initial home visit 2. Result of the nutrition screen is documented 3. Patients identified on initial screen as nutritionally-at-risk shall be referred to the provider for further orders regarding nutrition assessment and intervention 4. Patients identified as not nutritionally-at-risk shall be re-screened at regularly specified intervals or when their clinical or nutrition status changes

3 Purposes of cyclic feedings?

1. Allows freedom from the feeding equipment for a few hours each day 2. Ensures that nutrient requirements are met 3. Time off tube feeding during the day often increases appetite during transition

6 possible GI age related changes?

1. Altered GI motility such as delayed gastric emptying 2. Sensory response 3. Decreased muscle mass 4. Decreased strength or pressure 5. Decreased secretions 6. Decreased immune function

7 components for how PN ingredients should be ordered?

1. Amounts per day (for adult patients) or amounts per kilogram per day (for pediatric and neonatal patients) 2. Electrolytes as complete salt form 3. Full generic name for each ingredient using the Joint Commission approved abbreviations and avoiding ISMP error prone abbreviations, symbols and dose designations 4. Dose for each macronutrient and electrolyte 5. Dose for vitamins (including MVI and individual entities) 6. Dose for trace elements (including multi-components and/or individual entities) 7. Dose for each non-nutrient medications

What are the 4 symptoms of hypocalcemia?

1. Anorexia 2. Nausea/Vomiting 3. Dehydration 4. Neuromuscular irritability

What are 3 components of geriatric nutrition assessment?

1. Anthropometric measurements 2. Biochemical markers 3. Quality of life measures

What 2 types of medications have case reports shown an association of decreased effectiveness with the intake of dietary fiber?

1. Antidepressants 2. Lipid-lowering agents

Name 2 roles of selenium in infants.

1. Antioxidant 2. Central Nervous system development

Name the 6 conditionally indispensable amino acids?

1. Arginine 2. Cysteine 3. Glutamine 4. Glycine 5. Proline 6. Tyrosine

Gastrectomy patients are at risk for a deficiency of which vitamin? 1. B12 2. Folic acid 3. Thiamine 4. B6

1. B12

What 2 nutritional factors are associated with macrocytic anemia (large red blood cells)?

1. B12 2. folate

List 3 consequences of ileal resection that result in increased diarrhea.

1. Bile salt pool is depleted and fat absorption is reduced 2. The loss of bile salts in the colon reduces the ability of the colon to reabsorb water and salt 3. Resection of the ileocecal valve leads to decreased transit time and influx of nutrients in the large intestine

List 2 impacts that occur with ileal resection due to it being the site of reabsorption for bile salts?

1. Bile salt pool is depleted and fat absorption is reduced 2. The loss of bile salts into the colon reduces the ability of the colon to reabsorb water and salt resulting in diarrhea

List the 6 components of bile.

1. Bile salts 2. Bile pigments 3. Cholesterol 4. Lecithin 5. Alkaline phosphatase 6. Electrolytes

Which 2 enteral feeding methods are most popular with home enteral nutrition.

1. Bolus feeding 2. Cyclic feeding

5 considerations after GI surgery that may impact the absorptive function of the bowel?

1. Bowel length 2. Specific segment of small bowel that has been resected 3. Residual disease in the remaining intestine 4. Absence of colon and/or ileocecal valve 5. Prior gastric resection

According to the Centers for Medicare and Medicaid Services, which of the following is an indication for home parenteral nutrition? 1. Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz 2. Gastrointestinal losses totaling 20% of oral intake 3. Need for bowel rest of 1-2 weeks duration 4. Failure to maintain weight on an oral diet

1. Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz

According to the Centers for Medicare and Medicaid Services, which of the following is an indiction for home parenteral nutrition? 1. Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz 2. Gastrointestinal losses totaling 20% of oral intake 3. Need for bowel rest of 1-2 weeks duration 4. Failure to maintain weight on an oral diet

1. Bowel resection resulting in 5 feet small bowel beyond the ligament of Treitz

A morbidly obese 12 year old female is admitted to the hospital for an evaluation of sleep apnea. A diet history reveals that she drinks 3 10 ounce cans of soda, 24 ounces of juice and 8 ounces of chocolate milk daily. In what mineral may she be deficient? 1. Calcium 2. Phosphorus 3. Selenium 4. Potassium

1. Calcium

A morbidly obese 12 year old female is admitted to the hospital for an evaluation of sleep apnea. A diet history reveals that she drinks 3 10 ounce cans of soda, 24 ounces of juice and 8 ounces of chocolate milk daily. In what mineral may she be deficient? 1. Calcium 2. Phosphorus 3. Selenium 4. Potassium

1. Calcium

An increase in the accumulation of formula sediment in the inner lumen of the feeding tube decreasing tube patency is seen more often with which 2 types of formulas?

1. Calorically dense 2. High fiber

What aspects of HPN require specific justification to be covered under Medicare?

1. Calorie prescription outside the range of 20-35 calories per kg per day 2. Protein outside the range of 0.8-1.5 grams per kg per day 3. Lipid use greater than 1500 grams per month

List 3 aspects of home parenteral nutrition (HPN) that require specific justification for medicare coverage.

1. Calorie prescription outside the range of 20-35 calories per kg per day 2. Protein prescription outside the range of 0.8-1.5 grams per kg per day 3. Lipid use greater than 1500 grams per month

Most enteral formulas designed for oral consumption are composed primarily of: 1. carbohydrates 2. protein 3. fat 4. vitamins

1. Carbohydrates

Why are their often gastrointestinal (GI) toxicities in the first 2-3 weeks post-stem cell transplant? (3 reasons)

1. Chemotherapy and total body irradiation 2. Medications 3. Early graft vs. host disease

What populations are at risk for marasmus? (4)

1. Chronic illness 2. Prolonged starvation 3. Elderly 4. Anorexia nervosa

When would selective screening for iron deficiency anemia be a better option (2)?

1. Communities with a historically low incidence of anemia 2. Where there are generally good infant dietary practices related to iron nutrition

List the 13 components of a complete PN order.

1. Complete patient identifiers 2. Birth date or age 3. Allergies 4. Height and dosing weight in metric units 5. Diagnosis/diagnoses 6. Indications for PN 7. Administration route/vascular access device (peripheral vs. central) 8. Contact information for prescriber 9. Date and time order submitted 10. Administration date and time 11. Volume and infusion rate 12. Infusion schedule (cyclic or continuous) 13. Type of formulation (TNA versus dextrose/amino acids and separate IVFE)

Which trace element accumulation is associated with Wilson's disease? 1. Copper 2. Manganese 3. Selenium 4. Iron

1. Copper

In response to illness and trauma, there is an increase in which of the following hormones? 1. cortisol, epinephrine, growth hormone and glucagon 2. insulin, epinephrine, estrogen and somatostatin 3. Glucagon, gastrin, insulin-like growth factor and renin 4. Leptin, cortisol, growth hormone and cholecystokinin

1. Cortisol, epinephrine, growth hormone and glucagon

Malnutrition is most common in which of the following forms of inflammatory bowel disease? 1. Crohn's disease 2. Ulcerative colitis 3. Microscopic colitis 4. Collagenous colitis

1. Crohn's disease

Which of the following metabolic complications is most likely to occur in patients with short bowel syndrome with small bowel bacterial overgrowth? 1. D-lactic acidosis 2. D-lactic alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis

1. D-lactic acidosis

What are 4 expected physiological changes over time that older adults experience?

1. Decreased bone mineral mass 2. Decreased lean body mass 3. Redistribution of fat 4. Decrease in total body water

List the 7 major risk factors for aspiration.

1. Decreased consciousness 2. Documented previous aspiration 3. Vomiting 4. Tracheal intubation 5. Neuromuscular disease 6. Persistent high gastric residual volumes 7. Prolonged suine positioning

List 9 risk factors for aspiration

1. Decreased level of consciousness 2. Previous aspiration 3. Vomiting 4. Tracheal intubation 5. Neuromuscular disease 6. Persistent high gastric residual volumes 7. Prolonged supine positioning 8. Age 9. Large diameter feeding tube

What 5 things have been implicated in the etiology of sarcopenia?

1. Decreased physical activity 2. Malnutrition 3. Increased cytokine activity 4. Oxidative stress 5. Abnormalities in growth hormone (decreased growth hormone production)

Which of the following is a benefit of closed enteral feeding systems? 1. Decreased risk for microbial contamination 2. Maximum hang time of 8-12 hours 3. Packaging amenable to addition of medication or modular 4. Decreased incidence of gastric intolerance

1. Decreased risk for microbial contamination

What 2 things make aspiration more likely in critically ill children?

1. Decreased strength and coordination of pharyngeal muscles 2. Weak cough reflex

What are 2 reasons critically ill children have an increased risk of aspiration?

1. Decreased strength and coordination of pharyngeal muscles 2. Weak cough reflex

An infant has complete ileal resection with preservation of the ileocecal valve. Of the following, the primary nutrition-related concern will be 1. Decreased vitamin B12 absorption 2. Water-soluble vitamin malabsorption 3. Dumping syndrome 4. Protein malabsorption due to decreased cholecystokinin secretion

1. Decreased vitamin B12 absorption

List the 3 responsibilities for home infusion provided by the home infusion company.

1. Delivery of nutritional products 2. Appropriate supplies for the delivery of nutrition 3. Nursing care required to educate about and monitor the prescribed therapy

List 8 signs of the ebb response following burn injury.

1. Depressed energy expenditure 2. Hyperglycemia 3. Low plasma insulin 4. Loss of plasma volume 5. Decreased oxygen consumption 6. Decreased blood pressure 7. Reduced cardiac output 8. Decreased body temperature

List 8 characteristics of the ebb response following burn injury.

1. Depressed resting energy expenditure 2. Hyperglycemia 3. Low plasma insulin 4. Loss of plasma volume 5. Decreased oxygen consumption 6. Decreased blood pressure 7. Reduced cardiac output 8. Decreased body temperature

In addition to aggressive refeeding, which of the following places a patient at risk for hypophophatemia? 1. diabetic ketoacidosis (DKA) 2. tumor lysis syndrome 3. vitamin D deficiency 4. acute kidney injury (AKI)

1. Diabetic ketoacidosis (DKA)

List 16 signs and symptoms of celiac disease in childhood

1. Diarrhea 2. Constipation 3. Chronic abdominal pain 4. Abdominal distention 5. Vomiting 6. Short stature 7. Weight loss 8. Inadequate weight gain 9. Dental enamel defects 10. Dermatitis herpetaformis 11. Reduced bone mineral density 12. Iron deficency anemia 13. Fatigue 14. Migraines 15. Joint pain 16. Delayed puberty

3 patient conditions that increase the risk of zinc deficiency.

1. Diarrhea 2. Malabsorption 3. Hypermetabolic states (stressed, sepsis, burns, venous ulcers, serious injured)

What effect does fiber have on gastro-intestinal transit time? 1. Dietary fiber results in delayed gastric emptying 2. The effects of fiber in the upper GI tract do not differ from the effects of fiber in the colon 3. Fiber in the distal ileum increases gastric emptying 4. Consumption of insoluble fiber increases gastric emptying

1. Dietary fiber results in delayed gastric emptying

List 5 requirements for Medicare coverage of home parenteral nutrition (HPN) under the Prosthetic device act?

1. Documented evidence of inability to tolerate feeding through the enteral route 2. Patients with </= 5 feet of small bowel beyond the ligament of Treitz 3. Gastrointestinal losses exceeding 50% of oral intake (2.5-3 liters per day in and > 1.25 to 1.5 L/day out) 4. Bowel rest is required for at least 90 days 5. 20-35 calories per kilogram per day is prescribed

Where are the primary sites (2) of cholecystokining and secretin secretion?

1. Duodenum 2. Jejunum

List 3 benefits of non-nutritive sucking in the enterally fed patient.

1. During tube feeding improves digestion of enteral feedings 2. thought to stimulate the secretin of lingual lipase, gastrin, insulin and motilin through vagal innervation in the oral mucosa 3. May prevent the subsequent development of an oral aversion when the child is physiologically capable of oral feeding

List the phases of metabolism after burns.

1. Ebb 2. Flow 3. Adaptive

List the 13 signs of the flow phase following a burn injury.

1. Elevated catecholamines 2. Elevated or normal plasma insulin 3. Hyperglycemia 4. Elevated glucagon 5. Elevated glucocorticoids 6. High glucagon-to-insulin ratio 7. Catabolism 8. Increased body temperature 9. Increased cardiac output 10. Redistribution of polyvalent cations (zinc, iron) 11. Mobilization of metabolic reserves 12. Increased urinary excretion fo nitrogen, sulphur, magnesium, phosphorus and potassium 13. Accelerated gluconeogenesis

List 12 characteristics of the flow response after burns.

1. Elevated catecholamines 2. Elevated or normal plasma insulin 3. Hyperglycemia 4. Elevated glucagon and glucocorticoids 5. high glucagon-to-insulin ratio 6. catabolism 7. Increased body temperature 8. Increased cardiac output 9. Redistribution of polyvalent cations (zinc and iron) 10. Mobilization of metabolic reserves 11. Increased urinary excretion of nitrogen, sulphur, magnesium, phosphorus and potassium 12. Accelerated gluconeogenesis

What are the characteristics of thiamin deficiency leading to wet beriberi? (4)

1. Enlarged heart 2. Nonspecific electrolyte alterations 3. Profound vasodilation 4. Peripheral neuritis

3 benefits of using continuous feeding method in the critically ill patient population?

1. Enteral pumps to control the rate and volume of formula 2. Better tolerance to tube feeding with fewer gastric complaints 3. Possible lowered risk of aspiration by prevention of gastric distention

List the 3 types of medications which should not be crushed and given through the feeding tube.

1. Enteric coated 2. Controlled release 3. Sustained release

3 possible side effects with megastrol acetate?

1. Exacerbate underlying diabetes mellitus 2. Rarely leads to adrenal suppression 3. Small increase in the risk of deep venous thrombosis

What are disadvantages of high protein delivery in patients on CRRT? (3)

1. Exacerbation of uremia 2. Increased demand on hepatic and renal function 3. Increased cost

Which of the following is NOT a component of geriatric nutritional assessment? 1. Exercise level 2. Anthropometry 3. Quality of life 4. Biochemical markers

1. Exercise level

2 routes by which bacterial contamination can occur in the enterally fed patient?

1. Exogenously through the feeding equipment 2. Endogenously through retrograde contamination of the feeding apparatus from the patient's own infected secretions

Biliary atresia in infancy is most frequently associated with which of the following? 1. Fat malabsorption 2. Chylothorax 3. Zinc deficiency 4. Essential fatty acid deficiency

1. Fat malabsorption

List 6 signs of iron deficiency anemia.

1. Fatigue 2. Headache 3. Pallor 4. Reduced work performance 5. Impaired behavioral ad intellectual performance 6. Impaired ability to maintain body temperature

Which of the following is a primary cause of oozing stools in a tube fed patient? 1. Fecal impaction 2. Fluid restriction 3. Physical inactivity 4. Narcotic usage

1. Fecal impaction

Name the 2 protocols to decrease the potential for contamination in enteral feedings of human milk for neonates or immunocompromised infants in the hospital setting.

1. Feeding systems (bags, syringe, tubing) should never be reused 2. Feeding systems should not be used for more than 4 hours

What intervention can be utilized to prevent feeding tube occlusion associated with gastric residual volume (GRV) assessment in the adult patient? 1. Feeding tube should be flushed with 30 mL of water following GRV assessment 2. Place the patient in reverse Trendelenberg position prior to GRV assessment 3. Hold enteral feedings 1 hour prior to GRV assessment 4. Instill 60 mL of air into the tube prior to GRV assessment

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

What intervention can be utilized to prevent feeding tube occlusion associated with gastric residual volume (GRV) assessment in the adult patient? 1. Feeding tube should be flushed with 30 mL of water following GRV assessment 2. Place the patient in reverse Trendelenberg position prior to GRV assessment 3. Hold enteral feedings one hour prior to GRV assessment 4. Instill 60 mL of air into the tube prior to GRV assessment

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

Which of the following preterm growth charts allows for comparison for preterm infants from 22 weeks gestational age up through 10 weeks post term age? 1. Fenton 2. Ehrenkranz 3. Dancis 4. Lubchenco

1. Fenton

List 3 important parts of planning for a home nutrition support patient that are not traditionally an integral component of a performance improvement plan?

1. First-dose precautions 2. Discharge instructions 3. Consent for care

List 3 important parts of planning for home nutrition support patients that are not traditionally an integral component of a performance improvement plan.

1. First-dose precautions 2. Discharge instructions 3. Consent for care

Name 3 things that commonly lead to constipation in enterally fed patients.

1. Fluid restriction 2. Physical inactivity 3. Narcotic usage

What 2 concerns need to be accounted for when developing a nutrition care plan for high output GI fistula?

1. Fluids and electrolytes will need to be managed and replaced carefully 2. Protein and calorie requirements may be elevated due to nutrient losses via fistula drainage and/or sepsis

What are the 3 practice recommendation to maintain feeding tube patency in the adult patient?

1. Flush 30 mL of water every 4 hours during continuous feeding and before and after feedings 2. Flush with 15 mL before, between and after medication administration 3. Flush with 30 mL of water after gastric residual volume measurements

Which of the following has been shown to reduce plasma homocysteine concentrations? 1. folic acid 2. vitamin E 3. L-carnitine 4. Ascorbic acid

1. Folic acid

2 vitamin deficiencies that lead to macrocytic anemia?

1. Folic acid 2. Vitamin B12

What 3 nutrients have studies shown to reduce plasma homocysteine concentrations?

1. Folic acid 2. Vitamin B6 3. Vitamin B12

What ailments have been linked to sarcopenia? (5)

1. Functional disability 2. Falls 3. Decreased bone density 4. Glucose intolerance 5. Decreased heat and cold tolerance

Which of the following medications is most likely to contribute to hyponatremia in an older adult? 1. Furosemide 2. Digoxin 3. Omeprazole 4. Ciprofloxacin

1. Furosemide

3 negative side-effects of using corticosteroids in pediatric Crohn's disease?

1. Further depress growth 2. Negatively impact bone mineral density 3. Negatively impact mucosal healing

Name 4 reasons infants with chronic lung disease often have high calorie needs.

1. GER 2. Emesis 3. Chronic infections 4. Increased work of breathing

A child with cerebral palsy and a gastric feeding tube is admitted t the hospital for a fundoplication. This procedure is used to treat? 1. Gastroesophageal reflux 2. Oral/motor dysfunction 3. Malnutrition 4. Esophagitis

1. GERD

Wha distinguishes Gastroesophageal Reflux (GER) from Gastroesophageal Reflux Disease (GERD) in infants? 1. GERD is characterized by the presence of significant complications 2. GER is associated with failure to thrive 3. GER is associated with arching of the back and irritability with no other symptoms 4. GERD typically requires surgical fundoplication

1. GERD is characterized by the presence of significant complications

Which form of glutamine supplementation improves physical compatibility and stability for admixture in PN solutions? 1. Glutamine dipeptide 2. Free glutamine 3. L-glutamine powder 4. Protein bound glutamine

1. Glutamine dipeptide

2 benefits of initiating enteral feedings at full strength formula at a slow rate and steadily advancing?

1. Goal rates achieved earlier 2. Reduces the risk for microbial contamination by minimizing the number of times the formula is manipulated

3 common concerns of the caregiver with home enteral nutrition?

1. Guilt that they are able to eat an oral diet 2. Enteral feedings administered in public may cause social embarrassment 3. Fatigue is a result of nocturnal feedings or frequent enteral care during the day that requires additional work for the caregiver

An NPO post-operative patient has been on 2-in-1 parenteral nutrition (PN) for 3 weeks. He develops a diffuse scaly dermatitis, hair loss, anemia and thrombocytopenia. Which of the following is the probable cause? 1. He has not been receiving IV fat emulsion IVFE for 3 weeks 2. He has been receiving trace elements 3 times per week due to a national shortage 3. He is receiving 20 kcal/kg per day from PN because of hyperglycemia 4. He has PN related cholestasis and is experiencing fat malabsorption

1. He has not been receiving IVFE for 3 weeks

List 2 groups of patients who should not have blindly placed feeding tubes.

1. Head and neck pathology 2. Status post gastric bypass surgery

List 3 common complications associated with overfeeding?

1. Hepatic steatosis 2. Azotemia 3. Hypertriglyceridemia

Which of the following is a indication for the use of parenteral nutrition (PN)? 1. High output fistula 2. Crohn's disease 3. Pancreatitis 4. Hyperemesis gravidarum

1. High output fistula

What 2 medication types can be used to treat gastric hypersecretion? Which is preferred?

1. Histamine-2 receptor antagonist 2. Proton pump inhibitors PPIs suppress significantly more acid than H2-blockers

Name the 2 categories of parameters the SGA uses to evaluate nutritional status.

1. Historical 2. Physical Exam

Name 2 ways to calculate fluid needs in infants.

1. Holliday-Segar method 2. Body Surface area BSA

Why is delivery of adequate protein to acutely ill patients requiring dialysis critical? (3 reasons)

1. Hypercatabolism 2. Obligatory use of protein as a preferred fuel source during the stress response 3. Likelihood of significant protein losses in CRRT effluent

2 signs of glucose intolerance in infants on PN?

1. Hyperglycemia 2. Hypertriglyceridemia

List 4 possible consequences of overfeeding.

1. Hyperglycemia 2. Weight gain 3. accumulation of carbon dioxide 4. Hepatobiliary effects

List the 4 frequently caused nutrient disorders with cyclosporine use for immune suppression after solid organ transplant.

1. Hyperkalemia 2. hypomagnesemia 3. Hyperglycemia 4. Hypercholesterolemia

List 3 mechanisms drugs can cause diarrhea in patients receiving enteral nutrition.

1. Hyperosmolarity (such as those that contain magnesium or sorbitol) 2. Direct laxative effect (such as kayexalate) 3. Antibiotics (without necessarily causing C. difficile overgrowth)

All of the following are clinical symptoms of syndrome of inappropriate antidiuresis (SIAD) EXCEPT: 1. hypervolemia 2. increased urinary sodium 3. hyponatremia 4. increased urinary osmolality

1. Hypervolemia

List the 3 clinical features of acute disease-associated malnutrition caused by an acute inflammatory response.

1. Hypoalbuminemia 2. Edema 3. Anasarca

List 3 abnormalities seen with vitamin D deficiency.

1. Hypocalcemia 2. Osteomalacia 3. Osteoporosis

A patient receiving digoxin and parenteral nutrition who is experiencing signs of digoxin toxicity should be assessed for 1. Hypokalemia 2. Hypoxalcemia 3. Hypermagnesemia 4. Hyperphosphatemia

1. Hypokalemia

List 3 physiological conditions associated with a delayed bone age.

1. Hypothyroidism 2. Growth hormone deficiency 3. Cushing syndrome

What 3 conditions are associated with a delayed bone age?

1. Hypothyroidism 2. Growth hormone deficiency 3. Cushing syndrome

3 benefits of non-nutritive sucking in the enterally fed neonate?

1. Improves digestion of enteral feedings 2. Stimulate the secretion of lingual lipase, gastrin, insulin and motilin through vagal innervation in the oral mucosa 3. May prevent subsequent development of an oral aversion when the child is physiologically capable of oral feeding

Which of the following is the most appropriate situation for nurses to insert a nasogastric feeding tube without physician supervision? 1. In a patient status post stroke on the inpatient medical unit 2. Pre-operatively just prior to transfer to the operating room (OR) 3. In a patient with head and neck trauma admitted to the ICU 4. In a patient with head and neck trauma admitted to the ICU

1. In a patient status post stroke on the inpatient medical unit

Which of the following is the most appropriate situation for nurses to insert a nasogastric feeding tube without physician supervision? 1. In a patient status post stroke on the inpatient medical unit 2. Pre-operatively just prior tt transfer to the OR 3. In a patient with head and neck trauma admitted to the ICU

1. In a patient status post stroke on the inpatient medical unit

5 common factors associated with the majority of PN prescribing errors?

1. Inadequate knowledge regarding PN therapy 2. Certain patient characteristics related to PN therapy (age, impaired renal function) 3. Miscalculation of PN dosages 4. Specialized PN dosage formulation characteristics 5. Prescribing nomenclature

What are the risk of a sedentary lifestyle in older adults? (3)

1. Increased risk for malnutrition 2. Decline of functional status 3. Development of chronic diseases

Name 6 patient types that would not be ideal candidates for initiation of PN in the home setting do to requiring more frequent monitoring and clinical assessment than can be managed at home?

1. Infants 2. IV drug abusers 3. Patients with diabetes 4. Fluid and electrolyte disorders 5. Acid/base disorders 6. Those at risk for refeeding syndrome

List 5 patient groups which may not be ideal for initiation of PN in the home setting.

1. Infants 2. Intravenous drug abusers 3. Patients with diabetes 4. Fluid and electrolyte/acid-base disorders 5. Those at risk for refeeding syndrome

What 2 clinical conditions decrease serum albumin?

1. Inflammation 2. Hypervolemia

Mrs. Jones suffered from a stroke 2 weeks ago and has significant dysphagia. A PEG was placed and an isotonic enteral formula has been infusing continuously at goal rate for 2 days with appropriate flushing (30 mL 3x/day). Mrs. Jones begins to complain of bloating and is mildly distended (to 4 cm from baseline) upon examination. Which of the following interventions would be the best initial strategy to reduce her unpleasant symptoms? 1. Initiate a bowel regimen if constipation suspected 2. Hold enteral nutrition and initiate a pain reliever 3. Switch to a higher fiber enteral nutrition formula 4. Change to bolus feeding regimen

1. Initiate a bowel regimen if constipation suspected

Mrs. Jones suffered from a stroke 2 weeks ago and has significant dysphagia. A PEG was placed and an isotonic enteral formula has been infusing continuously at goal rate for 2 days with appropriate flushing (30 mL TID). Mrs. Jones begins to complain of bloating and is mildly distended (to 4 cm from baseline) upon examination. Which of the following interventions would be the best initial strategy to reduce her unpleasant symptoms? 1. Initiate a bowel regimen if constipation suspected 2. Hold enteral nutrition and initiate a pain reliever 3. Switch to a higher fiber enteral nutrition formula 4. Change to bolus feeding regimen

1. Initiate a bowel regimen if constipation suspected

Hyperglycemia is the most common complication associated with PN administration name 3 reasons stress hyperglycemia occurs in acutely ill and septic patients?

1. Insulin resistance 2. Increased gluconeogenesis and glycogenolysis 3. Suppressed insulin secretion

List 4 ways chronic steroid use can lead to osteopenia.

1. Interfere with calcium and vitamin D metabolism 2. Increase protein catabolism 3. Alter bone formation and resorption 4. Interfere with the growth hormone-insulin-like growth factor axis

Name 3 consequences of decreased glutamine levels.

1. Intestinal mucosa atrophy 2. Impaired immune function 3. Decrease protein synthesis

Name 3 signs/symptoms that meconium ileus and fibrosing colonopathy share. What is the major difference?

1. Intestinal obstruction 2. Mass in the right lower quadrant 3. Abdominal pain - Etiology: Meconium ileus is not caused by high dose enzyme therapy

TBW is distributed among what 3 compartments?

1. Intracellular 2. Extracellular 3. Transcellular

Which trace element deficiency is most likely to occur in long-term parenteral nutrition (PN)-dependent patients after 3 to 6 months of therapy? 1. Iron 2. Copper 3. Chromium 4. Manganese

1. Iron

What 2 nutritional factors are associated with microcytic hypochromic anemia (small red blood cells that are pale in color due to decreased heme pigment).

1. Iron 2. Copper

JD is an 85 year old male whose hight is 63 inches and who weighs 45 kg. His weight 10 years ago was 55 kg. His weight loss has been non-volitional and gradual, and he has no major health problems. Which of the following statements most appropriately describe JD's weight loss? 1. JD demonstrates a decrease in lean body mass known as sarcopenia, which occurs during the aging process 2. JD's weight loss is not a normal phenomenon. He should be evaluated for an underlying disease process 3. JD demonstrates a decrease in fat mass, which occurs with the aging process 4. JD should be placed on a specialized nutrition regimen to replace the weight he has lost

1. JD demonstrates a decrease in lean body mass known as sarcopenia, which occurs during the aging process

Which of the following tubes requires immediate replacement if it becomes dislodged? 1. Jejunostomy tube 2. Nasogastric tube 3. Nasojejunal tube 4. Nasoduodenal tube

1. Jejunostomy

Which of the following tubes requires immediate replacement if it becomes dislodged? 1. Jejunostomy tube 2. Nasogastric tube 3. Nasojejunal tube 4. Nasoduodenal tube

1. Jejunostomy tube

Which of the following metabolic alterations is NOT associated with the development of tube feeding syndrome? 1. Ketonemia 2. Dehydration 3. Azotemia 4. Hypernatremia

1. Ketonemia

Why are glutamine dipeptide formulas the form used in PN admixtures? Name the 2 forms.

1. L-alanyl-L-glutamine 2. Glycyl-L-glutamine Glutamine dipeptide products improve water solubility, stability during heat sterilization and the capability for prolonged shelf life when compounding in parenteral solutions. Free glutamine is unstable in parenteral solutions.

List 6 reasons constipation can occur with enteral nutrition.

1. Lack of adequate hydration 2. Long term fiber-free feedings 3. Prolonged bedrest 4. Impaction 5. Obstruction 6. Narcotics

An enzyme deficiency commonly seen in African Americans and Native Americans is: 1. lactase 2. maltase 3. amylase 4. sucrase

1. Lactase

Which of the following IV fluids most closely resemble jejunal and ileal electrolyte content? 1. lactated ringers 2. normal saline 3. 1/2 normal saline 4. D5 0.45% NaCl

1. Lactated ringers

List the 4 signs of copper deficiency that are also present in vitamin B12 deficiency.

1. Leukopenia 2. Neurological deterioration with sensory ataxia 3. Lower limb spasticity 4. Paresthesias

2 treatment options for lactose intolerance?

1. Low lactose diet 2. Supplemental oral lactase

6 biochemical findings in Vitamin D deficient rickets

1. Low or normal serum calcium 2. Low or normal serum phosphorus 3. High alkaline phosphatase 4. Increased parathyroid hormone 5. Low 25(OH) Vitamin D levels 6. Low to normal 1,25 (OH) Vitamin D levels

3 fistula situations where enteral nutrition may be possible?

1. Low output fistulas (< 500 mL/day) 2. Esophageal, gastric, duodenal or proximal jejunal fistulas with distal enteral access 3. Distal ileal or colonic fistulas with proximal enteral access

List 2 reasons blue dye is no longer recommended for the detection of aspiration of enteral formula.

1. Low sensitivity in detecting aspiration 2. Several reports of systemic toxicity, some resulting in death, have been published in recent years

In patient with fat malabsorption, an enteral product containing which of the following can provide a concentrated source of energy? 1. MCT 2. Free amino acids 3. Fructooligosaccharides 4. Long chain triglycerides

1. MCTs

The viscosity of a formula depends on the concentration and characteristics of what 2 things?

1. Macronutrients 2. Fiber

3 possible mechanisms for malnutrition in Crohn's disease.

1. Malabsorption from diseased small bowel mucosa 2. Increased nutrient requirements from active inflammation 3. Reduced oral food intake due to abdominal discomfort and diarrhea

5 factors that occur in inflammatory bowel disease that are associated with the development of metabolic bone disease?

1. Malnutrition 2. Vitamin D deficiency 3. Corticosteroid therapy 4. Magnesium deficiency 5. Chronic inflammation

What 2 labs may become elevated in patients with cholestasis? Why?

1. Manganese 2. Copper Manganese and copper may become elevated in patients with cholestasis because they are excreted via the biliary tract

What is 2 disadvantages of many liquid medications for enteral administration?

1. Many liquid medications are hyperosmolar which can lead to diarrhea 2. May have high viscosity which can lead to tube clogging

Which of the following is evidenced by a gradual wasting of body fat and somatic muscle with preservation of visceral proteins? 1. Marasmus 2. Mixed state 3. Kwashiorkor 4. Hypoalbuminemia

1. Marasmus

List 10 Medicare criteria for HPN under Medicare.

1. Massive small bowel resection (</= 5 feet of small bowel distal to the Ligament of Treitz) 2. Short bowel syndrome (enteral losses exceed 50% of enteral intake) 3. Weight loss 100% in </= 3 months 4. Serum albumin below 3.4 g/dL 5. Fecal fat tests demonstrating malabsorption 6. Gastrointestinal motility disorder refractory to maximum prokinetic medication 7. Diagnostic test showing dysmotility 8. Complete mechanical bowel obstruction (inoperable) 9. Bowel rest for at least 3 months (severe exacerbation of regional enteritis or proximal enterocutaneous fistula and tube feeding distal is not possible, symptomatic pancreatitis) 10. Weight maintenance cannot be possible using other methods (enteral feeding or pharmacological interventions)

Managed care and private insurance companies often use which established criteria/guidelines when approving coverage for home parenteral nutrition? 1. Medicare criteria 2. State-funded Medicaid program criteria 3. Oley Fondation criteria 4. ASPEN Standards for Specialized Nutrition Support: Home Care Patients

1. Medicare criteria

Managed care and private insurance companies often use which established criteria/guidelines when approving coverage for home parenteral nutrition? 1. Medicare criteria 2. State-funded Medicaid program criteria 3. Oley Foundation criteria 4. ASPEN Standards for Specialized Nutrition Support: Home Care Patients

1. Medicare criteria

In a patient with fat malabsorption, an enteral product containing which of the following can provide a concentrated source of energy? 1. Medium chain triglycerides 2. Free amino acids 3. Fructooligosaccharides 4. Long chain triglycerides

1. Medium chain triglycerides

Name 4 points where contamination can occur when using human milk for enteral feeding.

1. Milk expression 2. Milk storage 3. Preparation and mixing of ingredients 4. Assembling and handling feeding systems

Describe the 5 steps of protein digestion.

1. Minimal protein digestion takes place in the mouth or esophagus 2. Hydrochloric acid secreted by the parietal cells of the stomach denatures the protein and makes it more susceptible for enzymatic action 3. HCL converts the inactive pepsinogen to active pepsin 4. Pepsin activates other pepsinogen molecules or hydrolyzes specific peptide bonds into end products of large polypeptides, oligopeptides and free amino acids 5. This mixture known as acid chyme passes into the duodenum where majority of protein digestion takes place

The Omnibus Budget Reconciliation Act (OBRA) of 1987 provides the total assessment and process for facilities certified to participate in Medicare or Medicaid programs. Which of the following represents the core set of clinical and functional status elements which form the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid? 1. Minimum Data Set (MDS) 2. Resident Assessment Protocols (RAP) 3. Utilization Guidelines 4. Trigger Legend

1. Minimum Data Set (MDS)

List 5 data that should be included (but not limited to) in the performance improvement plan for home care providers of nutrition support?

1. Mortality 2. Hospital readmission 3. Complications 4. Patient/family satisfaction 5. Problem reporting and resolution

List 11 components of a proper discharge for enteral nutrition patients.

1. Name of the formula 2. Total daily volume 3. Route of administration 4. Timing/duration of administration 5. Care of the enteral access device 6. Product hang-time and stability at room temperature 7. Inspection of enteral products for defects and expiration dates 8. Infection prevention and control (standard precautions) 9. Actions to be taken in the event of late or missed administration of enteral nutrition 10. Proper storage of unused enteral products 11. Contact information for the home care company

A number of medications can cause anorexic effects and these effects may be more pronounced in the older adult. Name 3 classes of medications that may cause secondary effects of anorexia?

1. Narcotic analgesics 2. Histamine receptor antagonists 3. Antihypertensive agents

Name the common gastrointestinal (GI) toxicities seen in the first 2-3 weeks post-stem cell transplant that often preclude enteral feeding.

1. Nausea/vomiting 2. Delayed gastric emptying 3. Diarrhea

List 7 symptoms of vitamin D toxicity.

1. Nausea/vomiting 2. Weakness 3. Fatigue 4. Diarrhea 5. Headache 6. Confusion 7. Tremor

When used in assessment of critically ill children, how do predictive equations compare to indirect calorimetry? 1. No consistent comparison has been found 2. Equations typically overestimate needs 3. Equations typically underestimate needs 4. Equations correlate well with indirect calorimetry

1. No consistent comparison can be found

In which of the following older adult populations is toxicity with fat soluble drugs most likely? 1. Obese 2. Sedentary 3. Malnourished 4. Physically active

1. Obese

Which 3 oils are not good sources of linoleic or alpha-linolenic acids?

1. Olive 2. Canola 3. Palm

How often does the American Academy of Pediatrics recommend screening for iron deficiency anemia? 1. Once between the age of 9 and 12 month for all infants 2. Once between the ages of 2 and 6 years in all children 3. Once a year in all adolescents 4. Yearly if a child drinks > 24 ounces of milk per day

1. Once between the age of 9 and 12 months for all infants

How often does the American Academy of Pediatrics recommend screening for iron deficiency anemia? 1. Once between the age of 9 and 12 months for all infants 2. Once between the ages of 2 and 6 years in all children 3. Once a year in all adolescents 4. Yearly if a child drinks > 24 ounces of milk per day

1. Once between the ages of 9 and 12 months for all infants

Nutrition therapy for pediatric patients with < 20% total body surface area (TBSA) burn typically includes 1. oral intake of high calorie, high protein diet 2. Enteral nutrition therapy 3. Parenteral nutrition therapy 4. Enteral and parenteral nutrition therapy

1. Oral intake of high calorie, high protein diet

The chronic use of steroids in premature infants has been associated with 1. Osteopenia 2. Cholestasis 3. Neophrolithiasis 4. Hypoglycemia

1. Osteopenia

What 3 forms of glutamine supplementation are available?

1. Parenteral solutions 2. Predigested enteral formulas 3. Oral nutrition supplements

Which 5 elements of the EN order form are required on the EN formula label?

1. Patient identifiers 2. Product name 3. Enteral access delivery site 4. Administration method 5. Time/date the formula was prepared and hung

List the 5 elements the EN formula label should reflect and contain. Why?

1. Patient identifiers 2. Product name 3. enteral access delivery site 4. administration method 5. time/date the formula was prepared and hung - The importance of providing this information ensures the patient is receiving the formula ordered and that the infusing formula is not expired or exceeding the recommended hang time

EN initiation should be delayed until what 3 things are achieved to reduce the risk of intestinal ischemia?

1. Patient is fully volume resuscitated 2. Hemodynamically stable 3. Mesenteric perfusion has been restored

What populations has the sGA been found to be a good predictor of complications in? (3)

1. Patients undergoing gastrointestinal surgery 2. Liver transplantation 3. Dialysis

What 4 types of home and community-based professional nutrition educational services provided by a registered dietitian with a Medicare provider number are covered for reimbursement by Medicare?

1. Patients with diabetes 2. Patients with pre-dialysis kidney disease 3. Patients post-kidney transplant 4. Patient whose doctor or other healthcare provider refers them for the services

Which 3 amino acids are actually given in smaller amounts to neonates compared to adults?

1. Phenylalanine 2. Methionine 3. Glycine

Which three amino acids are actually given in smaller amounts to neonates compared with adults?

1. Phenylalanine 2. Methionine 3. Glycine

3 health care professionals who can replace nasogastric or nasoduodenal tubes?

1. Physician 2. Physician assistant 3. Appropriately trained nurse

Who can replace an NGT? (3)

1. Physician 2. Physician assistant 3. Appropriately trained nurse

Describe the plan, do, act and study phases of the PDSA cycle for quality improvement.

1. Plan 2. Do - implementation of a process improvement 3. Study - measures the results of the improvement effort 4. Act - determine if changes made should be permanent, includes standardization and documentation of the processes

Exclusive provision of specialized nutrition support (SNS) can induce remission in up to 85% of children with recently diagnosed Crohn's disease. Which form of SNS is recommended as first-line therapy? 1. Polymeric enteral formula 2. Elemental enteral formula 3. Parenteral nutrition 4. Gluten-free diet

1. Polymeric enteral formula

Exclusive provision of specialized nutrition support (SNS) can induce remission in up to 85% of children with recently diagnosed Crohn's disease. Which form of SNS is recommended for use as first-line therapy? 1. Polymeric enteral formula 2. Elemental enteral formula 3. Parenteral nutrition 4. Gluten-free diet

1. Polymeric enteral formula

What 2 outcomes does EFAD lead to?

1. Poor growth 2. Poor pulmonary status

Underfeeding is associated with 1. poor wound healing 2. hepatic steatosis 3. azotemia 4. hypertriglyceridemia

1. Poor wound healing

List 4 common complications associated with underfeeding in the absence of inflammation or infection.

1. Poor wound healing 2. Impaired organ function 3. Low transport protein levels

Name 3 possible etiologies for a patient having pain "inside of his stomach" with no redness or drainage after starting bolus home enteral feeds via G-tube. Which of these 3 is life-threatening?

1. Presence of infection 2. Pressure necrosis 3. Intraperitoneal leakage (life-threatening)

List 3 things pain at the G-tube site may indicate?

1. Presence of infection 2. Pressure necrosis on the inside or outside of the body 3. Intraperitoneal leakage (can be life threatening)

Name 2 types of formula recommended for premature infants during the first year of life.

1. Preterm infant formula 2. Fortified human milk

Name the 3 infant populations who are deemed at risk for iron deficiency according to AAP selective screening?

1. Preterm infants 2. Infants not receiving iron fortified formula 3. Infants fed human milk who are older than 6 months who are not consuming an iron rich diet

What 4 things should be added (fortified) to human milk to meet the needs of the rapidly growing premature infant?

1. Protein 2. Calcium 3. Phosphorus 4. Sodium

List 4 benefits of a standardized interdisciplinary EN feeding protocol.

1. Provide more EN 2. Use less parenteral nutrition 3. Start EN sooner 4. Provide a greater percentage of the goal calories

List 4 advantages of centers that use enteral feeding protocols.

1. Provide more EN 2. Use less parenteral nutrition 3. Start EN sooner 4. Provide a greater percentage of the goal calories compared to centers that do not have a EN feeding protocol in place

The Plan/Do/Study/Act (PDSA) cycle is employed as a 1. quality improvement problem-solving model 2. medical nutrition protocol 3. tool for measuring trends in older Americans 4. benchmarking tool used to compare institutions

1. Quality improvement problem-solving model

List 3 common causes of reflux in children receiving enteral nutrition.

1. Rapid administration of enteral formula 2. Delayed gastric emptying 3. Tube migration into the esophagus

Which of the following is considered to be diagnostic of infantile anorexia? 1. Refusal to eat adequate amounts of food for > 1 month 2. Failure to eat adequately associtaed with childhood depressive disorder 3. Failure to gain weight after a traumatic event 4. Chronic weight loss associated with a malabsorptive disorder

1. Refusal to eat adequate amounts of food for > 1 month

Which of the following is FALSE regarding regurgitation in infants? 1. Regurgitation is rare in infants 2. Regurgitation in neonates is related to relaxation of the lower esophageal sphincter 3. Regurgitation is usually transient and will resolve around 7-12 months of age 4. Regurgitation is associated with delayed gastric emptying

1. Regurgitation is rare in infants

List 2 patient populations for HPN at increased risk for aluminum toxicity.

1. Renal failure 2. Iron deficiency anema

List the 3 components of total energy expenditure.

1. Resting metabolic rate RMR 2. Energy required for the thermogenic effect of digestion 3. Energy expenditure associated with physical activity

5 components of a micronutrient assessment in PN patients?

1. Review nutrient intake 2. Potential nutrient losses 3. Medications 4. Medical and surgical history 5. Nutrition focused physical examination

3 reasons enteral feeding might not be the chosen treatment in hyperemesis?

1. Risk of aspiration 2. Physical discomfort 3. Aesthetics

Which of the following is the hallmark of frailty? 1. Sarcopenia 2. Chronic inflammation 3. Dementia

1. Sarcopenia

List 10 factors that contribute to frailty.

1. Sarcopenia 2. Unintentional weight loss (10 lbs in 1 year) 3. Self reported exhaustion 4. Weakness 5. Slow walking speed 6. Low physical activity 7. Inflammation 8. Chronic disease 9. Inadequate nutrition 10. Oxidative stress

List 6 hallmarks of frailty

1. Sarcopenia 2. unintentional weight loss (10 lbs in 1 year) 3. Self-reported exhaustion 4. Weakness 5. Slow walking speed 6. Low physical activity

List 5 signs of EFAD.

1. Scaly dermatitis 2. Alopecia 3. Thrombocytopenia 4. Anemia 5. Impaired wound healing

List 4 overt signs of EFAD.

1. Scaly dermatitis 2. Alopecia 3. Thrombocytopenia 4. Growth failure

List 3 consequences of hyperphosphatemia.

1. Secondary hyperparathyroidism 2. Renal osteodystrophy 3. Calcification of non-skeletal tissues

What labs does ASPEN recommend for weekly monitoring until the home PN patient is stable? (6 labs)

1. Serum glucose 2. Electrolytes 3. BUN 4. Creatinine 5. Magnesium 6. Phosphorus * some patients may warrant more frequent lab monitoring

What are the 6 lab tests ASPEN recommends monitoring weekly in home parenteral nutrition support patients until they become clinically stable.

1. Serum glucose 2. Electrolytes 3. Blood urea nitrogen 4. Creatinine 5. Magnesium 6. Phosporus

7 possible consequences of copper toxicity?

1. Severe nausea, diarrhea and vomiting 2. Coma 3. Hepatic necrosis 4. Liver failure 5. Renal failure 6. Vascular collapse 7. Death

What are the four general classifications of fatty acids?

1. Short chain (2-4 carbons) 2. Medium chain (6-12 carbons) 3. Long chain (14-18 carbons) 4. Very long chain (20 carbons and above)

List 5 benefits of early initiation of minimum enteral feeds in the neonate.

1. Shorter time to full enteral feeds 2. Faster weight gain 3. Improved feeding tolerance 4. Decreased length of hospitalization 5. Reduced incidence of serious infections in low birth weight and very low birth weight infants

List 5 benefits seen with early initiation of enteral feeds in the neonate.

1. Shorter time to full enteral feeds 2. Faster weight gain 3. Improved feeding tolerance 4. Decreased length of hospitalization 5. Reduced incidence of serious infections in low birth weight and very low birth weight infants

List 5 benefits associated with enteral nutrition.

1. Significant reduction in infectious morbidity 2. Decreased hospital length of stay 3. Reduced need for surgical intervention 4. Reduced multiple organ failure 5. Decreased mortality

3 benefits of the presence of an ileocecal valve and colon?

1. Significantly improves fluid and electrolyte absorption 2. Improves uptake of short chain fatty acids 3. May allow for survival without PN with as little as 50 cm of small bowel

Which 2 oils are good sources of alpha-linolenic acid?

1. Soybean 2. Canola

Which of the following individuals would best benefit from cyclic tube feeding? 1. Status post cerebrovascular accident (CVA) who has initiated oral foods during the day 2. Critically ill motorcycle accident victim in the ICU 3. Critically ill patients with diabetes and hyperglycemia 4. Post-operative bowel surgery patient who has an ileus

1. Status post cerebrovascular accident (CVA) who has initiated oral foods during the day

What negative impacts on nutritional status are associated with chronic steroid use (all of which lead to osteopenia)?

1. Steroids interfere with calcium and vitamin D metabolism 2. Increase protein catabolism 3. Alter bone formation and resorption 4. Interfere with the growth-insulin-like growth factor axis

How do short chain fatty acids benefit the colon? (2)

1. Stimulate water and sodium absorption 2. Provide a source of calories

Name 4 ways non-nutritive sucking improves digestion of the enterally fed neonate.

1. Stimulates secretion of lingual lipase 2. Stimulates gastrin 3. Stimulates insulin 4. Stimulates motilin

List the 4 physical exam factors used in the SGA.

1. Subcutaneous fat 2. Muscle wasting 3. Edema 4. Ascites These factors are subjective and at more than one body site

List 4 signs of moderate dehydration in infants.

1. Sunken eyes 2. Sunken fontanelle 3. Loss of skin turgor 4. Dry mucous membranes

Which 2 amino acids are higher in standard parenteral amino acid solutions for neonates than those from standard adult parenteral amino acids? Why?

1. Taurine 2. Tyrosine taurine and tyrosine are considered essential amino acids in neonates because of enzyme immaturity

Aside from meeting one of the 2 criteria for HEN under medicare coverage guidelines what 3 other criteria must the beneficiary meet?

1. Test of permanence 2. Beneficiary must require tube feeding to maintain weight and strength commensurate with overall health status 3. Adequate nutrition must not be possible by dietary adjustment and/or oral supplements

What are the 2 most common surgical techniques used in the treatment of severe reflux in the US? How are they performed?

1. Thal fundoplication 2. Nissen fundoplication Open or laporoscopic approach

Which of the following is true concerning aluminum contamination in long-term parental nutrition (PN)? 1. The amount on the manufacturer's label is greater than measured amounts 2. Each PN bag must provide the amount of aluminum per liter 3. The clinical manifestations of aluminum toxicity are specific and sensitive

1. The amount on the manufacturer's label is greater than measured amounts

In addition to meeting one of the two criteria under medicare for home enteral nutrition (HEN) (a permanent non-function or disease of the structures that normally permit food to reach the small bowel or a disease of the small bowel that impairs digestion and absorption of an oral diet) what additional 2 tests must they meet?

1. The beneficiary must also meet the test of permanence, which is based on the judgement of the attending physician and is substantiated int eh medical record. "Permanence" means that the condition is of indefinite duration, 90 days or greater. Permanence does not exclude the possibility of improvement. 2. The beneficiary must require tube feeding to maintain weight and strength commensurate with overall health status, and adequate nutrition must not be possible by dietary adjustment and/or oral supplements

Which of the following is TRUE regarding aspiration in critically ill children? 1. The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research 2. Increased gastric residuals are directly related to increased risk for aspiration 3. Children have strong coordination of pharyngeal muscles, making aspiration less likely than in adults 4. Children have strong cough reflex which helps protect them from aspiration

1. The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research

Which of the following is TRUE regarding aspiration in critically ill children? 1. the incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research 2. increased gastric residuals are directly related to increased risk for aspiration 3. children have strong coordination of pharyngeal muscles, making aspiration less likely than in adults 4. children have strong cough reflex which helps protect them from aspiration

1. The incidence of aspiration directly caused by enteral nutrition is difficult to determine due to a lack of good clinical research

According to current Medicare guidelines, coverage for an enteral feeding pump can be justified under which of these circumstances? 1. The patient is being fed using a jejunal feeding tube 2. The patient states that bolus tube feedings interrupt his daily schedule; his preference is to infuse feedings during the night using a pump 3. The patient's caregiver has difficulty preparing several bolus feedings each 4. The patient would like enteral feedings to infuse quickly

1. The patient is being fed using a jejunal feeding tube

List the three phases of the metabolic response to critical illness.

1. The stress phase 2. The catabolic phase 3. The anabolic phase

3 reasons blue dye is no longer recommended for the detection of aspiration of enteral formula?

1. The use of blue dye in detecting aspiration of formula has a low sensitivity 2. Several reports of systemic toxicity, some resulting in death, have been published in recent years 3. US FDA removed FD&C Blue #1 from the market 2003, other blue dyes such as methylene blue and FD&C Blue #2 may have similar or greater toxicity than Blue #1 and are not suitable alternatives

Which of the following describes a benefit of ethanol as a lock solution? 1. There is no known microbial resistance 2. Ethanol can be used as a procoagulant agent 3. Lock therapy has no effect on biofilm formation 4. Fibrin deposition in the catheter lumen increases

1. There is no known microbial resistance

A patient with chronic heart failure on high-dose furosemide is started on enteral nutrition for an inability to consume adequate oral nutrition. Despite a slow advancement to goal feeding rate, he suffers from electrolyte imbalance and peripheral neuritis. Deficiency of which vitamin should be suspected in the cause of his symptoms? 1. Thiamin 2. Vitamin B12 3. Folate 4. Riboflavin

1. Thiamin

Absorption and utilization of what 6 vitamins and minerals may be affected by regular alcohol intake?

1. Thiamin 2. Vitamin B6 3. Vitamin B12 4. Vitamin C 5. Iron 6. Zinc

What 2 TPN patient population are at risk for developing Mn toxicity?

1. Those receiving long-term PN (> 30 days) 2. Obstruction of the biliary duct and are unable to excrete Mn

Rapid intravenous infusion of potassium phosphate may result in 1. thombophlebitis 2. hypercalcemia 3. metabolic alkalosis 4. vitamin D deficiency

1. Thrombophlebitis

List 4 common/possible causes of nausea and vomiting in enterally fed patients.

1. Too rapid of a rate of bolus infusion 2. Gastric outlet obstruction caused by feeding tube migration 3. Excessive feeding volume 4. Gastroparesis

9 possible causes of nausea and vomiting in the enterally fed patient?

1. Too rapid of a rate of bolus infusion 2. Gastric outlet obstruction caused by feeding tube migration 3. Excessive feeding volume 4. Gastroparesis 5. Gastric irritation or atony 6. Distal obstruction 7. Anxiety 8. Other diseases 9. Medications

Other than abnormal potassium losses via the urine and stool, list 2 other possible causes of hypokalemia.

1. Transcellular shift of potassium from the extracellular fluid into cells 2. Inadequate dietary intake

The use of Lactobacillus GG in pediatric practice has been found to be MOST effective in 1. Treating infectious diarrhea 2. Reducing the incidence of NEC 3. Prolonging tie to remission in children with Crohn's 4. Eradicating heliobacter pylori infection

1. Treating infectious diarrhea

What are resident assessment protocols composed of? (4)

1. Triggers 2. Trigger legends 3. RAPs analysis 4. RAPs summary sheet

List 5 factors to consider when converting IV medications to enteral route.

1. Tube size 2. Composition 3. Amount of functional bowel 4. Distal tube tip placement 5. Medication site of absorption

4 considerations when converting intravenous medications to the enteral route.

1. Tube size and composition 2. amount of functional bowel 3. distal tube tip placement 4. site of medication absorption

List 3 types of approved VADs for HPN administration.

1. Tunneled central venous catheters 2. Implanted ports 3. Peripherally inserted central catheters

List the 3 types of vascular access devices (VADs) approved for home parenteral nutrition (HPN) administration.

1. Tunneled central venous catheters 2. Implanted ports 3. Peripherally inserted central catheters

3 factors which affect the measurement of GRVs?

1. Type of feeding tube 2. Body position 3. Location of the tip of the feeding tube

What 3 nonessential amino acids become conditionally essential in AKI?

1. Tyrosine 2. Arginine 3. Glutamine

List possible causes of diarrhea in the tube-fed patient.

1. Underlying medical condition 2. Tube-feeding intolerance 3. Medication effects 4. Infectious causes including bacterial contamination of enteral tube feeding formula or equipment 5. Clostridium difficile

List 4 possible causes of diarrhea in the tube fed patient.

1. Underlying medical condition 2. Tubefeeding intolerance 3. Medication effects 4. Infectious causes (bacterial contamination of enteral tube feeding formula or equipment and C.difficile)

List the 3 elements of treatment for infantile anorexia.

1. Understanding the child's temperament and level of arousal 2. Establishing a regular feeding schedule 3. Incorporation of behavioral techniques and feeding guidelines

Name the 2 options for iron deficiency anemia screening provided by the American Academy of Pediatrics

1. Universal screening or measurement of hemoglobin or hematocrit for all full term infants between 9 and 12 months 2. Selective screening or screening only infants deemed to be at risk (preterm infants, infants not receiving iron fortified formula and infants fed human milk who are older than 6 months who are not consuming an iron rich diet)

What 2 options for iron deficiency anemia screening does the American Academy of Pediatrics offer?

1. Universal screening or measurement of hemoglobin or hematocrit for all full term infants between 9 and 12 months 2. Selective screening or screening only infants deemed to be at risk such as preterm infants, infants not receiving iron fortified formula and infants fed human milk who are older than 6 months not consuming an iron rich diet

List 4 contraindications to NGT feedings.

1. Upper airway secretions 2. Nasal polyps 3. Recurrent sinusitis 4. Recurrent otitis

List 3 contraindications to NGT feedings.

1. Upper airway secretions 2. Nasal polyps 3. Recurrent sinusitis or otitis

3 recommendations for measuring GRVs?

1. Use a large bore feeding tube 2. Use a 60 mL syringe 3. Check GRVs the first 2 days of feeding

Which of the following therapies would be considered most appropriate in the nutritional management of chronic lung disease? 1. Use of a concentrated formula 2. Use of a high fat, low carbohydrate formula 3. Use of a hydrolyzed protein formula 4. Use of an MCT oil predominant formula

1. Use of a concentrated formula

Name 3 evidence based recommendations from ASPEN/SCCM for minimizing the risk of aspiration in critically ill patients.

1. Use of a prokinetic agents or narcotic antagonists 2. Small bowel feeding compared with gasric feeding 3. Head of bed elevated to 30-45 degrees

Which of the following therapies would be considered most appropriate in the nutritional management of chronic lung disease? 1. use of concentrated formula 2. use of a high fat, low carbohydrate formula 3. use of a hydrolyzed protein formula 4. use of an MCT oil predominant formula

1. Use of concentrated formula

List 3 evidence based guidelines for nutrition support in critically ill patients by ASPEN/SCCM regarding interventions to minimize the risk of aspiration in critically ill patients.

1. Use of prokinetic agents or narcotic antagonists 2. Small bowel feeding compared with gastric feeding 3. HOB elevated to 30-45 degrees

The clinical manifestations of copper deficiency can be similar to what other micronutrient deficiency? 1. Vitamin B12 2. Manganese 3. Vitamin E 4. Zinc

1. Vitamin B12

Levodopa is often used in the treatment of Parkinson's Disease. Which of the following vitamins has been demonstrated to reverse the effects of levodopa? 1. Vitamin B6 2. Vitamin B12 3. Vitamin C 4. Vitamin K

1. Vitamin B6

Using the Waterlow criteria, weight for length is evaluated as an index of which of the following? 1. Wasting due to acute malnutrition 2. Wasting due ot chronic malnutrition 3. Wasting caused by illness 4. Wasting caused by hypoaluminemia

1. Wasting due to acute malnutrition

Using the Waterlow criteria, weight for length is evaluated as an index of which of the following? 1. Wasting due to acute malnutrition 2. Wasting due to chronic malnutrition 3. Wasting caused by illness 4. Wasting caused by hypoalbuminemia

1. Wasting due to acute malnutrition

List 4 factors that impact total body water (TBW).

1. Weight 2. Age 3. Gender 4. Amount of body fat

List the 5 historical factors used in the SGA.

1. Weight history 2. Dietary intake 3. Gastrointestinal symptoms 4. Functional status 5. Metabolic demand

Name 4 significant complications associated with GERD

1. Weight loss or failure to thrive 2. Feeding difficulties 3. Arching of the back 4. Irritability

An 87 year old woman underwent a total abdominal colectomy. Her ileostomy output is 1.5-2.0 liters per day. Supplementation of which of the following micronutrients should be considered? 1. zinc 2. copper 3. vitamin D 4. chromium

1. Zinc

The most predominant clinical change seen with essential fatty acid deficiency EFAD is 1. a dry, scaly rash 2. increased susceptibility to infection 3. impaired wound healing 4. weight gain

1. a dry, scaly rash

Name 4 mortality risks with persistent diarrhea.

1. acute and chronic under nutrition 2. fluid loss and dehydration 3. micronutrient deficiencies 4. persistent diarrhea-associated infections

When administering multiple medications via enteral feeding tubes, medications should be: 1. administered separately, followed by a 15-30 mL water flush 2. mixed together in a 30 mL slurry and administered together 3. delivered in liquid form without water flushes 4. mixed directly into the feeding formulations for administration

1. administered separately, followed by a 15-30 mL water flush

Which of the following has been reported to be a significant independent predictor of morbidity and mortality in critically ill patients? 1. albumin 2. prealbumin 3. transferrin 4. retinol-binding protein

1. albumin

What 13 signs and symptoms copper deficiency can present with?

1. anemia 2. leucopenia 3. neutropenia 4. peripheral neuropathy 5. sensory ataxia 6. lower extremity spasiticity 7. parathesis in extremities 8. hypercholesterolemia 9. increased erythrocyte turnover 10. decreased ceruloplasmin 11. decreased erthrocyte copper/znc superoxide dismutase (SOD) 12. Abnormal EKG patterns 13. Myeloneuropathy

Most enteral formulas designed for oral consumption are composed primarily of: 1. carbohydrates 2. protein 3. fat 4. vitamins

1. carbohydrates

Transformation of free long chain fatty acids into acylcarnitines requires: 1. carnitine 2. choline 3. arginine 4. glutamine

1. carnitine

Oxidation of fatty acids for adenosine triphosphate ATP production occurs in 1. cells that contain mitochondria 2. the mitochondria of the adipocyte only 3. the red blood cells only 4. the blood stream

1. cells that contain mitochondria

A decrease in food intake in older adults is most likely attributable to 1. changes in taste and flavor sensations 2. delayed satiety 3. fear of incontinence 4. enhanced olfaction

1. changes in taste and flavor sensations

3 reasons for decreased food intake in older adults?

1. changes in taste and flavor sensations 2. less hunger 3. early satiety

Which of the following is a major contributing factor in the development of metabolic bone disease in patients with IBD? 1. corticosteroids 2. aluminum toxicity 3. blood transfusion 4. oxalic acid deficiency

1. corticosteroids

3 factors that can alter urinary urea nitrogen resulting in unreliable results?

1. creatinine clearance < 50 mL/min 2. low urine output 3. muscle atrophy

2 nutritional impacts of small bowel bacterial overgrowth?

1. deconjugation of bile salts and impaired micelle formation resulting in fat malabsorption 2. Increased SCFA production that decreases luminal pH, denature intestinal enzymes and increasing osmotic load leading to rapid gut transit, maldigestion and malabsorption

Which of the following is a benefit of closed enteral feeding systems? 1. decreased risk for microbial contamination 2. maximum hang time of 8-12 hours 3. packaging amenable to addition of medication or modular 4. decreased incidence of gastric intolerance

1. decreased risk for microbial contamination

What are the 2 advantages of closed enteral feeding systems.

1. decreased risk for microbial contamination 2. longer hang time (24-48 hours compared to 8-12 hours for open systems) require less nursing time for administration

List 4 commonly reported patient complications of home enteral nutrition.

1. decreased urination 2. tube clogging 3. tube leaking 4. ski problems at the tube site

An infant has a complete ileal resection with preservation of the ileocecal valve. Of the following, the primary nutrition-related concern will be? 1. decreased vitamin B12 absorption 2. water soluble vitamin malabsorption 3. dumping syndrome 4. protein malabsorption due to decreased CCK secretion

1. decreased vitamin B12 absorption

Zinc deficiency is most commonly associated with 1. diarrhea 2. carotenemia 3. coagulopathy disorder 4. cholestasis

1. diarrhea

List 15 common symptoms of celiac disease in childhood.

1. diarrhea 2. constipation 3. chronic abdominal pain 4. abdominal distention 5. vomiting 6. short stature 7. weight loss 8. inadequate weight gain 9. dental enamel defects 10. dermatitis herpetaformis 11. reduced bone mineral density 12. iron deficiency anemia 13. fatigue 14. migraines 15. joint pain

For coverage of HPN under the prosthetic device act which things are needed?

1. documented evidence of inability to tolerate feeding through the enteral route 2. typically covered for patients with </= 5 feet of small bowel beyond the ligament of Treitz 3. Gastrointestinal losses exceeding 50% of oral intake (2.5 to 3 liters per day in and > 1.25 to 1.5 L/day out) 4. Bowel rest for at lest 90 days

List 3 types of medications which should not be crushed and given through feeding tubes?

1. enteric coated 2. controlled-release 3. sustained release

Which of the following is a primary cause of oozing stools in a tube fed patient? 1. fecal impaction 2. fluid restriction 3. physical inactivity 4. narcotic usage

1. fecal impaction

List 2 guidelines to use with expressed human milk continuous feedings to reduce potential for contamination.

1. feeding systems that include bags, syringe or tubing should never be reused 2. feeding systems should not be used for more than 4 hours for neonates or immunocompromised infants in the hospital setting

List 4 characteristics that dominate the catabolic phase of the metabolic response to critical illness.

1. fever 2. hypercatabolism 3. gluconeogenesis 4. increased oxygen demand

What are the current practice recommendations to maintain feeding tube patency int he adult patient?

1. flush with 30 mL of water every 4 hours during continuous feeding and before and after intermittent feedings 2. flush with 15 mL before, between and after medication administration 3. flush with 30 mL of water after gastric residual volume measurements

A child with cerebral palsy and a gastric feeding tube is admitted to the hospital for a fundoplication. This procedure is used to treat 1. gastroesophageal reflux 2. oral/motor dysfunction 3. malnutrition 4. esophagitis

1. gastroesophageal reflux

List 4 reasons infants with chronic lung disease often have high calorie needs.

1. gastroesophageal reflux 2. emesis 3. chronic infections 4. increased work of breathing

List 3 signs and symptoms of infantile anorexia.

1. generally do not communicate that they are hungry 2. lack interest in food and eating 3. exhibit growth deficiency

The presence of which of the following facilitates the absorption of sodium in the lumen of the small intestine? 1. glucose 2. potassium 3. vitamin D 4. protein

1. glucose

2 things adversely effected in pediatric Crohn's disease?

1. growth 2. nutrition status

What 2 steps should be taken to avoid contamination when hanging an enteral set?

1. hands should be washed thoroughly before touching any component of the tube feeding system 2. formula should be transferred without touching the component of the feeding set that comes in contact with the formula

Name 2 symptoms of manganese toxicity.

1. headache 2. Parkinson-like abnormalities

The initiation of enteral tube feeding should be delayed when the patient is: 1. hemodynamically unstable 2. at a decreased level of consciousness 3. without bowel sounds 4. scheduled for discharge

1. hemodynamically unstable

What is the most appropriate feeding strategy for a morbidly obese trauma patient? 1. high protein, hypocaloric feeding 2. high protein, hypercaloric feeding 3. low protein, hypocaloric feeding 4. low protein, hypercaloric feeding

1. high protein, hypocaloric feeding

Nutrition support for solid-organ transplant patients receiving cyclosporine may need to be modified due to the presence of 1. hyperkalemia 2. hypoglycemia 3. hypermagnesemia 4. hypocholesterolemia

1. hyperkalemia

List 4 consequences of decreased vitamin D binding to VDRs.

1. hyperparathyroidism 2. stimulation of muscle fibers is decreased causing muscle weakness 3. renin activity is increased resulting in hypertension 4. potential for hyperlipidemia

List 3 electrolyte disturbances expected with prolonged nasogastric output.

1. hypokalemia 2. hyponatremia 3. hypochloremia

Supplemental arginine is considered therapeutic for 1. immune function and wound healing 2. fuel for rapidly dividing cells 3. increasing lean body mass 4. improving hepatic steatosis

1. immune function and wound healing

A patient receiving PN has a high ileostomy output. Which of the following changes to the PN prescriptions is most appropriate to recommend? 1. increse sodium and increase fluid volume 2. decrease water and decrease sodium 3. increase sodium and decrease protein 4. decrease sodium and increase fluid volume

1. increase sodium and increase fluid volume

Which of the following is not a common change in the body composition of healthy older adults? 1. increased body water 2. decreased bone mineral mass 3. decreased lean body mass 4. redistributed fatty tissue

1. increased body water

4 symptoms associated with EFAD?

1. increased susceptibility to infection 2. Impaired wound healing 3. Immune dysfunction 4. Dry, scaly rash

Dietary fiber may help to regulate normal defecation by 1. increasing stool weight and bulk 2. inhibiting the growth of colonic bacteria 3. reducing incidence of constipation 4. removing water from the colon

1. increasing stool weight and bulk

When using cyclic parenteral nutrition solutions for nonstressed, nondiabetic patients, age should be taken into account because compared to middle-aged adults, the older adults have 1. insulin resistance, leading to a lower glucose utilization and hyperglycemia 2. lower fat oxidation and lower glucose oxidation 3. Increased needs for fluid restriction 4. lower concentrations of free fatty acids

1. insulin resistance, leading to a lower glucose utilization and hyperglycemia

List the 3 common symptoms between meconium ileus and fibrosing colonopathy? What is the difference between the two?

1. intestinal obstruction 2. mass in the right lower quadrant 3. abdominal pain Meconium ileus is not caused by high dose enzyme therapy

Although they have a limited role in fat digestion in healthy adults what are the 2 enzymes in the upper GIT that play a role in fat digestion?

1. lingual lipase in the mouth 2. gastric lipase in the stomach

Copper toxicity is associated with 1. liver disease 2. kidney disease requiring hemodialysis 3. aggressive zinc supplementation 4. lung disease

1. liver disease

Increased mortality in maintenance hemodialysis patients has been associated with 1. low baseline body fat percentage and low muscle mass 2. elevated albumin and decreased CRP values 3. increased body mass index 4. decreased serum cholesterol

1. low baseline body fat percentage and low muscle mass

What are the 6 biochemical findings in Vitamin D deficient rickets?

1. low or normal serum calcium 2. low or normal serum phosphorus 3. high alkaline phosphatase 4. increased parathyroid hormone 5. Low 25(OH) vitamin D levels 6. low or normal 1,25 (OH) vitamin D

List 6 patient populations at risk for hypophosphatemia

1. malnourished patients aggressively refed 2. patients with DKA 3. chronic alcoholism 4. respiratory and metabolic alkalosis 5. critical illness 6. Fanconi syndrome

Failure to monitor which micronutrient in long-term parenteral nutrition (PN) patients is most likely to result in toxicity? 1. manganese 2. zinc 3. folate 4. molybdenum

1. manganese

Which can decrease the accuracy of an indirect calorimetry study? 1. mechanical ventilation with FiO2 >/= 60 2. holding routine nursing care or activities during the study 3. measurement made in a quiet thermoneutral environment 4. stable intake for the previous 12 hours

1. mechanical ventilation with FiO2 >/= 60

A patient in your intensive care unit has severe diarrhea secondary to clostridium difficile toxin. Which of the following acid-base disorders is likely to occur? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

1. metabolic acidosis

List 8 possible reasons for decreased oral intake by older adults.

1. multiple chronic medical conditions that require altered dietary intake 2. use of numerous medications which can impair food intake or alter digestion, metabolism and excretion 3. social isolation 4. economic hardships 5. decreased functional capacity related to shopping for or preparing foods 6. dementia 7. loss of taste and smell 8. difficulty chewing and swallowing

List the 2 clinical indicators of protein malnutrition on the physical exam.

1. muscle wasting 2. subcutaneous fat loss

Vitamin D (25 hydroxy vitamin D) deficiency can manifest as 1. muscle weakness 2. decreased production and excretion of PTH levels 3. hypotension 4. less than normal serum lipid levels

1. muscle weakness

RNA and DNA are hydrolyzed to form mononucleotides during the digestion of 1. nucleic acids 2. protein 3. fats 4. carbohydrate

1. nucleic acids

Nutrition therapy for pediatric patients with < 20% total body surface area TBSA burn typically includes 1. oral intake of high calorie, high protein diet 2. enteral nutrition 3. parenteral nutrition 4. enteral and parenteral nutrition therapy

1. oral intake of high calorie, high protein diet

Where are vitamin D receptors (VDR) located in the body? (4)

1. parathyroid glands 2. muscle tissue 3. cardiovascular system 4. kidneys

List 4 patient population who qualify for Medicare reimbursement for home and community-based professional nutrition educational services provided by a registered dietitian

1. patients with diabetes 2. pre-dialysis kidney disease 3. post-kidney transplant 4. patient whose doctor or other healthcare provider refers them for the services

Which of the following tests is not used to assess vitamin A status? 1. plasma carotenoid level 2. serum retinol concentration 3. plasma transthyretin-retinol binding protein (TTR-RBP) concentration 4. Serum retinol binding protein level

1. plasma carotenoid level

List the lab test for selenium status.

1. plasma glutathione peroxidase 2. selenium level in whole blood, plasma, serum or erythrocytes

Enteral nutrition is recommended initially over the parenteral route to avoid some of the more severe complications associated with PN in pregnancy?

1. pneumothorax 2. puncture of nearby artery 3. air embolism 4. infections (due to immunologic suppression) 5. thrombosis (due to hypercoagulable state 6. sepsis 7. cardiac issues due to electrolyte imbalances 8. gallbladder dysmotility 9. intrahepatic cholestasis 10. requires closer monitoring and incur a higher cost

List the 3 ways a 70% ethanol lock solution has been shown to reduce catheter-related blood stream infections CRBSIs attributed to its antimicrobial action.

1. protein denaturation 2. diffusion through the polysaccharide matrix of a biofilm 3. prevention of fibrin sheath formation

List 6 examples of modular products

1. protein powders 2. carbohydrate powders 3. fat emulsion 4. MCT oil 5. fiber 6. specific amino acids

List 3 possible causes of reflux in children receiving enteral nutrition.

1. rapid administration of enteral formula 2. delayed gastric emptying 3. tube migration in to the esophagus

Constipation in the enterally fed patient is most often associated with all of the following EXCEPT 1. rapid or bolus infusion 2. obstruction 3. lack of adequate hydration 4. prolonged bed rest

1. rapid or bolus infusion

Constipation in the enterally fed patient is most often associated with all of the following except: 1. rapid or bolus infusion 2. obstruction 3. lack of adequate hydration 4. prolonged bed rest

1. rapid or bolus infusion

List 4 reasons for malnutrition in patients with liver disease.

1. reduced caloric intake from anorexia and early satiety 2. Fat malabsorption from altered bile acid circulation 3. Increased protein and fat oxidation 4. Increased energy expenditure

List 4 strategies to help improve nausea related to delayed gastric emptying in the tube fed patient.

1. reduction or discontinuation of narcotic medications 2. use of low fat formula 3. administering enteral formula at room temperature 4. reducing the rate and/or volume of tube feeding infusion

Which of the following is considered to be diagnostic of infantile anorexia? 1. refusal to eat adequate amounts of food for > 1 month 2. failure to eat adequately associated with childhood depressive disorder 3. failure to gain weight after a traumatic event 4. chronic weight loss associated with a malabsorptive disorder

1. refusal to eat adequate amounts of food for > 1 month

Which of the following is FALSE regarding regurgitation in infants? 1. regurgitation is rare in infants 2. regurgitation in neonates is related to relaxation of the lower esophageal sphincter 3. regurgitation is usually transient and will resolve around 7-12 months of age 4. regurgitation is associated with delayed gastric emptying

1. regurgitation is rare in infants

List 5 benefits in patients with severe acute pancreatitis on EN vs. PN nutrition support

1. significant reduction in infectious morbidity 2. decreased hospital LOS 3. Reduced need for surgical intervention 4. Reduced multiple organ failure 5. Decreased mortality

Absorption of large polypeptides, oligopeptides and free amino acids takes place in the 1. small intestine 2. stomach 3. large intestine 4. mouth

1. small intestine

List 4 symptoms of hyperphosphatemia.

1. soft tissue and vascular calcification 2. secondary hyperparathyroidism 3. renal osteodystrophy 4. hypocalcemia with associated symptoms

List 4 sings to monitor for indications that dehydration is worsening in infants.

1. sunken eyes 2. sunken fontanelle 3. loss of skin turgor 4. dry mucous membranes

11 elements to be included in the discharge instructions of patient/caregiver regarding home enteral nutrition?

1. the name of the formula 2. Total daily volume 3. Route of administration 4. Timing/duration of administration 5. Care of the enteral access device 6. Product hang-time and stability at room temperature 7. Inspection of enteral products for defects and expiration dates 8. Infection prevention and control (standard precautions) 9. Action to be taken in the event of late or missed administration of enteral nutrition 10. Proper storage of opened and unused enteral products 11. Contact information of home care company

Deficiencies of what 5 vitamins and minerals have all been described after gastric bypass surgery?

1. thiamin 2. zinc 3. vitamin B12 4. Iron 5. Copper

The use of Lactobacillus GG in pediatric practice has been found to be MOST effective in: 1. treating infectious diarrhea 2. reducing the incidence of NEC 3. prolonging time to remission in children with Crohn's 4. eradicating heliobacter pylori infection

1. treating infectious diarrhea

Selenium status can be assessed by determining the selenium level in: (4 choices)

1. whole blood 2. plasma 3. serum 4. erythrocytes

List 4 conditions that may limit folate absorption.

1. zinc deficiency 2. chronic alcohol consumption 3. changes in jejunal luminal pH 4. impaired bile secretion

What is the recommended protein intake for patients with cirrhosis? Why?

1.0-1.5 g/kg/day to prevent muscle catabolism and promote gluconeogenesis

Name 2 research based methods for unclogging a feeding tube.

1.Mechanical declogging device 2. Pancreatic enzyme with sodium bicarbonate

How is extracellular fluid proportionally distributed?

1/4 is in the intravascular space and 3/4 is in the interstitial space

What levels of plasma or serum selenium represent adequate selenium status?

100 mcg/L

What percentage of carbohydrate calories are lactose in standard term infant formulas?

100%

What are IVFEs composed of in the US?

100% soybean oil

Based on bone health evidence what is the RDA for calcium in children 4-8 years of age?

1000 mg/day for children 4-8 years of age

What type of fatty acid is Lauric acid?

12 carbon atoms, medium chain fatty acid

What is the half life of retinol-binding protein?

12 hours

What is the hang time for open system enteral feeding containers at home?

12 hours

What is the recommended hang time for open system enteral feeding at home? In the hospital?

12 hours at home and 8 hours in the hospital

Based on bone health evidence what is the RDA for calcium in children and adolescents 9-18 years of age?

1300 mg/day for children and adolescents 9-18 years of age

What is the half life of serum albumin (visceral hepatic protein)?

14 to 20 days

What is the current recommendation for glycemic target by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) is to maintain the glucose in what range for the majority of critically ill adult patients?

140-180 mg/dL

What is the GFR for stage 4 kidney damage with severe, low GFR?

15-20 mL/min/1.73 M2

How does the Holliday-Segar method calculate fluid needs?

1st 10 kg - 100 mL/kg/day 2nd 10 kg - 50 mL/kg/day Each additional kg: 20 mL/kg/day (</= 50 kg) or 15 mL/kg/day (> 50 kg)

How are fluids calculated using the Holliday-Segar method?

1st 10 kg - 100 mL/kg/day, 2nd 10 kg 50 mL/kg/day, each additional kg - 20 mL/kg/day (</= 50 kg) or 15 mL/kg (> 50 kg)

How many calories are in 1 mL of 20% IVFE?

2 calories

Assuming normal organ function, term neonates weighing 3 to 10 kg on long term parenteral nutrition how much selenium should be supplemented each day?

2 mcg/kg/day

What is the recommended dosage of selenium supplementation in term neonates weighting 3-10 kg with normal organ function?

2 mcg/kg/day

What is the half life of prelbumin?

2-3 days

In a stable infant how much protein should be provided by parenteral support?

2-3 g/kg/day (10-20% kcals)

In a stable infant what is the macronutrient breakdown recommended for parenteral nutrition support?

2-3 g/kg/day of protein (10-20% of kcals), < 30% kcals from fat, and 45-50% of calories from carbohydrates

What is the suggested daily amount of potassium in preterm infants, term infants and children?

2-4 mEq/kg

What is the suggested daily amount of potassium required for maintenance in a preterm infant, term infant or child receiving parenteral nutrition?

2-4 mEq/kg

How much exogenous iron is recommended during the period of stable growth beginning at 4-8 weeks and continuing until 12-15 months of age?

2-4 mg/kg/day

In an infant with adequate energy intake what is the MINIMUM amount of fat emulsion containing long chain fatty acids needed to prevent essential fatty acid deficiency? 1. 0.2-0.4 g/kg/day 2. 0.5-1.0 g/kg/day 3. 1.1-1.5 g/kg/day 4. 1.8-2.0 g/kg/day

2. 0.5-1.0 g/kg/day

In an infant with adequate energy intake, what is the MINIMUM amount of fat emulsion containing long chain fatty acids needed to prevent essential fatty acid deficiency? 1. 0.2-0.4 g/kg/d 2. 0.5-1.0 g/kg/d 3. 1.1-1.5 g/kg/d 4. 1.8-2.0 g/kg/d

2. 0.5-1.0 g/kg/day

What are the protein requirements for a stable patient receiving peritoneal dialysis (PD)? 1. 0.6-0.8 g/kg/d 2. 1.2-1.3 g/kg/d 3. 1.5-1.8 g/kg/d 4. 2.0-2.2 g/kg/d

2. 1.2-1.3 g/kg/d

In a 45 year old patient with a normal liver and kidney function and nonhealing wounds suspected of having a vitamin A deficiency, supplementation of vitamin A (25,000 IU/day) should usually be given for a maximum of 1. 3 days 2. 14 days 3. 90 days 4. 180 days

2. 14 days

What is the recommended intake of selenium for term infants receiving long-term total parenteral nutrition? 1. < 1 mcg/kg/day 2. 2 mcg/kg/day 3. 3-4 mcg/kg/day 4. 5-6 mcg/kg/day

2. 2 mcg/kg/day

What is the suggested daily amount of potassium required for maintenance in an infant receiving parenteral nutrition? 1. 0.8-1 mEq/kg 2. 2-4 mEq/kg 3. 5-6 mEq/kg 4. 7-8 mEq/kg

2. 2-4 mEq/kg

Vitamin D (25, hydroxyvitamin D) deficiency is defined as a serum level less than 1. 100 ng/mL 2. 20 ng/mL 3. 50 ng/mL 4. 120 ng/mL

2. 20 ng/mL

Which of the following is the most appropriate fluid requirement for a healthy 78 year old adult? 1. 20 ml fluid/kg/day 2. 25 ml fluid/kg/day 3. 35 ml fluid/kg/day 4. 45 ml fluid/kg/day

2. 25 ml/kg/day

How much fluid per day is required to maintain fluid balance? 1. 15-25 mL/kg/day 2. 30-40 mL/kg/day 3. 45-55 mL/kg/day 4. 60-70 mL/kg/day

2. 30-40 mL/kg/day

Wha is the hang time for expressed human milk when used for continuous enteral feedings? 1. 2 hours 2. 4 hours 3. 8 hours 4. 12 hours

2. 4 hours

What is the hang time for expressed human milk when used for continuous enteral feedings? 1. 2 hours 2. 4 hours 3. 8 hours 4. 12 hours

2. 4 hours

Upon initiation of home parenteral nutrition (HPN), laboratory data should be obtained within: 1. 24 hours 2. 48 hours 3. 72 hours 4. 96 hours

2. 48 hours

Upon initiation of home parenteral nutrition (HPN), laboratory data should be obtained within: 1. 24 hours 2. 48 hours 3. 72 hours 4. 96 hours

2. 48 hours

What is the daily maintenance fluid requirement for a 5 kg infant? 1. 300 mL 2. 500 mL 3. 700 mL 4. 1000 mL

2. 500 mL

The risk of metastatic calcification in soft tissues begins to increase when the product of calcium x phosphorus exceeds 1. 25 2. 55 3. 75 4. 95

2. 55

What is the optimal sodium concentration of an oral rehydration solution for patients with short bowel syndrome? 1. 40 mmol/L 2. 90 mmol/L 3. 140 mmol/L 4. 190 mmol/L

2. 90 mmol/L

In patients with severe acute pancreatitis, the use of enteral nutrition via nasojejunal feeding tube rather than parenteral nutrition is associated with 1. an increased incidence of hyperglycemia 2. a lower risk of developing infectious complications 3. a greater incidence of negative nitrogen balance 4. a decreased frequency of pancreatic stimulation

2. A lower risk of developing infectious complications

Which of the following strategies is a common cause for feeding tube occlusion? 1. Optimal flushing between medications 2. Administration of high protein/high fiber formula 3. Choosing liquid medication over pill 4. Frequent checking of gastric residuals

2. Administration of high protein/high fiber formula

Preterm infant formula or fortified human milk is used for premature infants during the first year of life. What is the rationale for this? 1. Preterm formula contains a higher percentage of carbohydrate as lactose, compared to term formula 2. After the first month, unfortified human milk contains inadequate protein for the premature infant 3. Term formula contains more MCT than desired 4. Preterm formula is easier to absorb than unfortified human milk

2. After the first month, unfortified human milk may contain inadequate protein for the premature infant

Preterm infant formula or fortified human milk is used for premature infants during the first year of life. What is the rationale for this? 1. Preterm formula contains a higher percentage of carbohydrate as lactose, compared to term formula 2. After the first month, unfortified human milk may contain inadequate protein for the premature infant 3. Term formula contains more MCT than desired 4. Preterm formula is easier to absorb than unfortified human milk

2. After the first month, unfortified human milk may contain inadequate protein for the premature infant

Phosphofructokinase, a rate-limiting enzyme of glycolysis, is inhibited when ATP is abundant. Why is this inhibition important? 1. Facilitates gluconeogenesis to maintain euglycemia 2. Allows the cell to divert glucose to be stored as glycogen 3. Promotes catabolism 4. Enhances the Tricarboxylic Acid (TCA) Cycle

2. Allows the cell to divert glucose to be stored as glycogen

Which of the following medication classes used in the older adult population will least likely contribute to anorexia? 1. Narcotic analgesics 2. Antihistamines 3. Histamine receptor antagonists 4. Antihypertensive agents

2. Antihistamines

The decision to terminate enteral feeding in a patient in a persistent vegetative state whose wishes have been made known through an advance directive is based on the ethical principle of 1. Justice 2. Autonomy 3. Beneficence 4. Nonmalfeasance

2. Autonomy

Which of the following is a possible complication of dietary fiber-containing enteral formulas? 1. Altered absorption of minerals 2. Bloating and flatulence 3. Increased effectiveness of some medications 4. Fluid retention

2. Bloating and flatulence

Which of the following factors has been associated with an increase in prescribing errors related to PN formulations? 1. Standardized PN order form 2. Calculation of PN dosages 3. PN components ordered as amount per day 4. PN components listed in the same sequence on order form as PN label

2. Calculation of PN dosages

Valproic acid has been shown to induce a deficiency in which of the following nutrients? 1. Copper 2. Carnitine 3. Fatty acids 4. Essential amino acids

2. Carnitine

Which of the following is a best practice recommendation in enteral nutrition (EN) formula safety? 1. Mix or reconstitute enteral formulations at the bedside 2. Change the enteral feeding administration set every 24 hours with open systems 3. Limit hang time of closed system EN formulas to no more than 12 hours 4. Store powdered formulas reconstituted in advance at room temperature for up to 24 hours

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

Which of the following is a best practice recommendation in enteral nutrition (EN) formula safety? 1. Mix or reconstitute enteral formulations at the bedside 2. Change the enteral feeding administration set every 24 hours with open systems 3. Limit hang time of closed-system EN formulas to no more than 12 hours 4. Store powdered formulas reconstituted in advance at room temperature for up to 24 hours

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

Which of the following can result in an invalid indirect calorimetry measurement? 1. enterocutaneous fistula 2. chest tube leak 3. hemodynamic stability 4. inspired oxygen (FiO2) less than 60%

2. Chest tube leak

Which of the following feeding schedules would be most appropriate for a critically ill patient with labile and poorly controlled blood glucose concentrations? 1. Bolus 2. Continuous 3. Gravity drip 4. Nocturnal infusion

2. Continuous

Which oils are included in commercial enteral formulas to provide a high supply of linoleic and alpha-linolenic acids? 1. Corn, olive, safflower and canola oils 2. Corn, soybean, safflower and canola oils 3. Coconut, olive, palm and canola oils 4. Coconut, soybean, safflower and canola oils

2. Corn, soybean, safflower and canola oils

Which of the following is NOT a research based method to restore patency to clogged feeding tubes? 1. Water flush 2. Cranberry juice flush 3. Mechanical declogging devices 4. Pancreatic enzyme mixed with sodium bicarbonate

2. Cranberry juice flush

Which of the following compromises the reliability of urinary urea nitrogen to calculate nitrogen balance? 1. protein intake < 0.5 g/kg/day 2. creatinine clearance < 50 mL/min 3. diuresis > 2.5 L 4. fecal nitrogen > 1 g

2. Creatinine clearance < 50 mL/min

In a preterm infant, which of the following amino acids is separately added to parenteral nutrition solutions due to solubility concerns? 1. Glycine 2. Cysteine 3. Methionine 4. Phenylalanine

2. Cysteine

Which of the following is a major risk factor for aspiration in critically ill patients? 1. Gastric residual volume < 150 mL 2. Decreased level of consciousness 3. Age 4. Small diameter feeding tube

2. Decreased level of consciousness

Which of the following is a metabolic alteration noted during the ebb response following burn injury to a pediatric patient? 1. Elevated catecholamines 2. Decreased resting energy expenditure 3. Elevated plasma insulin 4. Anabolism

2. Decreased resting energy expenditure

Symptoms of diarrhea, bloating and flatulence after ingestion of sugar are caused by 1. hydrolysis of lactose into monosaccharides 2. deficiency of brush border oligosaccharidases 3. decreased osmotic pressure in the colon 4. digestion of starches in the small intestine

2. Deficiency of brush border oligosaccharidases

Nephrolithiasis, caused by calcium oxalate stones, can occur in patients with short bowel syndrome (SBS) who 1. Have no remaining colon 2. Do not maintain adequate hydration 3. Have no remaining ileum 4. Take 500 mg calcium 2-3 times per day

2. Do not maintain adequate hydration

Which of the following is the best way to determine chromium deficiency? 1. Serum chromium levels 2. Empiric treatment when deficiency is suspected 3. Urinary chromium levels 4. Serum glucose to insulin ratio

2. Empiric treatment when deficiency is suspected

The majority of dietary folate is reabsorbed via which of the following mechanisms? 1. Oncotic pressure 2. Enterohepatic circulation 3. Plasma hydrostatic pressure 4. Passive diffusion

2. Enterohepatic circulation

A seven month-old infant fed reconstituted infant formula and other age-appropriate complementary foods may be at risk of over-supplementation with which of the following? 1. Vitamin A 2. Fluoride 3. Vitamin E 4. Iron

2. Fluoride

Methotrexate acts by interfering with the normal intracellular metabolism of which of the following nutrients? 1. thiamin 2. folate 3. carnitine 4. vitamin D

2. Folate

In the patient with a newly placed gastrostomy or jejunostomy tube, observation of which of the following conditions at the tube exit site would signal concern for infection? 1. Serosanguineous drainage 2. Foul-smelling drainage 3. Coffee-ground drainage 4. Vile-colored drainage

2. Foul-smelling drainage

Which of the following interventions has NOT been proven effective in reducing the risk of aspiration associated with enteral tube feeding in critically ill patients? 1. Elevating the head of the bed to 30-45 degrees 2. Frequent checking of GRVs 3. Placing the distal end of the tube into the small bowel 4. Using motility agents for patients with high gastric residual volumes

2. Frequent checking of GRVs

Which of the following interventions has NOT been proven effective in reducing the risk of aspiration associated with enteral tube feeding in critically ill patients? 1. Elevating the head of the bed to 30-45 degrees 2. Frequent checking of gastric residual volumes 3. Placing the distal end of the tube into the small bowel 4. Using motility agents for patients with high gastric residual volumes

2. Frequent checking of gastric residual volumes

A patient on long term home enteral nutrition suddenly develops nausea and vomiting. The most likely cause is: 1. Frequent use of sorbitol-containing medications 2. Gastric outlet obstruction 3. Low osmolarity formula 4. Sudden decrease in enteral feeding rate

2. Gastric outlet obstruction

A patient on long-term home enteral nutrition suddenly develops nausea and vomiting. The most likely cause is 1. frequent use of sorbitol-containing medications 2. gastric outlet obstruction 3. low osmolarity formula 4. sudden decrease in enteral feeding rate

2. Gastric outlet obstruction

Persistent hyperglycemia in patients with type 2 diabetes can result in the development of 1. cholestasis 2. glucolipotoxicity 3. hepatic steatosis 4. macrocytic anemia

2. Glucolipotoxicity

Mucosal atrophy that accompanies bowel rest may result from an absence of 1. short chain fatty acids 2. glutamine 3. glucose 4. L-cysteine

2. Glutamine

An assessment of functional status may aid in determining nutrition risk. Which of the following provides an assessment of functional status? 1. Intelligence quotient exam 2. Handgrip strength assessment 3. Measurement of fat mass 4. Visual exam

2. Handgrip strength assessment

The acceptable macronutrient distribution range (AMDR) 1. is defined as the Tolerable Upper Intake level for a particular energy source 2. Has been set for Omega-3 fatty acids, Omega-6 fatty acids and total fat 3. Provides a guide to assist in the treatment of chronic diseases related to fat intake 4. Is also known as the Estimated Average Intake (EAR)

2. Has been set for Omega-3 fatty acids, Omega-6 fatty acids and total fat

Which of the following best describes the utility of aluminum in parenteral solutions? 1. Potentiates the action of insulin 2. Has no known biologic function 3. Decreases the incidence of bone fractures

2. Has no known biologic function

Which of the following acute changes in serum chemistries would be expected in a patient who is experiencing tumor lysis syndrome? 1. hypercalcemia and hypomagnesemia 2. hyperkalemia and hyperphosphatemia 3. hypernatremia and hypermagnesemia 4. hypoalbuminemia and hyperphosphatemia

2. Hyperkalemia and hyperphosphatemia

Potential metabolic causes for a respiratory quotient (RQ) greater than 1 include all of the following EXCEPT 1. overfeeding 2. hypoventilation 3. excess CO2 production 4. provision of excess sodium bicarbonate

2. Hypoventilation

Which of the following best describes the typical age-related changes in body composition known as sarcopenia, that contribute to a decrease in energy related requirements 1. Decreased fat mass and increased lean body mass 2. Increased fat mass and decreased lean body mass 3. Increased fat mass and increased lean body mass 4. Decreased fat mass and decreased lean body mass

2. Increased fat mass and decreased lean body mass

Which of the following is associated with adaptation to starvation? 1. Increased glycogenesis 2. Increased lipid oxidation 3. Decreased gluconeogenesis 4. Increased glucose oxidation

2. Increased lipid oxidation

Which of the following does NOT describe the use of minimum enteral feeds in preterm neonates? 1. Prevents gut atrophy 2. Increases the risk of necrotizing enterocolitis 3. Improves feeding tolerance and time to full enteral feeds 4. Should be started as soon as medically feasible

2. Increases the risk of necrotizing enterocolitis

A pregnant patient is admitted with hyperemesis gravidarium (HEG), Which of the following is a clinical indication for PN use? 1. vomiting NOT controlled with supportive care within 48 hours 2. intolerance to EN trial and supportive care measures 3. patient refusal of EN tube placement 4. fluid and electrolyte imbalances

2. Intolerances to EN trial and supportive care measures

Which of the following is the most appropriate indicator of malnutrition? 1. involuntary weight loss of 5% of usual body weight over 3 months 2. Involuntary weight loss of 10% of usual body weight over 6 months 3. weight less than 10% of ideal body weight 4. weight less than 15% of ideal body weight

2. Involuntary weight loss of 10% of usual body weight over 6 months

A patient awaiting liver transplant has been taking a diuretic to control ascites and peripheral edema. Which of the following acid-base disorders is expected? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis

Skin care around a feeding tube site should be accomplished by cleaning with: 1. Alcohol 2. Mild soap and water 3. Iodine-povidone 4. Hydrogen peroxide

2. Mild soap and water

A 4 month old male has acute onset of diarrhea for 48 hours. His parents noticed that he hasn't been wetting as many diapers and his mucous membranes are slightly dry. His anterior fontanel is soft and not sunken. He normally ingests milk based formula ad lib. Which of the following is the most appropriate nutrition intervention for this infant? 1. 1/2 strength infant formula 2. Oral rehydration therapy 3. Full strength soy formula 4. Short course of parenteral nutrition

2. Oral rehydration therapy

Which of the following should always appear on the label of an enteral feeding product given to a patient in the hospital? 1. Product name, rate, volume, additives, caloric density, date and time the formula was prepared and hung 2. Patient identification, product name, administration method, date and time the formula was prepared and hung 3. Patient's name, product name, rate, strength, osmolality, date and time the formula was prepared and hung 4. Patient's name, room number, strength, additives, volume, date and time the formula was prepared and hung

2. Patient identification, product name, administration method, date and time the formula was prepared and hung

Which of the following should always appear on the label of enteral feeding product given to a patient in the hospital? 1. Product name, rate, volume, additives, caloric density, date and time the formula was prepared and hung 2. Patient identification, product name, administration method, date and time the formula was prepared and hung 3. Patient's name, product name, rate, strength, osmolality, date and time the formula was prepared and hung 4. Patient's name,, room number, strength, additives, volume, date and time the formula was prepared and hung

2. Patient indentification, product name, administration method, date and time the formula was prepared and hung

One method of minimizing the complications associated with refeeding syndrome is to initiate an electrolyte replacement protocol before nutrition therapy begin. Which of the following is true regarding such a plan? 1. Potassium, magnesium, and calcium are the most important electrolytes to closely monitor 2. Patients considered not-at-risk should also be included in the protocol 3. The protocol should replete all electrolytes ONLY via the feeding tube 4. Feeding should be delayed until the risk of electrolyte imbalance is eliminated

2. Patients considered not-at-risk should also be included in the protocol

Early initiation of enteral feeding has been suggested to benefit ICU patients by reducing infectious complications, length of hospital stay and even possibly reducing mortality. Which group of patients might be at significant risk from early enteral feeding? 1. Cancer patients who underwent surgery of the gastrointestinal tract 2. Patients with increasing vasopressor support 3. Traumatic brain injury patients with intracranial pressure controlled by hypertonic saline 4. Patients admitted to the hospital with acute on chronic pancreatitis

2. Patients with increasing vasopressor support

Which of the following is the MOST practical approach for managing micronutrients in long-term parenteral nutrition PN patients? 1. Obtain serum values for all vitamins and trace elements yearly 2. Perform a micronutrient assessment every 6 months 3. Provide micronutrients only when laboratory values indicate abnormal levels 4. Do not use commercial preparations; provide each micronutrient individually

2. Perform a micronutrient assessment every 6 months

An older adult patient without IV access requires strict bowel rest and PN for 6 weeks. Which of the following vascular access devices should be employed? 1. A port 2. Peripherally inserted central catheter (PICC) 3. Peripheral access 4. Short-term central venous catheter

2. Peripherally inserted central catheter (PICC)

The most common complication seen after per cutaneous endoscopic gastrostomy (PEG) tube placement is: 1. Buried bumper syndrome 2. Peristomal infection 3. Gastric ulceration 4. Colocutaneous fistulas

2. Peristomal infection

The most common complication seen after percutaneous endoscopic gastrostomy PEG tube placement is: 1. Buried bumper syndrome 2. Peristomal infection 3. Gastric ulceration 4. Colocutaneous fistula

2. Peristomal infection

Which of the following is NOT associated with a delayed bone age in a child with short stature? 1. Hyperthyroidism 2. Precocious puberty 3. Cushing syndrome 4. Growth hormone deficiency

2. Precocious puberty

Which of the following is NOT associated with a delayed bone age in a child with short stature? 1. Hypothyroidism 2. Precocious puberty 3. Cushing syndrome 4. Growth hormone deficiency

2. Precocious puberty

When transitioning a patient from hospital to home parenteral nutrition (HPN) support, screening criteria should include which of the following? 1. Transportation needed to make it to lab draws 2. Presence of electricity and sanitary water supply in the home 3. Cellular telephone access 4. A caregiver

2. Presence of electricity and sanitary water supply in the home

According to the ASPEN PN Safety Consensus Recommendations all of the following are considered to be mandatory for the PN order form EXCEPT 1. Full generic name for each ingredient (unless brand name can identify unique properties of specific dosage form) 2. Recommended laboratory monitoring 3. Infusion schedule (continuous or cyclic) 4. Electrolytes ordered as complete salt form rather than individual ion

2. Recommended laboratory monitoring

A patient with oral cancer, who has gained 10 lbs since starting home bolus enteral feedings via gastrostomy tube complains of pain and pressure on the "inside of his stomach" but no redness or drainage at the exterior gastrostomy site. Which of the following is the most appropriate response for the clinician? 1. Tell the patient to take over the counter pain medication and rotate the G tube 180 degrees each day 2. Refer the patient to the gastroenterologist or enterostomal nurse 3. Decrease the infusion volume of the formula in half to avoid excessive distention of the stomach 4. Change to a slower tube feed infusion by using a gravity bag for feedings

2. Refer the patient to the gastroenterologist or enterostomal nurse

Which type of insulin should be used when initiating enteral nutrition in a hospitalized diabetic patient? 1. Premixed NPH/Regular insulin 2. Regular Insulin 3. NPH insulin 4. Insulin glargine

2. Regular insulin

Which type of insulin should be used when initiating enteral nutrition in a hospitalized diabetic patient? 1. Premixed NPH/Regular insulin 2. Regular insulin 3. NPH insulin 4. Insulin glargine

2. Regular insulin

Which of the following is NOT true of essential fatty acid deficiency EFAD in patients with cystic fibrosis (CF)? 1. Biochemical EFAD may be seen in both pancreatic sufficient and insufficient patients 2. Routine supplementation of omega-3 fatty acids is essential in the management of CF 3. Those patients with moderate to severe lung disease are at high risk for EFAD 4. Poor growth and pulmonary status correlate with biochemical markers of EFAD

2. Routine supplementation of omega-3 fatty acids is essential in the management of CF

In 2010 the Institute of Medicine (IOM) concluded that available scientific evidence supports a key role of calcium and vitamin D in 1. cancer outcome 2. skeletal health 3. cardiovascular disease outcome 4. all of the above

2. Skeletal health

Which of the following is the most likely cause of watery diarrhea and bloating in the enterally fed adult patient? 1. Lactose content of the enteral formula 2. Sorbitol content of liquid medications 3. Sorbitol content of the enteral formula 4. Lactose content of liquid medications

2. Sorbitol content of liquid medications

An older adult nursing home resident with a history of constipation has a newly placed percutaneous endoscopic gastrostomy tube. Which of the following formulas would most likely be the best choice? 1. Concentrated 2 kcal/mL formula 2. Standard 1 kcal/mL formula with fiber 3. High nitrogen formula 4. Predigested formula

2. Standard 1 kcal/mL formula with fiber

Which of the following are considered the lowest risk candidates for initiation of parenteral nutrition PN in the home setting would be 1. Infants 2. Teenagers 3. Intravenous drug abusers 4. Diabetic patients

2. Teenagers

Which of the following best reflects the use of specialized nutrition support (SNS) in patients with a Do Not Resuscitate (DNR) status? 1. The DNR status is a contraindication to the provision of SNS 2. The DNR status should not preclude the initiation of SNS if the indications exist 3. The provision of SNS to a patient with a DNR status is based on individual state laws 4. SNS cannot be withheld or withdrawn in a patient with a DNR order, even if all agree that SNS is no longer meeting the desired goal

2. The DNR status should not preclude the initiation of SNS if the indications exist

Linoleic acid and alpha-linolenic acid are referred to as essential fatty acids for humans because 1. they are the only fatty acids that can be used for ATP production 2. they cannot be synthesized by humans and must be obtained through diet 3. they are the only fatty acids absolutely required to sustain life 4. they require L-carnitine to enter the mitochondria

2. They cannot be synthesized by humans and must be obtained through diet

Malnourished women with hyperemesis gravidarum who require specialized nutrition support are likely to require supplementation of: 1. chloride 2. thiamin 3. vitamin E 4. manganese

2. Thiamin

Initially, how often should electrolytes be monitored in a patient on home parenteral nutrition support? 1. Daily 2. Weekly 3. Monthly 4. Bi-monthly

2. Weekly

The subjective global assessment used to evaluate the nutritional status of patients includes 1. dietary intake, delayed hypersensitivity skin testing, weight history 2. weight history, dietary intake and gastrointestinal symptoms 3. laboratory indices, weight history and gastrointestinal symptoms 4. Arm anthropometry, dietary intake and laboratory indices

2. Weight history, dietary intake and gastrointestinal symptoms

In persons with phenylketonuria (PKU), tyrosine becomes an essential amino acid due to 1. an increase in the tyrosine hydroxylase enzyme 2. a deficiency in the phenylalanine hydroxylase enzyme 3. an increase in the phenylalanine hydroxylase enzyme 4. a decrease in the tyrosine hydroxylase enzyme

2. a deficiency in the phenylalanine hydroxylase enzyme

Protein-energy malnutrition is most common in which of the following types of liver disease? 1. viral hepatitis 2. cirrhosis 3. hepatic steatosis 4. nonalcoholic steatohepatitis (NASH)

2. cirrhosis

Which of the following feeding schedules would be most appropriate for a critically ill patient with labile and poorly controlled blood glucose concentrations? 1. bolus 2. continuous 3. gravity drip 4. nocturnal infusion

2. continuous

Which of the following is NOT a research-based method used to restore patency to clogged feeding tubes? 1. Water flush 2. Cranberry juice flush 3. Mechanical declogging devices 4. Pancreatic enzyme mixed with sodium bicarbonate

2. cranberry juice flush

Which of the following is a metabolic alteration noted during the ebb response following burn injury to a pediatric patient? 1. elevated catecholamines 2. decreased resting energy expenditure 3. elevated plasma insulin 4. anabolism

2. decreased resting energy expenditure

Which of the following are counter-regulatory hormones responsible for the hypercatabolism observed in critically ill trauma patients? 1. glycogen, insulin, norepinephrine 2. glucagon, epinephrine, cortisol 3. glycerol, serotonin, thymoglobulin 4. glycerin, leptin, adenosine

2. glucagon, epinephrine, cortisol

Mild hypercalcemia, defined as a total serum calcium of 10.3 - 12.9 mg/dL, should initially be treated with 1. sodium phosphate 2. hydration 3. hemodialysis 4. bisphosphonates

2. hydration

Which of the following is most likely to be observed first, if a non-diabetic older adult is overfed? 1. hepatobiliary effects 2. hyperglycemia 3. weight gain 4. accumulation of carbon dioxide

2. hyperglycemia

A 62 year old female with impaired renal function was prescribed sulfamethoxazole/trimethoprim for a urinary tract infection. What electrolyte disorder is likely to occur? 1. Hypermagnesemia 2. Hyperkalemia 3. Hypercalcemia 4. Hyperphosphatemia

2. hyperkalemia

Under conditions of sepsis and stress, which of the following metabolic alterations are most likely to occur? 1. increased glucose production and increased glucose uptake 2. increased glucose production and decreased glucose uptake 3. decreased glucose production and decreased glucose uptake 4. decreased glucose production and increased glucose uptake

2. increased glucose production and decreased glucose uptake

The primary fuel source for the brain after a 48 hour fast is 1. essential fatty acids 2. ketone bodies 3. carbohydrates 4. amino acids

2. ketone bodies

Consumption of soluble fiber contributes to: 1. lower levels of high density lipoprotein cholesterol 2. lower levels of total and low density lipoprotein cholesterol 3. lower risk of developing colon cancer 4. increased in blood glucose concentrations

2. lower levels of total and low density lipoprotein cholesterol

Skin care around a feeding tube site should be accomplished by cleaning with 1. alcohol 2. mild soap and water 3. iodine-povidone 4. hydrogen peroxide

2. mild soap and water

A respiratory quotient (RQ) of 0.87 most likely suggests 1. primarily fat oxidation 2. mixed substrate utilization 3. primary carbohydrate oxidation 4. primary protein oxidation

2. mixed substrate utilization

Which of the following is an important indicator of protein-energy malnutrition in chronic liver disease? 1. jaundice 2. muscle wasting 3. elevated liver function tests 4. hepatic encephalopathy

2. muscle wasting

A 4 month-old male has acute onset of diarrhea for 48 hours. His parents noticed that he hasn't been wetting as many diapers and his mucous membranes are slightly dry. His anterior fontanel is soft and not sunken. He normally ingests milk based formula ad lib. Which of the following is the most appropriate nutrition intervention for this infant? 1. 1/2 strength infant formula 2. Oral rehydration therapy 3. Full strength soy formula 4. Short course of parenteral nutrition

2. oral rehydration therapy

AF has had a nasogastric tube for suction in place for 48 hours secondary to a post-operative ileus. Which of the following electrolytes will be lost? 1. bicarbonate 2. potassium 3. calcium 4. phosphorus

2. potassium

In 2010 the Institute of Medicine (IOM) concluded that available scientific evidence supports a key role of calcium and vitamin D in 1. cancer outcome 2. skeletal health 3. cardiovascular disease outcome 4. all of the above

2. skeletal health

Presence of dietary fat in the distal ileum contributes to 1. increased gastric emptying 2. slowed intestinal transit 3. bacterial fermentation 4. production of short chain fatty acids

2. slowed intestinal transit

Which of the following is the most likely cause of watery diarrhea and bloating in the enterally fed adult patient? 1. lactose content of the enteral formula 2. sorbitol content of liquid medications 3. Sorbitol content of the enteral formula 4. Lactose content of liquid medications

2. sorbitol content of liquid medications

Which of the following are considered the lowest risk candidates for initiation of parenteral nutrition (PN) in the home setting would be 1. infants 2. teenagers 3. intravenous drug abusers 4. diabetic patients

2. teenagers

An old patient with alcoholism is admitted with small bowel obstruction and is started on PN providing 400 grams of dextrose. If, after 3 days, the patient develops mental status changes it is most likely due to a deficiency of 1. pyridoxine 2. thiamine 3. folic acid 4. vitamin C

2. thiamine

Which of the following has NOT been shown to delay weaning from mechanical ventilation in patients with COPD who are receiving enteral nutrition? 1. refeeding syndrome 2. tubefeeding syndrome 3. underfeeding 4. overfeeding

2. tubefeeding syndrome

Loss of parietal cells after a gastrectomy may lead to a deficiency of 1. vitamin C 2. vitamin B12 3. vitamin E 4. choline

2. vitamin B12

Zinc supplementation should be provided to patients with wounds 1. of any and all types 2. who are suspected to have a zinc deficiency 3. who are elderly 4. who have below normal zinc levels

2. who are suspected to have a zinc deficiency

What protein level does a recent study suggest for ICU patients receiving continuous renal replacement therapy?

2.0-2.5 g/kg/day

How many grams of fat per 100 mL are in 20% IVFE?

20 grams/100 mL

What is the WHO/UNICEF recommendation for zinc supplementation?

20 mg of zinc per day for 10-14 days for children with acute diarrhea and 10 mg per day for infants under 6 month of age to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months

What are WHO/UNICEF recommendations for zinc supplementation in diarrhea?

20 mg of zinc per day for 10-14 days for children with acute diarrhea and 10 mg per day for infants under 6 months of age to curtail the severity of the episode and prevent further occurrences in the ensuing 2-3 months

What is the caloric prescription for HPN under Medicare?

20-35 calories per kg per day

What is the supplementation dose for vitamin A in suspected deficiency? Why?

25,000 IU/day for 14 days, It can be toxic at high doses so the recommended course is up to 14 days

How many AMDRs are there for fat?

3, The AMDR has been established for Omega-3, Omega-6 and total fat

How long does the ebb response following burn injury last?

3-5 days

How long is the ebb response following burn injury?

3-5 days

A 65 year old female had complications associated with GI surgery, and was admitted to the intensive care unit with pneumonia and septic shock. After she became hemodynamically stable, she was started on parenteral nutrition secondary to a prolonged ileus. Prior to surgery, she was at her ideal weight. Currently her labs include albumin 2.0 mg/dL and creatinine 1.0 mg/dL. Her urine output is adequate. Which of the following best estimates her protein needs for initiation of parenteral nutrition therapy? 1. 0.6 g/kg 2. 0.8 g/kg 3. 1.5 g/kg 4. 2.5 g/kg

3. 1.5 g/kg

What is the recommended dietary protein intake in acutely ill patients receiving continuous renal replacement therapy (CRRT)? 1. 0.5-0.8 g/kg/day 2. 1.2-1.5 g/kg/day 3. 1.5-2 g/kg/day 4. 2.5-3 g/kg/day

3. 1.5-2 g/kg/day

Which of the following children is at greatest risk for iron deficiency anemia? 1. 4 month-old term infant exclusively fed human milk 2. 4 month corrected gestational age, former preemie on a transitional formula 3. 10 month-old switched form formula to whole milk 4. 17 month-old "picky eater"

3. 10 month-old switched form formula to whole milk

Which of the following children is at greatest risk for iron deficiency anemia? 1. 4 month-old term infant exclusively fed human milk 2. 4 month corrected gestational age, former preemie on a transitional formula 3. 10 month-old switched from formula to whole milk 4. 17 month-old "picky eater"

3. 10 month-old switched from formula to whole milk

In a 100 kg afebrile person with intact skin, insensible fluid loss from lungs and skin is approximately 1. 500 mL/day 2. 800 mL/day 3. 1000 mL/day 4. 1200 mL/day

3. 1000 mL/day

The initial protein requirements for a critically ill trauma patient weighing 70 kg are 1. 55-70 grams 2. 70-105 grams 3. 105-140 grams 4. 140-175 grams

3. 105-140 grams

What should be the MAXIMUM parenteral dextrose infusion rate for a term infant? 1. 4-8 mg/kg/min 2. 8-12 mg/kg/min 3. 14-18 mg/kg/min 4. 18-22 mg/kg/min

3. 14-18 mg/kg/min

What is the glycemic target for the majority of critically ill adult patients? 1. 80 to 110 mg/dL 2. 220 to 240 mg/dL 3. 140 to 180 mg/dL 4. 180 to 220 mg/dL

3. 140 to 180 mg/dL

What is the nutritional value of the following PN order? 2400 mL with 300 grams dextrose and 90 grams protein in addition to 225 mL 20% IVFE 1. 1830 kcal, 90 grams protein, 40 grams fat, 2625 mL 2. 2010 kcal, 90 grams protein, 40 grams fat, 2400 mL 3. 1830 kcal, 90 grams protein, 45 grams fat, 2625 mL 4. 1470 kcal, 90 grams protein, 45 grams fat, 2400 mL

3. 1830 kcal, 90 grams protein, 45 grams fat, 2625 mL

What is the recommended daily supplemental enteral iron dose for preterm infants, one month after birth? 1. 0.5-1 mg/kg/d 2. 1-2 mg/kg/d 3. 2-4 mg/kg/d 4. 5-6 mg/kg/d

3. 2-4 mg/kg/d

What is the recommended daily supplemental enteral iron dose for preterm infants, one month after birth? 1. 0.5-1 mg/kg/day 2. 1-2 mg/kg/day 3. 2-4 mg/kg/day 4. 5-6 mg/kg/day

3. 2-4 mg/kg/day

Home-prepared or blenderized enteral nutrition (EN) formulations should be discarded after 1. 6 hours 2. 12 hours 3. 24 hours 4. 48 hours

3. 24 hours

The nutritional needs of a patient with a bone marrow transplant are best met with: 1. 20-35 kcal/kg daily with >/= 1.5 g protein per kg body weight 2. 20-25 kcal/kg daily with 80% of total calories from carbohydrate 3. 30-35 kcal/kg/day with >/= 1.5 g protein per kg body weight 4. 30-35 kcal/kg/day with 80% of total calories from carbohydrate

3. 30-35 kcal/kg daily with >/= 1.5 g protein per kg body weight

According to the 2010 Healthcare Cost and Utilization Project (HCUP), what percentage of older adults in hospitals are diagnosed with malnutrition? 1. 10-20% 2. 30-40% 3. 50-60% 4. 70-80%

3. 50-60%

Immediately following neonatal cardiac surgery, which of the following is the best estimate of parenteral caloric requirements? 1. 90-100 kcal/kg/day 2. 120-170 kcal/kg/day 3. 55-60 kcal/kg/day 4. 100-110 kcal/kg/day

3. 55-60 kcal/kg/day

In transitioning from enteral tube to oral feeding may be discontinued when adequacy of oral intake meets at least: 1. 33% of nutrient needs 2. 50% of nutrient needs 3. 66% of nutrient needs 4. 90% of nutrient needs

3. 66% of nutrient needs

In transitioning from enteral tube to oral feeding, tube feeding may be discontinued when adequacy of oral intake meets at least: 1. 33% of nutrient needs 2. 50% of nutrient needs 3. 66% of nutrient needs 4. 90% of nutrient needs

3. 66% of nutrient needs

All patients admitted to the home care provider shall undergo nutrition screening using subjective and/or objective criteria within 1. 24 hours 2. 48 hours 3. 72 hours 4. 96 hours

3. 72 hours

To meet the Medicare payer criteria for home enteral or parenteral nutrition, the patient's condition must be considered to be "of long and indefinite duration". Which length of time below meets Medicare's test of permanence requirement? 1. 30 days 2. 60 days 3. 90 days 4. 120 days

3. 90 days

Which of the following enteral feeding schedules should be recommended to patients and their families when preparing for home enteral nutrition? 1. Schedule feedings outside of normal meal times 2. Schedule feedings during meal times 3. A schedule that allows for integration of feeding into the patient's and family's lifestyle 4. Feeding schedule that separated the patient during meal times to minimize the family's discomfort with the process

3. A schedule that allows for integration of feeding into the patient's and family's lifestyle

Which of the following enteral feeding schedules should be recommended to patients and their families when preparing for home enteral nutrition? 1. Schedule feedings outside of normal meal times 2. Schedule feedings during normal meal times 3. A schedule that allows for integration of feeding into the patient's and family's lifestyle 4. Feeding schedule that separated the patient during meal times to minimize the family's discomfort with the process

3. A schedule that allows for integration of feeding into the patient's and family's lifestyle

Which of the following is true regarding parenteral nutrition (PN)-associated metabolic bone disease? 1. Cyclic PN reduces the risk of developing metabolic bone disease 2. Excessive dietary protein may lead to a positive calcium balance 3. All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry 4. Adequate supplementation of calcium and phosphorus is achieved with PN

3. All patients on PN for longer than 1 year should be recommended for dual-energy x-ray absorptiometry

Which of the following best describes the treatment of diarrhea in inflammatory bowel disease? 1. cholestyramine is effective treatment for steatorrhea 2. patients with diarrhea should be treated with prebiotics 3. antidiarrheal agents once infectious etiology is ruled out 4. pharmacological therapy is withheld until diarrhea exceeds 1 L/day

3. Antidiarrheal agents once infectious etiology is ruled out

Which enteral feeding method provides 240 mL of formula via a syringe over as few as 4-10 minutes? 1. Intermittent feeding 2. Cyclic feeding 3. Bolus feeding 4. Continuous feeding

3. Bolus feeding

While a patient is receiving speech therapy, oral foods are provided during the daytime hours. To meet the patient's nutritional requirements, polymeric tube feeding is required during the night at a rate of 75 mL per hour over 10 hours. The night feeding is an example of 1. bolus feeding 2. intermittent feeding 3. cyclic feeding 4. continuous feeding

3. Cyclic feeding

Sarcopenia, a loss of lean body mass that occurs with aging, is also associated with 1. excess growth hormone 2. decreased cytokine activity 3. decreased bone density 4. decreased total body fat

3. Decreased bone density

Third party payers (insurance companies) are LEAST likely to reimburse which of the following home enteral nutrition expenses? 1. Feeding bags and tubing 2. Enteral feeding pumps 3. Enteral formula 4. IV pole and/or syringes

3. Enteral formula

Serum conjugated bilirubin level is elevated in an adult patient with short bowel syndrome. The patient has been receiving a 12 hour cycle of 3-in-1 home parenteral nutrition (HPN) solution. The clinician's initial plan may include: 1. Removal of all trace elements from HPN 2. Increasing lipid calories to prevent essential fatty acid deficiency 3. Evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion 4. Addition of carnitine and choline to the HPN

3. Evaluation for possible overfeeding of dextrose and/or intravenous fat emulsion

Ursodiol facilitates absorption of 1. carbohydrate 2. protein 3. fat 4. vitamin K

3. Fat

Patients receiving home parenteral nutrition HPN who belong to a support group are shown to experience which of the following? 1. Higher reactive depression 2. Lower quality of life (QOL) 3. Fewer hospital readmissions 4. Increased incidence of catheter-related sepsis

3. Fewer hospital readmissions

What intervention assists with maintaining feeding tube patency in the adult patient? 1. Administer medications through feeding tube with 5 mL water 2. Use a 20 mL or smaller syringe to flush small bore feeding tubes 3. Flush feeding tube with 30 mL of water every 4 hours during continuous feeding 4. Change feeding tubes every 72 hours

3. Flush feeding tube with 30 mL of water every 4 hours during continuous feeding

Which of the following describes an optimal method of preparing and administering medications via an enteral feeding tube? 1. crush tablets and add them directly into the enteral formula 2. administer liquid formulations undiluted to minimize fluid overload 3. flush the tube with water before and after each medication administered 4. add crushed tablets to liquid medications and administer the mixture together

3. Flush the tube with water before and after each medication administered

Which of the following is the BEST indication for use of a soy-based infant formula? 1. Diarrhea 2. Cow's milk protein allergy 3. Galactosemia 4. Regurgitation with feeds

3. Galactosemia

According to Medicare (and Medicaid) guidelines, under the prosthetic device act, home enteral nutrition (HEN) is covered for a patient who: 1. Cannot meet his/her nutrition requirements by oral intake 2. Has documented weight loss of 10% in 3 months and refuses to eat 3. Has permanent disease of the structures that normally permit food to reach the small bowel 4. Has a temporary (estimates as less than 3 months) impairment or disease of the mouth, esophagus or stomach that prevents food from reaching the small bowel

3. Has permanent disease of the structures that normally permit food to reach the small bowel

Choline supplementation has been investigated as a treatment for which of the following disease states? 1. Myocardial infarction 2. Pancreatic insufficiency 3. Hepatic steatosis 4. Alcoholic encephalopathy

3. Hepatic steatosis

A patient has an advanced directive stating a desire to forego medical technology, including nutrition and hydration, in order to prolong life. The patient is now in an irreversible vegetative state. In deciding whether to continue nutrition and hydration by medical means , the patient's surrogate decision maker must: 1. consult with a lawyer 2. have a psychiatric evaluation to be declared competent to make any decisions in the patient's care 3. honor the patient's expressed wish to withdraw nutrition and hydration by medical means 4. decide, based upon own values, to make a decision to withdraw the patient's nutrition and hydration by medical means

3. Honor the patients expressed wish to withdraw nutrition and hydration by medical means

Which of the following data should be collected in the home care provider's performance improvement plan? 1. First-dose precautions 2. Discharge instructions 3. Hospital readmission 4. Consent for care

3. Hospital readmission

Which of the following is a sign observed in PN patients with inadequate chromium intake? 1. Weight gain 2. Hypoglycemia 3. Hyperglycemia 4. Rhabdomyolysis

3. Hyperglycemia

Which of the following is true of aluminum toxicity in patients receiving long-term parenteral nutrition? 1. The clinical manifestations of aluminum toxicity are specific and sensitive 2. Aluminum toxicity is the primary etiology of parenteral nutrition-associated bone disease 3. Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia 4. Modern manufacturing practices have eliminated the risk of aluminum toxicity

3. Increased risk of aluminum toxicity exists in the setting of renal failure or iron deficiency anemia

Which of the following is most suggestive of malnutrition? 1. 10th percentile of tricep skinfold thickness 2. Voluntary body mass index change from 30 to 25 over 6 months 3. Involuntary weight loss of 10% usual body weight over 6 months 4. Albumin decrease from 4.0 to 3.5

3. Involuntary weight loss of 10% usual body weight over 6 months

Supplementation with which of the following nutrients is routinely restricted during the early stages of hematopoietic stem cell transplantation (HSCT)? 1. Sodium 2. Folate 3. Iron 4. Vitamin B12

3. Iron

Which of the following additives has the greatest risk of destabilizing the intravenous fat emulsion (IVFE) in a total nutrient admixture (TNA)? 1. Sodium chloride 2. Calcium acetate 3. Iron dextran 4. Potassium phosphate

3. Iron dextran

Which of the following areas of the gastrointestinal tract has the LEAST impact on nutrient absorption and intestinal adaptation following significant intestinal resection? 1. Colon 2. Ileum 3. Jejunum 4. Ileocecal valve

3. Jejunum

Medicare approved indications for home parenteral nutrition (HPN) include which of the following? 1. Supplement to enteral nutrition 2. End-stage renal disease (ESRD) 3. Long-term loss of gastrointestinal function 4. Delayed gastric emptying

3. Long-term loss of gastrointestinal function

Which of the following is true concerning manganese and patients on long-term parenteral nutrition (PN)? 1. Manganese deficiency occurs in patients on PN for greater than 1 year 2. Hypermanganesemia has been reported only in patients with cholestasis 3. Manganese in commercial trace element preparations may result in hypermaganesemia 4. The best indicator of manganese status is serum manganese

3. Manganese in commercial trace element preparations may result in hypermaganesemia

A malnourished patient with metastatic ovarian cancer is diagnosed with an inoperable partial mechanical small bowel obstruction. She is taking small amounts of a full liquid diet by mouth, but is unable to take enough nutrition to maintain her weight. She has lost 12%of her body weight in the past 2 months. According to current Medicare guidelines, this patient's home parenteral nutrition HPN will be covered under which of the following circumstances? 1. The physician must write an order for the patient to be nil per os or "nothing by mouth" 2. Medical record must include a radiology report documenting the presence of partial small bowel obstruction 3. Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option 4. No further documentation is necessary to confirm coverage

3. Medical record must document failure of an enteral tube feeding trial, or explain why an enteral feeding tube is not an option

Which of the following vascular access devices (VADs) should not be used for home parenteral nutrition (HPN)? 1. Hickman catheter 2. Peripherally-inserted central catheter (PICC) 3. Midline catheter 4. Implanted port

3. Midline catheter

Which of the following vascular access devices VADs should not be used for home parenteral nutrition (HPN)? 1. Hickman cateter 2. Peripherally-inserted central catheter (PICC) 3. Midline catheter 4. Implanted port

3. Midline catheter

A home enteral nutrition patient recently treated for pneumonia is noted to have a new onset diarrhea. Of the following, the first intervention should be to: 1. Change to an elemental feeding 2. Obtain an order for a bile-sequestering agent 3. Obtain a Clostridium difficile toxin stool assay 4. Obtain an order for an antidiarrheal medication

3. Obtain a Clostridium difficile toxin stool assay

Which of the following is a non-profit organization identified as a resource for home nutrition patients and their caregivers? 1. Academy of Nutrition and Dietetics 2. American Society for Parenteral and Enteral Nutrition 3. Oley Foundation 4. American Society for Clinical Nutrition

3. Oley foundation

Which of the following is NOT a contraindication to nasogastric tube feedings in a pediatric patient with cystic fibrosis? 1. Chronic sinusitis 2. Chronic otitis 3. Pancreatic insufficiency 4. Need for long term nutrition support

3. Pancreatic insufficiency

A 75 year old male admitted to the hospital with aspiration pneumonia, was deemed unsafe for an oral diet, and is now experiencing aspiration while receiving continuous enteral nutrition via an NG tube. Which of the following long-term feeding options would be the most appropriate? 1. Central parenteral nutrition (PN) 2. Percutaneous endoscopic gastrostomy (PEG) feeding 3. Percutaneous endoscopic jejunostomy (PEG) feeding 4. Peripheral PN

3. Percutaneous endoscopic jejunostomy (PEJ) feeding

Which of the following is NOT a common clinical symptom of celiac disease in childhood 1. Failure to Thrive 2. Constipation 3. Precocious puberty 4. Anemia

3. Precocious puberty

Which of the following is NOT a common clinical symptom of celiac disease in childhood? 1. Failure to thrive 2. Constipation 3. Precocious puberty 4. Anemia

3. Precocious puberty

Which is a benefit of using an electromagnetic placement device for NGT placement? 1. pH can be monitored 2. Checks the tip position relative to the pylorus 3. Provides a 3D localization 4. Shows a time-delayed perspective of the tube tip location

3. Provides a 3D localization

An end stage liver disease patient with refractory ascites is awaiting liver transplantation and is intolerant to tube feeding. His serum sodium is 123 mEq/L. Which of the following is most appropriate to recommend? 1. Restrict fluid, supplement sodium, provide 2.5 g protein/kg/day 2. Restrict fluid, restrict sodium, provide 0.5 g protein/kg/day 3. Restrict fluid, restrict sodium, provide 1.5 g/kg/day protein 4. Restrict fluid, supplement sodium, provide 1.0 g protein/kg/day

3. Restrict fluid, restrict sodium, provide 1.5 g protein/kg/day

Which of the following is a key concept that should be included in the post-discharge teaching regimen for a home parenteral nutrition HPN patient? 1. Reimbursement requirements 2. Normal values for electrolytes 3. Signs and symptoms of hypo/hyperglycemia 4. Components of the parenteral PN nutrition formula

3. Signs and symptoms of hypo/hyperglycemia

Which of the following is a common signs seen in a patient with vitamin D toxicity? 1. Hypocalcemia 2. Metabolic bone disease 3. Soft tissue calcification 4. Hypophosphatemia

3. Soft tissue calcification

A 14 year old with a 4 month history of intentional weight loss of 15% of her usual weight and a BMI less than the 5th percentile is diagnosed with anorexia nervosa. She is admitted to the hospital for medical stabilization and is unwilling to consume enough food to meet her nutritional needs. A 24 hour calorie count reveals that the patient is consuming a very restricted diet averaging 850 calories daily. Which of the following is the most appropriate nutrition intervention at this time: 1. peripheral parenteral nutrition 2. high calorie diet with a calorie count 3. structured meal plan with supplemental enteral feedings 4. ad lib diet with 72 hour calorie count

3. Structured meal plan with supplemental enteral feedings

Which of the following best describes the use of enteral nutrition support in hyperemesis gravidarum (HEG)? 1. Postpyloric placement of feeding tubes requires radiation exposure, which is an unacceptable risk during pregnancy 2. Concentrated, hypertonic enteral formulas are indicated to maximize delivery of nutrients needed during pregnancy in a smaller volume 3. Successful use has been reported and a trial of enteral nutrition prior to initiation of parenteral nutrition is appropriate 4. Prospective, randomized clinical trials have demonstrated the superiority of enteral nutrition over parenteral nutrition in regard to infectious complications and successful delivery of goal protein and calories

3. Successful use has been reported and a trial of enteral nutrition prior to initiation of parenteral nutrition is appropriate

A 2 month old infant, who has been exclusively fed with cow's milk based formula develops a full body rash. Which of the following would be the most appropriate next step? 1. Switch to a soy protein based formula 2. Switch to a high MCT oil formula 3. Switch to a protein hydrolysate based formula 4. Switch to a lactose free cow's milk based formula

3. Switch to a protein hydrolysate based formula

A 2-month old infant, who has been exclusively fed with cow's milk based formula develops a full body rash. Which of the following would be the most appropriate next step? 1. Switch to a soy protein based formula 2. Switch to a high MCT oil formula 3. Switch to a protein hydrolysate based formula 4. Switch to a lactose free cow's milk based formula

3. Switch to a protein hydrolysate based formula

Standard parenteral amino acid solutions available for neonates differ from standard adult parenteral amino acid solutions by having a higher content of? 1. Cysteine 2. Phenylalanine 3. Taurine and tyrosine 4. Methionine and glycine

3. Taurine and tyrosine

A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue enteral feeding. Which of the following is true regarding the dying patient? 1. Intravenous hydration should be used to reduce symptoms of nausea, vomiting, diarrhea and respiratory distress 2. Dehydration, starvation and ketosis produces a euphoric state that enhances the perception of hunger 3. The most common symptom when nutrition and hydration are withheld is dry mouth 4. Electrolyte imbalance should be expected and may produce a degree of analgesia

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

A terminally ill patient at home on hospice complains of nausea during enteral feedings. A decision is made to discontinue enteral feeding. Which of the following is true regarding the tying patient? 1. Intravenous hydration should be used to reduce symptoms of nausea, vomiting, diarrhea and respiratory distress 2. Dehydration, starvation and ketosis produces a euphoric state that enhances the perception of hunger 3. The most common symptom when nutrition and hydration are withheld is dry mouth 4. Electrolyte imbalance should be expected and may produce a degree of analgesia

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

Which water-soluble vitamins do not require Na+ co-transporters for absorption? 1. Vitamin C and Vitamin B6 2. Vitamin E and Vitamin D 3. Vitamin B12 and Folic acid 4. B1 and choline

3. Vitamin B12 and folic acid

On radiographic examination, a pediatric patient is found to have osteopenia and multiple fractures in various stages of healing. Serum laboratory results show: Calcium: low Phosphorus: low Creatinine: normal Alkaline phosphatase: high 25-OH vitamin D: low 1,25 (OH)2 vitamin D: low PTH: high Which of the following is the most likely diagnosis? 1. Renal tubular acidosis 2. Osteogenesis imperfecta 3. Vitamin D deficiency rickets 4. Vitamin D dependent rickets type 2

3. Vitamin D deficiency rickets

On radiographic examination, a pediatric patient is found to have osteopenia and multiple fractures in various stages of healing. Serum laboratory results show: Calcium: low Phosphorus: low Creatinine: Normal Alkaline phosphatase: high 25-OH vitamin D: low 1,25 (OH)2 vitamin D: low PTH: high Which of the following is the most likely diagnosis? 1. Renal tubular acidosis 2. Osteogenesis imperfecta 3. Vitamin D deficiency rickets 4. Vitamin D dependent rickets type 2

3. Vitamin D deficiency rickets

Which of the following vitamin considerations is most important in an older adult receiving a total nutrient admixture (3-in-1) parenteral nutrition (PN) as well as anticoagulation (Warfarin) therapy? 1. Vitamin D 2. Vitamin A 3. Vitamin K 4. Vitamin E

3. Vitamin K

Which statement is true regarding effects of fiber-supplemented diets on altered bowel elimination? 1. soluble fiber intake corrects constipation 2. fiber-containing formulas will reduce diarrhea in tube fed patients 3. wheat bran increases IBS symptoms of abdominal pain and bloating 4. high fiber diet increases incidence of involuntary stool leakage

3. Wheat bran increases irritable bowel syndrome IBS symptoms of abdominal pain and bloating

Which of the following medications is LEAST likely to cause diarrhea in a patient receiving enteral nutrition? 1. clindamycin 2. kayexalate 3. codeine 4. magnesium oxide

3. codeine

While a patient is receiving speech therapy, oral foods are provided during the daytime hours. To meet the patient's nutritional requirements, polymeric tube feeding is required during the night at a rate of 75 mL per hour over 10 hours. The night feeding is an example of: 1 bolus feeding 2. intermittent feeding 3. cyclic feeding 4. continuous feeding

3. cyclic feeding

In patients with severe acute pancreatitis enteral nutrition has been documented to provide the following benefits over Parenteral nutrition EXCEPT: 1. decreased infection rate 2. decreased hospital length of stay 3. decreased pain 4. decreased mortality

3. decreased pain

In an older adult who requires long term EN, which of the following complications is most often overlooked? 1. tube leaking 2. tube clogging 3. decreased urine output 4. skin problems at tube site

3. decreased urine output

A patient with acute kidney injury (AKI) who requires parenteral nutrition support would most likely benefit from a solution containing which of the following? 1. essential amino acids only 2. essential amino acids with arginine only 3. essential amino acids and nonessential amino acids 4. essential amino acids and branched chain amino acids

3. essential amino acids and nonessential amino acids

Sorbitol-induced hypokalemia is caused by 1. inadequate dietary intake 2. increased renal potassium loss 3. excess potassium loss in the stool 4. transcellular shift of potassium from the extracellular fluid into cells

3. excess potassium loss in the stool

Pancreatic enzymes supplemented at high doses in children with cystic fibrosis could result in: 1. steatorrhea 2. meconium ileus 3. fibrosing colonopathy 4. cystic fibrosis related diabetes

3. fibrosing colonopathy

Which intervention assists with maintaining feeding tube patency int he adult patient? 1. administer medications through feeding tube with 5 mL of water 2. use a 20 mL of smaller syringe to flush small-bore feeding tubes 3. flush feeding tube with 30 mL of water every 4 hours during continuous feeding 4. change feeding tube every 72 hours

3. flush feeding tube with 30 mL of water every 4 hours during continuous feeding

An 80 year old man, living alone at home, has experienced a 15 lb unintentional weight loss over the last year and a half. The clinician assessing his nutrition status finds that he has inadequate intake. Which of the following is LEAST likely to contribute to his weight loss? 1. decreased taste sensation 2. social isolation 3. food sensitivities 4. polypharmacy

3. food sensitivities

When initiating and advancing enteral feedings in the hospitalized patient, which of the following is most appropriate? 1. 1/2 strength formula at 25 mL/hr, advance to goal rate and strength over 5-7 days 2. 240 mL bolus feeds of full strength hypertonic formulas every 4 hours 3. full strength formula at 10-40 mL/hr and advance by 10-20 mL/hr every 8-12 hours to goal rate 4. 1/4 strength formula at goal rate. Advance to full strength over 3-5 days

3. full strength formula at 10-40 mL/hr and advance by 10-20 mL/hr every 8-12 hours to goal rate

Which of the following is the BEST indication for the use of a soy-baed infant formula? 1. diarrhea 2. cow's milk protein allergy 3. galactosemia 4. regurgitation with feeds

3. galactosemia

Enteral nutrition (EN) may be contraindicated in the early post-transplant period in adult patients with hematopoietic cell transplants because of: 1. increased incidence of sinusitis with enteral feedings 2. lack of benefit from enteral feedings in allogeneic patients 3. gastrointestinal toxicities related to the conditioning regimen 4. improved survival seen in autologous patients receiving parenteral nutrition

3. gastrointestinal toxicities related to the conditioning regimen

Which of the following are examples of monosaccharides? 1. galactose, sucrose, glucose 2. maltose, fructose and lactose 3. glucose, fructose and galactose 4. lactose, maltose and sucrose

3. glucose, fructose and galactose

Which of the following are examples of conditionally indispensable amino acids? 1. leucine and isoleucine 2. phenylalanine and valine 3. glutamine and arginine 4. histidine and tryptophan

3. glutamine and arginine

According to Medicare (and Medicaid) guidelines, under the prosthetic device act, home enteral nutrition (HEN) is covered for a patient who 1. cannot meet his/her nutrition requirements by oral intake 2. has documented weight loss of 10% in 3 months and refuses to eat 3. has a permanent disease of the structures that normally permit food to reach the small bowel 4. has a temporary (estimated as less than 3 months) impairment or disease of the mouth, esophagus or stomach that prevents food from reaching the small bowel

3. has a permanent disease of the structures that normally permit food to reach the small bowel

Which of the following data should be collected in the home are provider's performance improvement plan? 1. first dose precautions 2. discharge instructions 3. hospital readmissions 4. consent for care

3. hospital readmission

Which of the following is the best choice for feeding a pancreatic insufficient infant with cystic fibrosis? 1. protein hydrolysate formula with medium chain triglyceride (MCT) 2. free amino acid formula with MCT 3. Human milk 4. Standard infant formula

3. human milk

Metastatic calcification is a complication of 1. hyperkalemia 2. hypokalemia 3. hyperphosphatemia 4. hypophosphatemia

3. hyperphosphatemia

The only two organs in the body that have the necessary enzymes for gluconeogenesis are the liver and the 1. stomach 2. brain 3. kidney 4. small intestine

3. kidney

The only amino acid that is completely oxidized for energy within the muscle is 1. glycine 2. alanine 3. leucine 4. valine

3. leucine

Which of the following is common in both stress and starvation related malnutrition? 1. ketosis 2. hypoglycemia 3. lipolysis 4. hypermetabolism

3. lipolysis

Treatment for gastric phytobezoars includes all of the following EXCEPT 1. flushing with cola 2. enzymatic therapy with cellulase 3. meat tenderizer that contains papain 4. surgical removal of the bezoar

3. meat tenderizer that contains papain

Copper deficiency is associated with 1. leukocytosis 2. macrocytic anemia 3. microcytic hypochromic anemia 4. erythrocytosis

3. microcytic hypochromic anemia

A home enteral nutrition patient recently treated for pneumonia is noted to have new onset diarrhea. Of the following, the first intervention should be to: 1. change to an elemental feeding 2. obtain an order for a bile-sequestering agent 3. obtain a Clostridium difficile toxin stool assay 4. obtain an order for an antidiarrheal medication

3. obtain a Clostridium difficile toxin stool assay

Which is a benefit of using an electromagnetic placement device for nasogastric tube placement? 1. pH can be monitored 2. Checks the tip position relative to the pylorus 3. Provides a 3-dimensional localization 4. Shows a time-delayed perspective of the tube tip location

3. provides a 3-dimensional localization

In pulmonary insufficiency, excessive calorie administration may cause increased blood pCO2 resulting in 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

3. respiratory acidosis

Human immunodeficiency virus HIV associated lipodystrophy syndrome is 1. visceral adipose tissue loss 2. not observed in patients on highly active antiretroviral therapy HAART 3. selective subcutaneous adipose tissue loss 4. seen mostly in patients younger than 40 years old

3. selective subcutaneous adipose tissue loss

Which of the following methods of nutrition assessment evaluate subcutaneous fat and muscle wasting at multiple body sites to determine nutrition status? 1. Nutrition risk index (NRI) 2. Prognostic nutrition index (PNI) 3. Subjective Global Assessment (SGA) 4. Prognostic inflammatory and nutritional index (PINI)

3. subjective global assessment SGA

Standard parenteral amino acid solutions available for neonates differ from standard adult parenteral amino acid solutions by having a higher content of 1. cysteine 2. phenylalanine 3. taurine and tyrosine 4. methionine and glycine

3. taurine and tyrosine

Which of the following is NOT appropriate to tell a family regarding nutrition at the end of life? 1. dying patients rarely feel hungry or thirsty 2. fewer calories are needed at the end of life 3. the experience of eating remains unchanged at the end of life 4. patients should not be made to feel guilty if they do not wish to eat

3. the experience of eating remains unchanged at the end of life

A patient with Crohn's disease that involves the distal ileum should be closely monitored for malabsorption of 1. iron 2. calcium 3. vitamin B12 4. folic acid

3. vitamin B12

MCT do not require the formation of micelles or bile salts for absorption because they are 1. fat soluble 2. 2-5 carbons in length 3. water-soluble 4. anti-inflammatory

3. water-soluble

Hepatic encephalopathy is most likely to be improved by which of the following trace elements? 1. Selenium 2. Copper 3. Zinc 4. Chromium

3. zinc

What are fluid requirements for healthy adults age 55-75?

30 ml/kg

What is the incidence of peristomal infection in PEG tube placement?

30% of tubes placed

What is the recommended daily energy intake for patients over 60 who are receiving hemodialysis or peritoneal dialysis? 1. 25 kcal/kg on nondialysis days and 35 kcal/kg on dialysis days 2. 30-35 kcal/kg 3. 35 kcal/kg on nondialysis days and 25 kcal/kg on dialysis days 4. 40-45 kcal/kg

30-35 kcal/kg

What is the GFR for stage 3 kidney damage with moderate low GFR?

30-59 mL/min/1.73 M2

What is the normal length of the small intestine in adults?

300-600 cm

When is the ability to suck and swallow fully coordinated?

32-34 weeks gestation

What are fluid requirements for healthy adults age 18-55?

35 ml/kg

How many calories are in 1 gram of protein?

4

What type of fatty acid is butyric acid?

4 carbons, short chain fatty acids

What is the hang time for blenderized or reconstituted formulas at home?

4 hours

What percentage of total calories should be provided as fat in pediatric patients receiving parenteral nutrition support to prevent essential fatty acid deficiency (EFAD)?

4% of total calories

Triglycerides that require bile acids to facilitate enzymatic digestion and absorption are typically: 1. 3 carbons in length 2. 6 carbons in length 3. 9 carbons in length 4. 12 carbons in length

4. 12 carbons in length

The maximum time an open system enteral feeding formulation container should be used in the home setting is: 1. 6 hours 2. 8 hours 3. 10 hours 4. 12 hours

4. 12 hours

The maximum time an open system enteral feeding formulation container should be used in the home setting is: 1. 6 hours 2. 8 hours 3. 10 hours 4. 12 hours

4. 12 hous

Albumin has a half-life of approximately 1. 3 days 2. 8 days 3. 12 days 4. 20 days

4. 20 days

In the critically ill obese patient specific guidelines for the provision of calories and protein have been recommended by both the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition. For a patient with a BMI > 30 kg/m2, which of the following choices best reflects those recommendations for parenteral and enteral nutrition? 1. 15-20 kcal/kg IBW/day and less than 2.0 g/kg IBW/day 2. 15-20 kcal/kg IBW and greater than or equal to 2.0 g/kg IBW/day 3. 22-25 kcal/kg IBW/day and less than 2.0 g/kg IBW/day 4. 22-25 kcal/kg IBW/day and greater than or equal to 2.0 g/kg IBW/day

4. 22-25 kcal/kg IBW/day and greater than or equal to 2.0 g/kg IBW/day

A patient who weighs 75 kg is receiving 65 mL/hour of a 2-in-1 PN solution that contains 117 grams protein and 273 grams dextrose in addition to 250 mL of 20% IVFE. What is the daily caloric content of this regimen per kg body weight? 1. 27.5 kcal/kg/day 2. 21.9 kcal/kg/day 3. 26.5 kcal/kg/day 4. 25.3 kcal/kg/day

4. 25.3 kcal/kg/day

What is the approximate normal length of small intestine in adults? 1. 100 cm 2. 150 cm 3. 200 cm 4. 600 cm

4. 600 cm

The catabolic phase of the metabolic response to critical illness usually lasts? 1. 1 day 2. 3 days 3. 5 days 4. 7 days

4. 7 days

What is the glomerular filtration rate (GFR) of a patient with ESRD? 1. > 90 mL/min/1.73 M2 2. 30-59 mL/min/1.73 M2 3. 15-29 mL/min/1.73 M2 4. < 15 mL/min/1.73 M2

4. < 15 mL/min/1.73 M2

Which of the following is rue regarding the concept of quality of life in HPN patients? 1. Most patients believe that the HPN access catheter has little effect on their self-image or self-esteem 2. Patients with chronic bowel disease seem to cope less effectively than patients with acute gastrointestinal trauma 3. social isolation is not an issue since most infusions are cycled over night 4. Adjusting to HPN is easier for patients who have stability in their personal lives

4. Adjusting to HPN is easier for patients who have stability in their personal lives

What is the preferred approach recommended by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) for subcutaneous insulin administration in the hospitalized adult patient with diabetes mellitus? 1. Sliding-scale insulin therapy 2. Basal insulin therapy 3. Bolus insulin therapy 4. Basal-bolus insulin therapy

4. Basal-bolus insulin therapy

Which of the following is an example of a short chain fatty acid? 1. Lauric acid 2. Stearic acid 3. Oleic acid 4. Butyric acid

4. Butyric acid

Which formula is most likely to cause an occluded feeding tube? 1. Low fat formula 2. Low fiber formula 3. Peptide based formula 4. Calorically dense formula

4. Calorically dense formula

Which of the following methods of enteral nutrition delivery is preferred for critically ill patients? 1. Bolus feeding 2. Cyclic feeding 3. Intermittent feeding 4. Continuous infusion

4. Continuous infusion

Which of the following methods of enteral nutrition delivery is preferred fro critically ill patients? 1. Bolus feeding 2. Cyclic feeding 3. Intermittent feeding 4. Continuous infusion

4. Continuous infusion

Which of the following types of feeding delivery methods is most commonly used for patients with a jejunal feeding tube? 1. Bolus feeding 2. Gravity feeding 3. Intermittent feeding 4. Continuous pump feeding

4. Continuous pump feeding

A 51 year old female who is 10 years post gastric bypass surgery for obesity resented with numbness and tingling in her distal lower extremities that had progressively worsened. She was on an oral multivitamin supplement. She was significantly anemic and neutropenic. Her vitamin B12 level was normal as were her serum iron, ferritin and transferrin levels. What nutritional deficiency is the most likely cause of all of these symptoms? 1. Thiamin 2. zinc 3. folate 4. Copper

4. Copper

Which of the following is most likely to occur as the result of an age-related functional change in the gastrointestinal (GI) tract? 1. increased anorectal tone 2. enhanced immunoglobulin A responsiveness 3. increased calcium absorption 4. decreased gastric emptying

4. Decreased gastric emptying

The acute phase response has what effect on serum iron and ferritin levels? 1. Increases serum iron levels and increases serum ferritin levels 2. Increases serum iron levels and decreases serum ferritin levels 3. Decreases serum iron levels and decreases serum ferritin levels 4. Decreases serum iron levels and increases serum ferritin levels

4. Decreases serum iron levels and increases serum ferritin levels

The best method to administer psyllium soluble fiber via feeding tube is to: 1. mix with formula and infuse via a gravity feeding bag 2. mix with formula and infuse with feeding pump 3. mix with water and other medications and give by syringe followed by 15 mL water flush 4. dilute in water and give by syringe followed by 15 mL water flush

4. Dilute in water and give by syringe followed by 15 mL water flush

Dietary fat is predominately absorbed in what part of the gastrointestinal tract? 1. Ileum and colon 2. Stomach and duodenum 3. Distal jejunum and ileum 4. Duodenum and proximal jejunum

4. Duodenum and proximal jejunum

Home infusion providers should have policies that address 1. reimbursement criteria for phone consultations 2. availability of social workers to address psychosocial issues 3. replacement of central venous catheter 4. education, training and evaluation of patient/caregiver competency

4. Education, training and evaluation of patient/caregiver competency

According to the ASPEN PN Safety Consensus Recommendations all of the following are considered to be mandatory for the inpatient PN label EXCEPT 1. Infusion rate expressed in mL/hour 2. Beyond-use date and time 3. Size of in-line filter (1.2 or 0.22 micron) 4. Electrolyte content expressed in individual ions

4. Electrolyte content expressed in individual ions

Which of the following amino acids is most crucial in small intestinal structure and function? 1. Alanine 2. Leucine 3. Aspartate 4. Glutamine

4. Glutamine

Which of the following is a conditionally essential amino acid that is also a primary fuel source of enterocytes? 1. Tryptophan 2. Proline 3. Arginine 4. Glutamine

4. Glutamine

Which of the following best describes enteral glutamine supplementation in the critically ill patient not in multi organ failure? 1. Enteral glutamine is preferred over parenteral glutamine 2. Glutamine reduces systemic inflammation 3. Preferred glutamine dosage is 20-40 grams/day 4. Glutamine has not been shown to reduce length of stay

4. Glutamine has not been shown to reduce length of stay

According to the ASPEN PN Safety Consensus Recommendations, which of the following is the best method to express the dextrose content on the label of a PN formulation in order to avoid misinterpretation? 1. Volume of the percent original concentration added (500 mL of 50% dextrose) 2. grams per liter (250 g/L) 3. Percent of final concentration after admixture (35% dextrose) 4. Grams per 24 hour nutrient infusion (225 g/day)

4. Grams per 24 hour nutrient infusion (eg 225 g/day)

Medicare reimbursement for home and community-based professional nutrition educational services provided by a registered dietitian is restricted to patients who 1. Live alone 2. Have cancer 3. Are over the age of 65 4. Have diabetes or renal disease

4. Have diabetes or renal disease

An older adult with poor oral intake over a two month period requires specialized nutrition support. Which of the following electrolyte abnormalities is associated with aggressive nutrition support? 1. Hyperkalemia 2. Hypocalcemia 3. Hypermagnesemia 4. Hypophosphatemia

4. Hypophosphatemia

Which of the following is common effect of enteral fiber on the intestinal tract? 1. faster transit throughout 2. increased fecal bacteria concentrations 3. improvement in constipation 4. improvement in diarrhea

4. Improvement in diarrhea

Which of the following is a true statement regarding the effects of dietary fiber on the GI tract? 1. Faster transit time throughout 2. Wheat Bran will improve symptoms of abdominal pain and bloating in IBS 3. Improvement in constipation 4. Improvement of diarrhea in tubefed patients

4. Improvement of diarrhea in tubefed patients

which of the following best describes the benefit of megestrol acetate in patients with cancer-associated cachexia? 1. increase in lean muscle mass 2. decreases the risk of thromboembolic events 3. improves blood glucose control in diabetes mellitus 4. improves appetite and ameliorates weight loss

4. Improves appetite and ameliorates weight loss

A previously well nourished patient with persistent fever is admitted to the hospital. His laboratory tests reveal: albumin 2.1 g/dL, C-reactive protein 30 mg/L, serum calcium 7.2 mg/dL. Which of the following is the most likely etiology of the hypoalbuminemia? 1. Caloric deficiency 2. Protein deficiency 3. Hypocalcemia 4. Inflammatory response

4. Inflammatory response

Which of the following best describes the addition of blue dye to enteral feedings? 1. It prevents aspiration of enteral formula 2. Its use in detection of aspiration is highly sensitive 3. It should be added only in small amounts 4. It is no longer recommended for the detection of aspiration of enteral formula

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

which of the following best describes the addition of blue dye to enteral feedings? 1. It prevents aspiration of enteral formula 2. Its use in detection of aspiration is highly sensitive 3. It should be added only in small amounts 4. It is no longer recommended for the detection of aspiration of enteral formula

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

During extended periods of fasting (starvation), the main source of energy is from: 1. Protein catabolism 2. Gluconeogenesis 3. Glycolysis 4. Ketogenesis

4. Ketogenesis

Which of the following tests does not reflect selenium status? 1. Plasma selenium level 2. Erythrocyte concentration 3. Plasma glutathione peroxidase 4. Methionine

4. Methionine

Which of the following predictive equations has demonstrated the greatest accuracy in estimating actual resting metabolic rte in healthy obese and nonobese adults? 1. Owens using adjusted body weight 2. Harris-Benedict using actual body weight 3. Harris-Benedict using adjusted body weight 4. Mifflin-St. Jeor using actual body weight

4. Mifflin-St. Jeor using actual body weight

A 13 year-old boy whose body mass index (BMI) is at the 97th percentile on the Centers for Disease Control and Prevention growth chart for age and sex would be classified as 1. Underweight 2. Healthy weight 3. Overweight 4. Obese

4. Obese

The Short-form Mini Nutritional Assessment (MNA-SF) was derived from the Mini Nutritional Assessment (MNA) in order to: 1. Adapt the MNA for use in pediatric patients 2. Eliminate the need to obtain height and weight data for nutrition assessment 3. Allow patients to generate their own nutrition assessment with a questionnaire method 4. Obtain high diagnostic accuracy for detecting nutritional problems in older adults with a brief screening tool

4. Obtain high diagnostic accuracy for detecting nutritional problems in older adults with a brief screening tool

Non-nutritive sucking should be used in the enterally fed neonate less than 32 weeks corrected gestational age to promote: 1. mother/child bonding 2. weight gain 3. correct development of facial and jaw muscles 4. oral feeding when developmentally appropriate

4. Oral feeding when developmentally appropriate

The highest prevalence and severity of weight loss is found in patients with which of the following types of cancer? 1. lung and colon 2. breast and ovarian 3. prostate and testicular 4. pancreatic and gastric

4. Pancreatic and gastric

Which of the following is most likely to improve tolerance of enteral feeding in a postoperative patient with documented high gastric residual volume (GRV) receiving bolus feedings? 1. Holding every other feeding 2. Putting the patient in the prone position 3. Starting the patient on cisapride to aid with motility 4. Placing a small bowel feeding tube for continuous feeding

4. Placing a small bowel feeding tube for continuous feeding

Which of the following is most likely to improve tolerance of enteral feeding in a postoperative patient with documented high gastric residual volume (GRV) receiving bolus tube feedings? 1. Holding every other feeding 2. Putting a patient in the prone position 3. Starting the patient on cisapride to aid with motility 4. Placing a small bowel feeding tube for continuous feeding

4. Placing a small bowel feeding tube for continuous feeding

Which of the following is characteristic of cachexia in pediatric oncology patients? 1. Gradual weight loss 2. Maintenance of lean body mass at the expense of body fat 3. Decrease in energy expenditure 4. Progressive wasting of lean tissue and body fat

4. Progressive wasting of lean tissue and body fat

Which of the following is true regarding gastric residual volumes (GRV)? 1. GRV can be correlated with pneumonia and mortality 2. GRV correlates with the total volume of fluid present in the stomach 3. Small-bore feeding tubes should be used to draw GRV 4. Promotility agents should be considered when GRV remain > 250 mL

4. Promotility agents should be considered when GRV remain > 250 mL

A 32 year old female presents to the clinic seeking treatment for a sunburn-like rash. She also reports that she feels very sad and has no energy. Which of the following deficiencies should be considered? 1. Vitamin A 2. Vitamin K 3. Lipid 4. Protein

4. Protein

Enteral nutrition formulas supplemented with fiber are often used in the older adult to prevent constipation. Which of the following considerations is most important if this type of formula is chosen? 1. Addition of a prokinetic agent 2. Avoidance of lactose 3. Lowering feeding rate to prevent bloating 4. Provision of adequate water

4. Provision of adequate water

Which of the following methods of estimating energy requirements in critically ill children is the LEAST accurate when compared to resting energy expenditure measurement by indirect calorimetry? 1. Schofield Equation 2. White Equation 3. World Health Organization Equations 4. Recommended Dietary Allowance (RDA) for energy

4. Recommended Dietary Allowance (RDA) for energy

Which of the following methods of estimating energy requirements in critically ill children is LEAST accurate when compared to resting energy expenditure measured by indirect calorimetry? 1. Schofield Equation 2. White Equation 3. World Health Organization Equations 4. Recommended Dietary Allowance (RDA) for energy

4. Recommended Dietary Allowance RDA for energy

Indirect calorimetry (IC) calculates 1. total energy expenditure 2. nitrogen balance 3. heat released from the subject 4. resting energy expenditure REE and respiratory quotient RQ

4. Resting energy expenditure REE and respiratory quotient RQ

During discharge education, which of the following is the BEST way for a home nutrition support provider to know if a patient and/or caregiver understands enteral tube feeding delivery? 1. Verbal description of proper techniques 2. Written explanation of proper techniques 3. Appropriate responses to questions asked 4. Return demonstration of procedure techniques

4. Return demonstration of procedure techniques

During discharge education, which of the following is the BEST way for a home nutrition support provider to know if a patient and/or caregiver understands enteral tube feeding delivery? 1. Verbal description of proper techniques 2. Written explanation of proper techniques 3. Appropriate response to questions asked 4. Returned demonstration of procedure techniques

4. Returned demonstration of procedure techniques

What is the primary fuel for the colonocytes? 1. Medium chain fatty acids 2. Glucose 3. Glutamine 4. Short chain fatty acids

4. Short chain fatty acids

Which of the following methods to determine energy expenditure incorporates body surface area? 1. Harris Benedict Equation 2. Ireton-Jones Equation 3. Mifflin-St. Jeor Equation 4. Swinamer Equation

4. Swinamer Equation

Which of the following vitamin deficiencies is most likely to occur in an older adult who consumes alcohol on a regular basis? 1. vitamin k 2 vitamin a 3. vitamin d 4. thiamin

4. Thiamin

Which of the following best describes the use of artificial nutrition and hydration (ANH) in terminally ill patients? 1. Those who receive ANH have a more comfortable death 2. Those who have dysphagia survive longer with ANH 3. Those who receive ANH have a decrease in abnormal electrolytes 4. Those who receive no ANH do not experience more negative side effects than those who do

4. Those who receive no ANH do not experience more negative side effects than those who do

Patients/caregivers should receive discharge instructions regarding home enteral nutrition by qualified members of the healthcare team. All of the following is essential information to be taught during education EXCEPT? 1. Volume of formula per feed and total daily volume 2. Administration method and schedule 3. Care of the enteral access device and infection control 4. Total calories and protein provided per day

4. Total calories and protein provided per day

The biochemical defect in phenylketonuria (PKU) is a functional deficiency of the liver enzyme phenylalanine hydroxylase, which catalyzes the para-hydroxylation of phenylalanine to yield what amino acid? 1. Threonine 2. Alanine 3. Methionine 4. Tyrosine

4. Tyrosine

The biochemical defect in phenylketonuria (PKU) is a functional deficiency of the liver enzyme phenylalanine hydroxylase, which catalyzes the para-hydroxylation of phenylalanine to yield what amino acids? 1. Threonine 2. Alanine 3. Methionine 4. Tyrosine

4. Tyrosine

Up to 26% of enterally fed patients report nausea and/or vomiting. If delayed gastric emptying is suspected as the causative factor, which of the following is LEAST likely to improve the patient's symptoms? 1. Reduce or discontinue narcotic medications 2. Switch to a low fat enteral formula 3. Reduce the rate of enteral nutrition infusion 4. Use a more concentrated enteral formula

4. Use a more concentrated enteral formula

Which of the following best describes the appropriate use of powdered infant formula in healthcare facilities? 1. Freeze open containers and discard after 30 days from opening 2. Refrigerate open containers and discard after 30 days from opening 3. Use interchangeably with comparable steriel liquid formulations 4. Use only when alternative sterile liquid products are not available and when clinically necessary

4. Use only when alternative sterile liquid products are not available and when clinically necessary

Which of the following best describes the appropriate use of powdered infant formula in healthcare facilities? 1. Freeze open containers and discard after 30 days from opening 2. Refrigerate open containers and discard after 30 days from opening 3. Use interchangeably with comparable sterile liquid formulations 4. Use only when alternative sterile liquid products are not available and when clinically necessary

4. Use only when alternative sterile liquid products are not available and when clinically necessary

Which of the following is true concerning zinc status in long-term parenteral nutrition patients? 1. Serum zinc is a reliable indicator of zinc status 2. Parenteral doses of 50 mg/day have been proven safe 3. Parenteral zinc interferes with copper bioavailability 4. Zinc deficiency is the most commonly suspected trace element abnormality

4. Zinc deficiency is the most commonly suspected trace element abnormality

The basic structure of a triglyceride consists of: 1. phospholipid backbone with 3 fatty acid molecules attached via ester linkage 2. a fatty acid backbone with 3 glycerol molecules attached via ester linkage 3. a cholesterol backbone with 3 fatty acid molecules attached via ester linkage 4. a glycerol backbone with 3 fatty acid molecules attached via ester linkage

4. a glycerol backbone with 3 fatty acid molecules attached via ester linkage

Which of the following enzymes initiates the digestive process of carbohydrates in the mouth? 1. lipase 2. lactase 3. maltase 4. amylase

4. amylase

For the provision of PN in the United States, commercially available intravenous fat emulsions (IVFEs) 1. contain approximately 10% of total calories as linoleic acid 2. contain no alpha-linolenic acids 3. are composed mainly of safflower oil 4. are composed mainly of soybean oils

4. are composed mainly of soybean oils

Which of the following complications of EN is the most potentially dangerous in the older adult? 1. diarrhea 2. abdominal distention 3. leaking around the enterostomy tube insertion site 4. aspiration

4. aspiration

Which of the following types of feeding delivery methods is most commonly used for patients with a jejunal feeding tube? 1. bolus feeding 2. gravity feeding 3. intermittent feeding 4. continuous pump feeding

4. continuous pump feeding

An 85 year old nursing home resident was transferred to the hospital with anorexia, malnutrition and probable aspiration pneumonia. Which of the following nutrition plans would be most appropriate for this patient? 1. start the patient on a regular oral diet with supplements 2. establish central access with a peripherally inserted central catheter PICC 3. establish peripheral access ad initiate peripheral parenteral nutrition until enteral feedings can be established 4. determine the most appropriate enteral feeding route and establish tube feeding

4. determine the most appropriate enteral feeding route and establish tube feeding

Home infusion providers should have policies that address 1. reimbursement criteria for phone consultations 2. availability of social workers to address psychosocial issues 3. replacement of central venous catheter 4. education, training, and evaluation of patient/caregiver competency

4. education, training and evaluation of patient/caregiver competency

Hypoglycemia, requiring dextrose infusions to maintain euglycemia, is most likely to occur in which type of liver disease? 1. hepatic steatosis 2. well-compensated cirrhosis 3. decompoensated cirrhosis 4. fulminant hepatic failure

4. fulminant hepatic failure

Medicare reimbursement for home and community-based professional nutrition educational services provided by a registered dietitian is restricted to patients who: 1. live alone 2. have cancer 3. are over the age of 65 4. have diabetes or renal disease

4. have diabetes or renal disease

In patients with burns, providing caloric support above energy expenditure has been found to 1. decrease mortality 2. improve wound healing 3. decrease fat mass accumulation 4. have no effect on lean body mass preservation

4. have no effect on lean body mass preservation

Which of the following diets should be recommended to patients with a short bowel and colon in continuity? 1. high fat 2. high oxalate 3. high simple carbohydrate 4. high complex carbohydrate

4. high complex carbohydrate

What is the most common complication associated with PN administration? 1. hypophosphatemia 2. renal dysfunction 3. sepsis 4. hyperglycemia

4. hyperglycemia

A 68 year old woman with a history of cirrhosis is receiving enteral nutrition due to recent gastrointestinal surgery and worsening hepatic encephalopathy. Which of the following should be tried first? 1. decrease in protein provision to 0.6 g/kg/d 2. medium-chain triglyceride adding to tube feeding 3. formula enriched with branched-chain amino acids 4. lactulose and rifaximin therapy

4. lactulose and rifaximin therapy

In which part of the body are essential amino acids oxidized? 1. muscle 2. kidney 3. small intestine 4. liver

4. liver

In the body, glycogen is predominantly found in the 1. brain and liver 2. skeletal muscle and kidneys 3. small intestine and brain 4. liver and skeletal muscle

4. liver and skeletal muscle

A 13-year-old boy whose body mass index (BMI) is at the 97th percentile on the Centers for Disease Control and Prevention growth chart for age and sex would be classified as: 1. underweight 2. healthy weight 3. overweight 4. obese

4. obese

A patient with acute respiratory distress syndrome (ARDS) may benefit from a feeding formula containing supplemental: 1. arginine 2. glutamine 3. nucleic acids 4. omega-3 fatty acids

4. omega-3 fatty acids

Non-nutritive sucking should be used in the enterally fed neonate less than 32 weeks corrected gestational age to promote 1. mother/child bonding 2. weight gain 3. correct development of facial and jaw muscles 4. oral feeding when developmentally appropriate

4. oral feeding when developmentally appropriate

The referral process to a home infusion company for parenteral and enteral therapy includes scheduling all of the following EXCEPT: 1. formula delivery 2. adding equipment and supplies delivery 3. infusion nursing care 4. physical therapy

4. physical therapy

Gastric hypersecretions following significant small bowel resection can become problematic. Which of the following medications have shown to be the most successful in suppressing gastric hypersecretions? 1. Cholestyramine 2. Loperamide 3. Histamine-2 receptor antagonists 4. Proton pump inhibitors

4. proton pump inhibitors

Which of the following is NOT a cause of malnutrition in a patient with liver disease? 1. malabsorption 2. decreased caloric intake 3. abnormal fuel metabolism 4. reduced energy expenditure

4. reduced energy expenditure

Patients with short bowel syndrome would benefit most from octreotide injections in the presence of 1. an intact colon 2. short bowel secondary to mesenteric ischemia 3. short bowel secondary to inflammatory bowel disease 4. refractory diarrhea not controlled with standard antidiarrheal agents

4. refractory diarrhea not controlled with standard antidiarrheal agents

The use of enteral nutrition formulas enriched with branched chain amino acids is best used for patients with 1. cirrhosis 2. hepatic failure 3. liver transplantation 4. refractory encephalopathy

4. refractory encephalopathy

The energy for glucose transport is provided by active transport of 1. potassium into the cell 2. potassium out of the cell 3. sodium into the cell 4. sodium out of the cell

4. sodium out of the cell

Glucose and galactose gain access to enterocytes via 1. glucose-dependent insulinotropic peptide (GIP) 2. glucokinase 3. enterokinase 4. sodium-glucose transporter 1 (SGLUT-1)

4. sodium-glucose transporter 1 (SGLUT-1)

How should a critically ill patient's energy delivery be modified in response to resting energy expenditure (REE) measured by indirect calorimetry? 1. reduced by 10% if respiratory quotient exceeds 1.0 2. increased by a stress factor of 1.2-1.5 for sepsis or trauma 3. adjusted by a thermogenesis factor for enterally fed patients 4. used as the caloric target without addition of stress or activity factors

4. used as the caloric target without addition of stress or activity factors

What is the macronutrient breakdown of most oral enteral products?

40-60% kcals from carbohydrate, 15-25% from protein, 15-35% from fat

In a stable infant how much carbohydrate should be provided by parenteral support?

45-50% kcals

What is the usual osmolality of a 30 calorie per ounce concentrated standard infant formula?

450 mOsm/kg

What is a physical requirement for the use of PPIs?

50 cms of jejunum is necessary to absorb PPIs

What percentage of amino acids extracted by the liver are used for protein synthesis and oxidation?

57%

What grade level is recommended for patient education materials?

5th or 6th grade

What reading grade level is recommended for patient education materials?

5th or 6th grade

What is the GFR for stage 2 kidney damage with mild low GFR?

60-80 mL/minute/1.73 M2

What is the sodium concentration range of homemade or commercial oral rehydration solutions?

60-90 mmol/L

What is the RDA for vitamin D for children 1-18 years of age?

600 IU/day

What are the classifications for significant weight loss indicative of malnutrition?

7.5% in 3 months 10% in 6 months 5% in 1 month 20% in 1 year

What percentage of African Americans, Native Americans, Asian and Mediterranean descendents are deficient of lactase enzyme?

70-100%

Based on bone health evidence what is the RDA for calcium in children 1-3 years of age?

700 mg/day for children 1-3 years of age

How soon should all patients accepted by a home care provider undergo nutrition screening?

72 hours of acceptance or on the initial home visit

How much formula should be poured into an open administration set? Why?

8-12 hour supply, hang time of canned ready-to-use formulas should be no longer than 12 hours

How long are cyclic feedings generally administered over?

8-20 hours per day, depending on the patient's tolerance

When determining nitrogen balance, urea accounts for what percentage of total urine nitrogen losses? 1. 50% 2. 60% 3. 70% 4. 80%

80%

How is copper usually excreted from the body?

80% of coper is excreted in the bile

What is the estimated mean US reading level?

8th grade

How long must bowel rest be required for coverage of HPN by Medicare?

90 days

How much energy is often required to meet the needs of the growing neonate?

90-120 kcal/kg/d

How much energy is often required in order to meet the energy needs of the growing neonate?

90-120 kcal/kg/day

What is the GFR for stage 5 kidney failure?

< 15 (or dialysis) mL/min/1.73 M2

In a stable infant how much fat should be provided by parenteral support?

< 30% kcals from fat

What is considered excessive granulation tissue?

> 0.25 inches for adults or > 2 mm in pediatric patients

What is the GFR for stage 1 kidney damage with normal or high GFR?

> 90 mL/minute/1.73 M2

What is the recommendation for lock solutions? Why?

A 70% ethanol lock solution to reduce catheter-related blood stream infections (CRBSIs)

How do DNR orders impact SNS?

A DNR or DNAR order is not a contraindication to the provision of specialized nutrition support (SNS) in any state. If the indications for SNS exist, then SNS should be implemented, even as a time-limited trial. SNS can be withheld or withdrawn in patients with a DNR or DNAR if all concerned agree SNS is not meeting the agreed upon goal.

What may be needed in the case of frequent interruption of electrical service in the home environment of a patient receiving parenteral nutrition?

A back-up battery-powered infusion pump

In home infusion patients with frequent interruption of electrical service what else is needed at home?

A back-up battery-powered infusion pump may be needed

Why should D-lactic acidosis be suspected when there is unexplained metabolic acidosis in a patient with short bowel and an intact colon?

D-lactic acid is produced by the fermentation of malabsorbed carbohydrate in the colon. Humans lack the enzyme needed to metabolize D-lactic acid.

According to the evidence what nutrition support plan should be used for critically ill obese patients? Why?

Data on nutrition support in obese patients support the hypocaloric, high protein feeding strategy. High protein hypocaloric feeding is thought to maintain nitrogen balance and lean body mass while facilitating the mobilization of adipose tissue for fuel utilization.

What data was used for the Fenton growth chart? How was it validated?

Data previously collected by Babson and Benda, data was collected from a large sample size, the data is cross sectional and is best used to assess growth over time. Validation of the chart occurred by using that for the National Institute of Child Health and Human Neonatal Research Network, CDC growth charts, intrauterine growth data and postnatal growth data

As nutrition support is a high-risk, problem prone treatment what data should be collected in the home care provider's performance improvement and outcome measurement activities? (5 categories)

Data to be collected should include but not be limited to: 1. Mortality 2. Hospital readmission 3. Complications 4. Patient/family satisfaction 5. Problem reporting and resolution

When do post-procedural complications present with PEG tube placement?

Days to months after placement

Why does resection of the ileocecal valve result in malabsorption?

Decreases transit time and an influx of nutrients moves into the large intestine which can result in malabsorption

How may nausea and/or vomiting be prevented or resolved in the enterally fed patient?

Decreasing the rate or volume of enteral infusion

Although the etiology of nausea and vomiting is multifactorial what is a common source of this tubefeeding intolerance?

Delayed gastric emptying

Describe continuous feeding.

Deliver formula from an administration set into the feeding tube via an enteral pump to guarantee a continuous rate

What is a common fallacy about nutrition and hydration in terminally ill patients? What is the evidence?

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

What is parenteral nutrition associated cholestasis (PNAC)?

A condition of impaired secretion of bile or frank biliary obstruction that may occur in adults patients receiving long-term parenteral nutrition (PN)

How does brush border oligosaccharidase deficiency lead to symptoms of diarrhea, bloating and flatulence after ingestion of sugar?

A deficiency in brush border oligosaccharidases allows osmotically active undigested oligosaccharides to cause a shift of water into the intestinal lumen. The resulting increased pressure exerted by luminal contents increases further when colonic bacteria act on remaining oligosaccharides, thus increasing the number of osmotically active particles. Formation of CO2 and H2 from disaccharides further increases flatulence and bloating

What diet should be recommended to patients with short bowel and colon in continuity? Why?

A diet high in complex carbohydrates (50-60%) and low in fat (20-30%) has been shown to reduce fecal calorie loss and to increase overall energy absorption in short bowel syndrome (SBS) patients with at least a portion of their colon present. This diet also reduces steatorrhea and decreases oxalate absorption. Regardless of bowel anatomy the provision of complex carbohydrates in the diet of SBS patients is preferred because tey reduce the osmotic load and may exert a positive effect on the adaptation process. In the intestine, starch is broken down more slowly than simple sugars thus improving tolerance. in addition some starches will be converted to SCFA by colonic bacterial fermentation and used as energy

What does the evidence show about the prevalence and severity of weight loss in patients with cancer?

A large multicenter cooperative study of patients with 12 types of cancer found that over half of cancer patients present with weight loss at the time of diagnosis. The lowest prevalence of weight loss was found in patients with sarcomas, breast and hematologic cancers. Patients with prostate, colon and lung cancers had an intermediate prevalence of weight loss. The highest prevalence of weight loss came from patients with pancreatic and gastric cancers

What is the evidence for use of Lactobacillus GG?

A meta-analysis of randomized, controlled studies concluded that Lactobacillus GG is a safe and effective as a treatment for children with acute infectious diarrhea. Current research does not support use of Lactobacillus GG as therapy for treatment of NEC, Crohn's or heliobacter pylori in infants or children, however research has been done with other strain of probiotics in NEC, Crohn's and heliobacter pylori

Why is plasma carotenoid not used as a marker of vitamin A status?

A plasma carotenoid level is not used as carotenoids are metabolized to retinol

What does fluoroscopy require?

A radiologist to be in attendance, this would not be done un-supervised

What is phosphofructokinase?

A rate-limiting enzyme of glycolysis

What is the evidence for not withholding EN until patient is fully volume resuscitated, hemodynamically stable and mesenteric perfusion has been restored?

A recent retrospective trial indicates early EN in hemodynamically unstable patients receiving mechanical ventilation may decrease mortality; however, due to inherent study limitations further prospective randomized trials are needed before guideline changes can be made

What is the new evidence for possible adjusting the guideline on waiting for hemodynamic stability, volume resuscitation and mesenteric perfusion prior to starting enteral feeds?

A recent retrospective trial indicates early enteral nutrition in hemodynamically unstable patients receiving mechanical ventilation may decrease mortality; however, due to inherent study limitations further prospective randomized trials are needed before guidelines changes can be made

What may be necessary in patients with tube feeding syndrome?

A reduction in protein loads may be necessary if the ability to excrete byproducts of protein metabolism during adequate fluid provision is compromised

When would a temporary protein restriction be indicated in hepatic encephalopathy?

A temporary protein restriction (0.6 to 0.8 g/kg/day) may be indicated if the patient fails to respond to medical management or until the cause of encephalopathy can be identified and elminitated

What is carnitine?

A trimethyl amino acid similar in structure to choline, it is a required as a cofactor for transformation of free long-chain fatty acids into acylcarnitines and transport into the mitochondria

How much iron does the AAP recommend infants not receiving human milk receive? Preterm infants?

AAP recommends that infants not receiving human milk receive an iron-fortified formula and that preterm infants receive at least 2 mg/kg per day of elemental iron from 1-12 months of age

How does AKI impact serum phosphate?

AKI can lead to high phosphorus levels as a result of decreased excretion

Describe acute respiratory distress syndrome ARDS.

ARDS is associated with an inflammatory response leading to diffuse alveolar damage and lung capillary endothelial injury

What is hypokalemia almost always the result of?

Abnormal potassium losses via the urine or stool

Name 2 lab values that would be abnormal in renal tubular acidosis.

Abnormalities in serum creatinine and anion gap

What biochemical findings would be reflected with renal tubular acidosis?

Abnormalities in serum creatinine and anion gap

How does achlorhydria impact the absorption of vitamin B12 supplements?

Absorption of crystalline vitamin B12 the form utilized in vitamin supplements and fortified foods, is not affected by gastric acid

What is the current statistics (2010) on malnutrition in hospitalized patients?

According to the 2010 Healthcare Cost and Utilization Project (HCUP) 58.3% of hospitalized patients with a malnutrition diagnosis in the 2010 National Inpatient Sample (NIS), which contains discharge data from 1051 hospitals in 45 states, approximately a 20% stratified sample of US hospitals, were over the age of 65 years

What is the function of enterokinase?

Activates trypsinogen into trypsin

What phase following burn injury is signaled by elevated catecholamines and elevated or normal plasma insulin?

Acute phase of the flow response

What is the evidence for addition of fiber to tubefed patients?

Addition of fiber to tubefeed in ill patient has shown less diarrhea and more firm stools, however, note that studies in this area do not consistently show benefit. NOTE that there is controversy in this area in defining constipation and diarrhea and many factors may also effect GI motility besides fiber including stress, illness, exercise, hormones, infections etc.

What may be required with liquid medications when administered enterally? Why?

Additional dilution to minimize tube occlusion and adverse effects

How are complications such as formation of an esophageal or intestinal bezoar with fiber administration be avoided?

Adequate fluid provision and avoiding underhydration

What is important about the nutrition support regimen adequacy in the mechanically ventilated patient?

Adequate nutrition and balanced hydration is necessary for successful weaning from mechanical ventilation. Both overfeeding and underfeeding have been associated with prolonged ventilator dependence.

What is the function of adipocytes?

Adipocytes store energy as fat

Why is iron deficiency anemia important to identify in young infants and children?

Adverse effects on behavior and development

After initial certification for parenteral nutrition when is recertification required?

After 6 months of therapy

When is surgical intervention for GERD considered?

After other therapies have failed fundoplication surgical intervention is considered

When does the flow phase occur following burn injury? When is the peak of the flow phase?

After the ebb phase (3-5 days) these metabolic alterations occur quickly and the acute phase peaks between the 6th and 10th day following burn injury

When does the acute phase occur after burns?

After the ebb phase, these metabolic alterations occur quickly, and the acute phase peaks between the 6th and 10th day following burn injury

What should be considered in patients with abdominal distention?

Aggressive bowel regimens need to be considered in these patients to reduce distention and prevent impaction

How does aging impact substrate utilization? (2 changes) How does this impact parenteral nutrition?

Aging has been associated with alterations in substrate use metabolism. Substrate oxidation was compared between older and middle-aged adults during cyclic parenteral nutrition. Glucose oxidation decreases as age increases and can affect treatment tolerance during cyclic parenteral nutrition. The decreased glucose oxidation is possibly the result of higher insulin resistance in the older adult. Increased fat oxidation was correlated with increased age. Older adults had higher concentrations of free fatty acids compared to that of middle-aged patients, which suggests that as age increases so does mobilization of free fatty acids from adipose tissue

What carbon chain length necessitates L-carnitine to enter the mitochondria?

All fatty acids > 10 carbons

What are the revised recommendations to ensure adequate vitamin D status in infants?

All infants, including those who are exclusively breastfed, are now recommended a minimum daily intake of 400 IU of vitamin D beginning soon after birth

Aside from mineral deficiencies such as magnesium and calcium what else can increased intake of juices, sodas and sweetened beverages result in? Is there any evidence to the contrary?

Also associated with obesity risk in this population A more recent study suggests that caloric beverages (milk, juice, sweetened beverages) consumed by children were complementary to each other, and that more of a focus needs to be on total caloric intake for weight management, and promoting balanced nutrient intake. Other recent findings claim that over consumption of juice in particular is not necessarily associated with decreased intake of milk and other food groups. It remains important to adhere to age appropriate recommendations for such beverages to ensure that proper nutrition is practices.

Is carnitine deficiency a common concern?

Although a primary deficiency of carnitine is rare, it has been documented in preterm infants and chronic renal failure

Is lactose intolerance often the cause of watery diarrhea in enterally fed patients? Why?

Although lactose intolerance is well known to result in watery diarrhea and bloating, the vast majority of adult enteral products are lactose free and the lactose content of most individual dosage forms of medication is too small to result in significant problems

Why is feeding in excess of energy expenditure in burn patients not recommended?

Although patients with burns have increased needs, feeding in excess of energy expenditure may cause hyperglycemia, hepatic steatosis and prolonged ventilator dependence. One study of critically ill burn patients showed that caloric delivery beyond 1.2 x measured resting energy expenditure did not conserve lean body mass but was associated with increased fat mass accumulation

What is the evidence behind zinc supplementation in diarrhea?

Although some studies suggest that zinc does not significantly reduce stool output or the duration of diarrhea the overwhelming bulk of evidence continues to support empiric zinc therapy for childhood diarrhea in low income countries. Recent studies demonstrate that zinc supplementation decreases the duration of diarrheal episodes , risk of hospitalization, all-cause mortality and diarrheal mortality with an estimated decrease in mortality of 23%

What does the research show about zinc supplementation for childhood diarrhea?

Although some studies suggest that zinc does not significantly reduce stool output or the duration of diarrhea, the overwhelming bulk of evidence continues to support empiric zinc therapy for childhood diarrhea in low income countries. Recent studies demonstrate that zinc supplementation decreases the duration of diarrheal episodes, risk of hospitalization, all-cause mortality and diarrheal mortality, with an estimated decrease in mortality of 23%

What is the evidence for omega-3 supplementation in cystic fibrosis?

Although supplementation with omega-3 fatty acids are sometimes used in the management of CF, results from clinical trials have shown mixed results and further trials are needed to determine the efficacy of routine EFA supplementation in the management of CF

What is the function of aluminum physiologically?

Aluminum has not been shown to have any biologic function but is present as a contaminant in many PN components

What are conditionally indispensable amino acids?

Amino acids are synthesized from other amino acids under normal conditions but require a dietary source in order to meet increased needs caused by metabolic stress

What is lipase?

An enzyme released from the pancreas that is important in the digestion of fat

What is PKU? How does it impact amino acid metabolism? What is the treatment?

An inborn error of phenylalanine metabolism caused by a deficiency of the hepatic enzyme phenylalanine hydroxylase (PAH). PAH catalyzes the hydroxylation of phenylalanine to tyrosine. In the absence of PAH, phenylalanine levels become extremely high and tyrosine becomes deficient. Treatment with a phenylalanine-free diet and tyrosine supplementation is used for chronic management

What may occur with a calorically dense or high fiber formula that decreases tube patency?

An increase in the accumulation of formula sediment in the inner lumen of the feeding tube

What is the mitochondria? What is its function?

An organelle found in most eukaryotes whose primary function is to generate ATP via oxidative phosphorylation, the major source of cellular energy

When is anabolism established following burn injury?

Anabolism is not established until the adaptive phase of the flow response

During which phase after burns does anabolism begin?

Anabolism is not established until the adaptive phase of the flow response.

As part of the physcial examination what type of specific measurements can be used to assess subcutaneous fat and muscle mass?

Anthropometric measurements such as tricep skin fold and mid-arm muscle circumference and hand grip strength

What has Lactobacillus GG been studied in regard to? Why?

Antidiarrheal properties, diarrhea is common in infants and children and contributes significantly to morbidity and mortality (especially in developing countries)

What are the recommendations for antidiarrheal usage in IBD? Why?

Antidiarrheals should not be given to patients with IBD until the possibility of an infectious etiology of the diarrhea has been ruled out. Otherwise, there is a risk of developing toxic megacolon that can result in mortality and morbidity.

What is valproic acid?

Antiepileptic drug

How much TBW is contained in the intracellular fluid?

Approximately 2/3 of total body water

How much of body weight is water?

Approximately 50-60% of body weight

Why is arginine considered an "immune-enhancing" agent?

Arginine is a major substrate for nitric oxide production. Under normal conditions, small quantities of nitric oxide have a beneficial effect on immune function and tissue oxygenation. Thus, arginine is considered an "immune-enhancing" agent

What is the function of arginine?

Arginine is a semi-essential amino acid that has demonstrated importance in immune function and wound healing

Why is arginine supplementation used? What are the drawbacks?

Arginine, which increases the production of nitric oxide, has been shown to have positive effects on recovery from trauma and surgery through its effect on blood flow, immune function, wound healing and organ failure. In conditions of pronounced vasodilation, as in septic shock, the production of nitric oxide would be expected to exacerbate hemodynamic instability. Increased mortality and morbidity in this population has been demonstrated in some studies.

How does alcohol related thiamine deficiency often present?

As Wernicke's encephalopathy which presents as mental status changes, confusion, nystagmus, gait ataxia and polyneuritis

How are closed enteral feeding systems packaged? What is the benefit of this?

As bags or rigid containers pre-filled with 1 liter of sterile enteral nutrition formula due to the container design, minimal manipulation is required prior to administration and additions or changes to the formula are not easily accomplished, both decreasing the risk of microbial contamination

How does WHO define acute diarrhea?

As less than 14 days in duration

How long must HPN therapy be required for to qualify for Medicare?

At least 90 days

How can parenteral glutamine impact mucosal atrophy?

Atrophic changes during bowel rest have been decreased with glutamine supplemented parenteral nutrition

Define biliary atresia.

Atrophy of the bile duct

What is biliary atresia? What does it cause?

Atrophy of the bile ducts, causes obstruction of bile flow from the liver into the biliary system and small intestine There is a significant decrease in the concentration of intraluminal bile acids that are needed for micelle formation and fat absorption. The result is fat and fat soluble vitamin malabsorption

Define the ethical principle of autonomy.

Autonomy is an ethical principle based on respect and upholding the patient's right to self-determination

What is Mosteller's formula?

BSA(M2) where M2 is the square root of the following: Height(cm) x Weight(kg) / 3600, this value is multiplied by maintenance fluid requirement of 1500 mL per day

What is the evidence for use of omega-3 fatty acids in ARDS and ALI?

Based on 3 level 1 studies the Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient in 2009 recommended patients with ARDS and severe ALI be placed on an enteral formulation characterized by an anti-inflammatory lipid profile. Subsequent to the publication of those guidelines and recommendations have been studies published in 2011 showing that enteral supplementation of omega-3 fatty acids did not result in improved biomarkers of inflammation or clinical outcomes

What is the test of permanence for HEN coverage guidelines under medicare?

Based on the judgement of the attending physician and is substantiated in the medical record. "Permanence" means that the condition is of indefinite duration, 90 days or greater. Permanence does not exclude the possibility of improvement

What is the evidence for using omega-3 fatty acid formulas in ARDS?

Based on three level I studies, the Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient in 2009 recommended patients with ARDS and sever ALI be placed on an enteral formulation characterized by an anti-inflammatory lipid profile. Subsequent to the publication of those guidelines and recommendations have been studies published in 2011 showing that enteral supplementation of omega-3 fatty acids did not result in improved biomarkers of inflammation of clinical outcomes

Why is iron deficiency anemia important to identify in young infants and children?

Because of the adverse effects on behavior and development

What is the current recommendation for protein in stressed trauma patients?

Because of the increased protein loss that is associated with critical illness, protein needs are elevated. . The current recommendation for stressed trauma patients is that 20-25% of total nutrient intake be provided as protein. This equates to roughly 1.5-2.0 g/kg/day.

Why are linoleic acid and alpha-linolenic acid considered essential fatty acids?

Because they cannot be synthesized naturally by humans and must be supplied exogenously via the diet

Define the ethical principle of beneficence.

Beneficence is an ethical principle in which health care providers actively seek the good of the patient.

When would a BCAA enriched formula be used in hepatic encephalopathy?

Benefits of BCAA enriched formula are still debated, but may be considered for patients with severe encephalopathy who have not responded to aggressive medical therapy

What process is used to produce energy from fatty acids?

Beta oxidation

When does infantile anorexia usually occur?

Between 6 months to 3 years of age and often occurs during the transition to spoon and self feeding

What is the role of bile acids in fat digestion?

Bile acids act as emulsifiers

What are bile acids?

Bile acids are detergent-like derivatives of cholesterol produced by the liver, which aid i triglyceride emulsification and the formation of micelles in the small intestine

What are bile salts?

Bile salts are sodium and potassium salts of bile acids

Why is iron supplementation routinely restricted during the early stages of hematopoietic stem cell transplantation?

Blood product support is required before, during and following HSCT with resultant iron overload. Iron overload may adversely affect overall survival post-HSCT increasing the likelihood of acute graft-versus-host disease, bloodstream infection and sinusoidal obstruction syndrome of the liver

Why is weight status important in drug dosing of fat soluble drugs?

Body composition is an important determinant of drug response. Distribution of fat soluble drugs is increased in the obese older adult because the proportion of adipose tissue to lean body mass is increased in these individuals. Prolonged clearance and increased potential toxicity may result from excessive accumulation in adipose tissue

What is BMI?

Body mass index is a screening tool used to identify children over 2 years of age and adolescents who are outside of their healthy weight ranges

What is BMI used for?

Body mass index, a screening tool used to identify children over 2 years of age and adolescents who are outside of their healthy weight ranges

What is the simplest way to deliver gastric feeding that is popular with home care patients?

Bolus feeding

Define bolus feedings.

Bolus feedings are generally an amount of 240-480 mL delivered by gravity or a syringe over 15 minutes into the stomach

What is one of the most useful diagnostic tests in assessing a child with abnormal growth?

Bone age

What is the impact of both non-fiber and fructooligosaccharide (FOS) containing enteral formulas on stool?

Both can decrease overall concentration of fecal bacteria compared with a normal diet

What causes buried bumper syndrome?

Buried bumper syndrome is a result of erosion of the internal bolster into the gastric mucosa

Why does buried bumper syndrome occur? What is the rate of occurrence?

Buried bumper syndrome is a result of erosion of the internal bolster into the gastric mucosa, 0.3-2.4% of patients

How should skin care around a feeding tube site be accomplished?

By cleaning with mild soap and water, rinsing and drying thoroughly. Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure

How has psyllium fiber been successfully administered via feeding tubes?

By diluting 1 tsp with 80 mL water, inject by syringe and follow with 15 mL water flush

How can EFAD be prevented in pediatric patients receiving parenteral nutrition support?

By providing approximately 4% of total calories as fat, in most cases IVFE at 0.5-1.0 g/kg/day will meet this goal

Describe the difference between prolonged fasting/starvation versus cachexia in children with cancer?

Cachexia in children with cancer is an advanced state of wasting characterized by excess depletion of skeletal muscle mass and adipose tissue. Mechanisms of protein conservation and decreased energy expenditure that allow prolonged survival in the chronic fasting state appear to be lost or inhibited in cancer

How does cancer cachexia in children compare to prolonged fasting and starvation?

Cachexia is an advanced state of wasting characterized by excess depletion of skeletal muscle mass and adipose tissue. Mechanisms of protein conservation and decreased energy expenditure that allow prolonged survival in the chronic fasting state appear to be lost or inhibited in cancer

Give an alternative way to calculate fluid needs in infants other than the Holliday-Segar method.

Calculating Body Surface Area (BSA). The BSA is based on the assumption that caloric expenditure is proportional to BSA.

What is the hang time for closed system EN?

Can be safely used for 24-48 hours after opening, depending on manufacturer's guideline

How much do insensible losses from the lungs and skin contribute to overall fluid losses?

Can contribute up to 1L per day

Why do caregivers of patients receiving enteral nutrition often report guilt?

Caregivers of patients receiving enteral nutrition (EN) express guilt that they are able to eat an oral diet

In the situation of liver dysfunction with TPN after other causes of liver dysfunction have been addressed what may be added to PN if a deficiency exists? What is the evidence of for this?

Carnitine The role of carnitine in the prevention of PNAC in adults has not bee n established

What is the physiological role of carnitine?

Carnitine is involved in the metabolism of fatty acids, transports long chain fatty acids into the mitochondria

How does ulceration of the gastric mucosa occur with PEG placement? What is the prevalence?

Caused by excessive tension between the external and internal bolster which leads to erosion and bleeding, occurs in only 0.3-2.5% of cases

What is the physiological impact of biliary atresia?

Causes obstruction of bile flow from the liver into the biliary system and small intestine, therefore there is a significant decrease in the concentration of intraluminal bile acids that are needed for micille formation and fat absorption, the result is fat and fat soluble vitamin malabsorption

What types of significant complications accompany hypermaganesemia in home PN patients?

Cerebral and hepatic complications

What is cheilosis? What 4 vitamin deficiencies is it a sign of?

Cheilosis - cracking of the corners of the mouth 1. Riboflavin 2. Niacin 3. Iron 4. Pyridoxine

What is the most common reason for GI toxicity in the first 2-3 weeks post-stem cell transplant?

Chemotherapy and total body irradiation

What is infantile anorexia characterized by?

Child's refusal to eat adequate amounts of food for at least 1 month. Children with infantile anorexia generally do not communicate that they are hungry, lack interest in food and eating and exhibit growth deficiency

What population group should not have their fluid needs estimated by BSA method?

Children < 10 kg

What is the definition of obese in children?

Children with age and sex specific BMIs > 95th percentile

What is the definition of overweight in children?

Children with age and sex specific BMIs between the 85th and 94th percentile

What BMI indicates overweight in children?

Children with age and sex specific BMIs between the 85th and 94th percentile are classified as obese

What BMI indicates obesity in children?

Children with age and sex specific BMIs greater than or equal to 95th percentile are classified as obese

In what percentage of TBSA burns do children usually require nutrition support?

Children with burns covering > 20% TBSA generally cannot meet their nutrient needs by oral intake alone

What is cholestyramine used for?

Cholestyramine is used to treat bile salt malabsorption, can be used with antidiarrheal agents for patients who have undergone extensive bowel resection

Aside from manganese, copper and carnitine what other nutrient may be related to the development of PN-associated liver dysfunction? What is the evidence for providing this?

Choline deficiency also may be related to the development of PN-associated liver dysfunction, but there is no commercially available injectable choline preparation and benefits of supplementation have not been proven

What occurs in chromium deficiency?

Chromium deficiency impairs glucose metabolism which may result in hyperglycemia

What is the metabolic function of chromium?

Chromium potentiates the action of insulin and is important in glucose and lipid metabolism

How does chronic steroid use correlate with nutritional status? Why?

Chronic steroid use can have a negative impact on nutritional status. Steroids interfere with calcium and vitamin D metabolism, increase protein catabolism, alter bone formation and resorption and interfere with the growth hormone-insulin-like growth factor axis all of which could lead to osteopenia

Why is a late evening snack indicated in cirrhosis? Would tube feeding, branched chain amino acids or parenteral nutrition be useful?

Cirrhotic patients have depleted glycogen stores and utilize more fat as fuel during periods of prolonged starvation. This accelerated starvation phenomenon can be seen in an overnight fast of 12 to 18 hours. A late evening snack may help prevent fasting-associated starvation. Provided the patient is able to consume adequate oral intake, tube feeding and BCAA would have no role. PN is not indicated with a functional gut

How does codeine usually impact GI function?

Codeine may actually result in constipation.

What is the etiology of colocutaneous fistula with PEG tube placement?

Colocutanous fistulas occur when the colon is inadvertently puncutured during placement

How is aluminum toxicity best avoided?

Complications of aluminum intake are best avoided by minimizing the use of aluminum-containing agents such as antacids, sucralfate, etc.

Are concentrated enteral formulas a useful strategy for enterally fed patients with nausea due to delayed gastric emptying?

Concentrated enteral solutions generally contain more fat and can further contribute to enteral intolerance by presenting a higher osmotic load to the GIT

What form of carbohydrate should be avoided in short bowel syndrome? Why?

Concentrated sugars should be avoided because they generate a high osmotic load and potentiate stool output

What was the RDA for vitamin D based on?

Conditions of minimal sun exposure due to the variability of vitamin D synthesis in the skin from UV light and the risks of skin cancer

What GI symptom may result from fluid restriction, physical inactivity and narcotic usage?

Constipation

Why should a standard 1 kcal/mL formula with fiber be recommended as the first choice for older adults with PEG feedings?

Constipation is common in the elderly. In addition to providing adequate fluid, a fiber-containing formula may help minimize constipation. Fiber helps propel waste through the colon. If fiber is added to the enteral regimen, patients must receive a minimum of 1 mL of fluid per kcal to prevent solidification of waste in the colon and constipation.

How does insoluble fiber impact gastric emptying?

Consumption of insoluble fiber and the presence of fiber in the distal ileum results in decreased gastric emptying

What is the electrolyte content of half normal saline (0.45% sodium chloride)?

Contains only sodium 77 mEq/L and chloride: 77 mEq/L

What enteral feeding method delivers formula from an administration set into the feeding tube via enteral pump to guarantee a steady rate?

Continuous feeding

What is the preferred method of feeding in the small bowel?

Continuous feeding (bolus and gravity feeding are poorly tolerated)

What is the preferred method of feeding to the small bowel?

Continuous feeding is the preferred method as bolus and gravity feeding are poorly tolerated in the small bowel

Define continuous feeding.

Continuous feedings are delivered at a prescirbed rate without interruption

What type of feeding schedule may facilitate more steady and predictable blood glucose concentrations in critically ill patients?

Continuous infusions of enteral feeding and insulin may facilitate more steady and predictable blood glucose concentrations in critically ill patients

Once an enteral feeding tube is placed what can be done for medications?

Conversion from intravenous medications to enteral route

What deficiency is rare but presents with anemia, leucopenia, neutropenia and symptoms of peripheral neuropathy?

Copper

Describe the characteristics of Wilson's disease?

Copper accumulation in the liver and other organs can occur in Wilson's disease which is characterized by a genetic deficiency of copper metabolism

What nutritional deficiency can be a complication of celiac disease?

Copper deficiency

What is often used as first-line therapy in pediatric Crohn's disease?

Corticosteroids

What is often used as first-line therapy in pediatric Crohn's disease? What is the down-side?

Corticosteroids Can depress growth and negatively impact bone mineral density and mucosal healing

When should cow's milk be introduced to infant's diets? What is the current recommendation for milk intake?

Cow's milk should not be introduced before 12 months of age To avoid iron deficiency anemia, children should avoid excessive milk intake, which can displace the intake of food items with greater iron content

When can cow's milk be introduced into the diet? Why?

Cow's milk should not be introduced before 12 months of age. To avoid iron deficiency anemia, children should avoid excessive milk intake, which can displace the intake of food items with greater iron content

Why are NGT feedings not contraindicated in CF patients suffering from pancreatic insufficiency?

While cystic fibrosis is associated with pancreatic insufficiency, pancreatic enzymes are given simultaneously to assist with adequate absorption of nutrients

Why would NGT feedings not be contraindicated in cystic fibrosis (CF) patients suffering from pancreatic insufficiency?

While cystic fibrosis is associated with pancreatic insufficiency, pancreatic enzymes are given simultaneously to assist with adequate absorption of nutrients.

Is human milk a good source of iron?

While human milk is low in iron content, it is very efficiently absorbed

Is it necessary to have social workers available for reimbursement of home infusion providers?

While it would be helpful in many cases to have social workers and other support agencies available, this is not necessary for a home care policy. They can make referrals as appropriate.

What could hyperglycemia indicate in a non-diabetic older adult being enterally fed?

While the etiology of the hyperglycemia will need to be determined, this observation could possibly indicate overfeeding

How does addition of a carbohydrate modular to increase caloric density of formula impact the osmolality of the formula?

Will increase the osmolarity

How will the addition of a fat modular impact osmolality?

Will not impact osmolality

How does addition of a fat modular to increase caloric density of formula impact the osmolality of the formula?

Will not impact osmolarity

What disease causes copper toxicity?

Wilson's disease

How is aluminum toxicity treated?

With deferoxamine an agent that chelates aluminum

Under Medicare guidelines when are enteral infusion pumps covered? Give 7 examples.

With documentation that gravity feeding is not tolerated or contraindicated ex. 1. Reflux 2. Aspiration 3. Dumping syndrome 4. Glycemic control 5. Circulatory overload 6. Slow infusion rate 7. Jejunal feeding

How do private payers and managed care organization programs determine coverage for home parenteral/enteral nutrition in general?

With private payers and managed care organizations frequently require preauthorization or pre-certification. Most require that the therapy be medically necessary and the sole source of nutrition. Many insurance policies establish their own criteria for EN and PN wile others follow the guidelines for coverage set forth by Medicare

What is a main strategy for reducing the risk of NEC? What do studies show about this strategy?

Withhold enteral feeds for prolonged periods of time Some studies now refute this practice by demonstrating that early initiation of minimum enteral feeds does NOT increase the risk of NEC and showed benefits such as shorter time to full enteral feeds, faster weight gain, improved feeding tolerance, decreased length of hospitalization and reduced incidence of serious infections in low birth weight and very low birth weight infants

Does parenteral nutrition solution require refrigeration?

Yes

Is cysteine an essential amino acid in infants?

Yes

Will Medicare approve HPN for fat malabsorption?

Yes

Is glucose still used for glycogen synthesis during fasting?

Yes but to a lesser degree

Is regurgitation common in infants?

Yes, is very common and does not necessarily signify a problem

What deficiency may occur with biliary atresia, chronic malnutrition, cirrhosis and chronic stress that is difficult to assess and detect due to laboratory limitations?

Zinc

Why is zinc supplementation recommended in hepatic encephalopathy?

Zinc deficiency is very common in liver disease. Data suggest that supplementation with oral zinc is associated with improvement in amino acid metabolism and encephalopathy

Why is zinc deficiency commonly associated with diarrhea?

Zinc helps regenerate gut epithelium and increase levels of brush border enzymes. Zinc losses are increased due to the diarrhea, further exacerbating absorption of nutrients in the gut

Describe zinc and its functions.

Zinc is an essential trace mineral necessary for the synthesis of granulation tissue and re-epithelialization and also exerts an anti-inflammatory and antimicrobial effect

What is dexamethasone?

a potent steroid used to assist with ventilator weaning of premature infants

What is precocious puberty usually associated with?

advanced bone age

What is ketonemia?

an elevated circulating ketone bodies secondary to increased fatty acid oxidation occurring with starvation, catabolic illness or inadequate dietary carbohydrate intake

How is bone age evaluated?

bone age is evaluated by a radiography of the patient's knee and left wrist using norms for different ages and sexes a trained observer can estimate the degree of maturation of the bones

According to safe enteral nutrition guidelines what is the hang time for human breast milk?

change every 4 hours

How is puberty impacted by celiac disease?

delayed puberty, not precocious puberty is a symptom of celiac disease

What chemical should not be present in administration sets for HBM human breast milk?

di (2-ethylhexyl) phthalate (DEHP) free

What does frequent use of sorbitol-containing medications often cause in enterally fed patients?

diarrhea

What symptom may manifest with impaction? Why?

diarrhea, passage or secretion of fluid around the impaction may be responsible for the loose stool. The patient may intermittently pass small volumes of liquid stool and experience abdominal distention and cramping

Why are high levels of fluoride a risk for enamel fluorosis?

during normal enamel maturation, the increased mineralization in the developing tooth is accompanied by the loss of matrix proteins that are secreted early in development. Sufficiently high levels of fluoride can disrupt this process and increase enamel porosity. The greater the amount of fluoride intake during development, the greater the prevalence of enamel fluorosis

What is the purpose of the emulsification process of bile acids?

emulsification process and micelle formation makes triglycerides and fatty esters available for hydrolysis by intestinal lipases and esterases

How do some experts define "chronic" diarrhea?

episodes lasting more than 30 days

What does an RQ greater than 1.0 indicate? What should be done?

excessive CO2 production, may be due to overfeeding or lipogenesis and increased respiratory demand Indicates the need to decrease the total caloric and carbohydrate delivery

Purpose of nocturnal feeds?

frequently used to supplement oral intake and promote unobstructed activity during the day

What should be avoided with enteral feeding when possible to optimize meeting calorie and protein needs?

holding of feedings

Why do patients receiving home parenteral nutrition require a home/cellular telephone or other means of contacting someone outside the home?

in the event of a medical emergency. The appropriate health care personnel or emergency center must be contacted as soon as possible.

What is the incidence of buried bumper syndrome?

incidence of this complication ranges from 0.3% to 2.4% of patients

What may be used other than serum retinol concentration for assessing vitamin A status?

measurement of retinol binding protein, TTR-RBP

What type of formula is recommended for exclusive enteral nutrition in pediatric Crohn's disease?

polymeric enteral formula no advantage to elemental formula has been noted and polymeric enteral formulas are typically less expensive and have better tolerance for oral administration. Research suggests that use of polymeric formula rather than elemental formula may promote higher weight gain

What nutrition concern is present in all forms of cirrhosis?

protein-energy malnutrition

What do plasma or serum levels of selenium represent?

recent selenium intake

What pathway do red blood cells use for ATP production? why?

red blood cells do not contain mitochondria i their cytoplasm and rely on the metabolic pathway of glycolysis for ATP for energy

How should enteral medications be administered?

regardless of the type or dosage form or number of medications to be administered, each medication should be given separately flushing with at least 15-30 mL of water prior to, between and after administration to prevent potential drug-drug and drug-nutrient interactions

What protein is required for retinol transport?

retinol-binding protein RBP (TTR-RBP is required for retinol transport in the plasma)

What is the main concern when granulation occurs?

that it can cause more moisture accumulation under the external bolster, increasing the risk for skin breakdown

Define meconium

the dark green substance forming the first feces of a newborn infant.

What is the definition of classic phenylketonuria (PKU)?

the deficiency of phenylalaline hydroxylase which prevents the hydroxylation of phenylalanine to tyrosine which causes a build up of phenylalanine in the blood and a subsequent deficiency of tyrosine

According to safe enteral nutrition guidelines how often should the administration set be changed (open system)?

the feeding administration set should be changed every 24 hours

What does the estimated risk of enamel fluorosis in infants fed reconstituted infant formula correlate with?

the fluoride concentration in the drinking water

Is lactose-free cow's milk infant formula recommended in galactosemia?

the galactose content (approximately 20 mg/L) of lactose-free cow's milk infant formula is considerably higher than soy and hypoallergenic formulas therefore lactose-free cow's milk formula is not recommended for treatment of galatosemia

Is cow's milk a sufficient source of iron for babies?

the iron content of cow's milk is inadequate and not efficiently absorbed by infants. Cow's milk should not be introduced before 12 months of age

What form are the overwhelming majority of enteral dietary lipids in?

the overwhelming majority of enteral dietary lipids (approximately 90%) are ingested in the form of triglycerides

Why is iron requirement lower soon after birth?

the rate of growth and erythropoiesis are noted to slow down after birth

Why does the American Academy of Pediatrics recommend iron fortified formula/supplemental iron in infants beginning at 4-8 weeks?

the rate of growth and erythropoiesis are noted to slow down soon after birth, during such circumstances iron requirements are lower, an exogenous source of 2-4 mg/kg/day of iron is recommended during the period of stable growth beginning at 4-8 weeks and continuing until 12-15 months of age

Where is the receiver placed during electromagnetic placement for NGT? where does this follow the tip placement to?

the receiver is placed on the patient at the xiphoid process therefore the magnet follows the tip placement relative to the lower esophageal sphincter, not the pylorus

Describe the teach back process?

the teach-back process is an active process in which the learner can demonstrate health care skills and verbalize home care instructions. This process allows the educator to verify understanding, to correct inaccurate information and to reinforce new home care skills

If a patient is being transferred to the OR and requires enteral access who should place the tube?

the tube should be placed in the OR either by the anesthesia staff or the surgeon after the patient is under sedation

Why is the incidence of aspiration directly caused by enteral nutrition difficult to determine?

there have not been standardized definitions of what constitutes aspiration, nor have there been adequate descriptions in all studies of the actual cause of aspiration in each particular patient

What is bacterial contamination correlated with?

there is a correlation between prolonged length of enteral product hang time and bacterial contamination

What aspect of enteral feeding correlates with bacterial contamination?

there is a correlation between prolonged length of enteral product hangtime and bacterial contamination

How should the administration set be handled by staff?

to avoid contamination, hands should be washed thoroughly before touching any component of the tube feeding system and formula should be transferred without touching the component of the feeding set that comes in contact with the formula

Why is short-acting insulin (regular insulin) typically used when initating enteral nutrition?

tolerance and titration may be unpredictable, this type of insulin may minimize the risk of hypoglycemia resulting from continued absorption fo insulin from an intermediate (premixed NPH/regular insulin, NPH insulin) or long acting (glargine) insulin product in the even that enteral nutrition is interrupted for any reason

What is the definition of mild hypercalcemia?

total serum calcium of 10.3 - 12.9 mg/dL

What are common symptoms with the introduction of a new or large amount of dietary fiber?

transient abdominal discomfort (bloating and flatulence)

What is ursodiol?

ursodeoxycholic acid is a form of bile acid that may potentially improve fat absorption

What places a patient at greater risk of pressure necrosis and ulceration at the tube site?

weight gain after tube placement places a patient at greater risk of pressure necrosis and ulceration at the tube site because of increase in abdominal girth

What is the general guideline for oral intake adequacy (to discontinue enteral feeds)?

while there is no clinically proven points at which tube feeding should be discontinued with adequacy of oral intake, a general guideline is that oral intake should meet at least 66% of nutrient intake

What is dexamethasone? What is its common use in infants?

Dexamethasone is a potent steroid, used to assist with ventilator weaning of premature infants

What metabolic disturbance does diarrhea lead to and why?

Diarrhea induces gastrointestinal losses of bicarbonate and can cause a metabolic acidosis (normal anion gap)

How does soluble fiber impact gastric emptying?

Dietary fibers included in a liquid and solid meal with a purified source of pectin (soluble fiber) slows gastric emptying, as does consumption of a solid meal high in natural food fiber

Describe the metabolism of dietary folate.

Dietary folate is converted to monoglutamate by jejunal enzymes for entry into the intestinal cell. It undergoes further reduction before entry into the portal circulation for reabsorption via enterohepatic circulation

What 3 electrolyte abnormalities may contribute to digoxin toxicity?

Digoxin has a narrow therapeutic range. Hypercalcemia, hypokalemia and hypomagnesemia may contribute to digoxin toxicity

What can be done to liquid dosages of medications to prevent tube clogging from the high viscosity?

Diluted with water prior to administration

What is the theory behind omega-3 supplementation in cystic fibrosis?

Disruption of the exocrine function of the pancreas leads to malabsorption of fat, protein and fat-soluble vitamins in CF patients. Essential fatty acid deficiency may contribute to inflammatory pathways contributing to the pulmonary and gastrointestinal symptoms associated with CF.

Where is vitamin B12 absorbed?

Distal ileum

What GI effects do agents such as narcotics or diphenhydramine have?

Documented anticholinergic effects often resulting in constipation

What is the most common symptom when feeding or fluids are withheld?

Dry mouth Easily alleviated with good mouth care

What is the most common symptom when feeding or fluids are withheld?

Dry mouth, which is easily alleviated with good mouth care

Why would women with hyperemesis gravidarum be at risk for Wernicke's encephalopathy? What is the treatment?

Due to poor intake, decreased thiamin levels are frequently seen in patients with hyperemesis gravidarum, increasing the risk for Wernicke's encephalopathy, a potentially fatal neurologic syndrome. Thiamin supplementation should be considered with the initiation of dextrose containing fluids in patients with hyperemesis gravidarum

Why do we use the term SIAD instead of SIADH?

Due to the fact that not all afflicted patients show elevated circulating levels of ADH, the expression "syndrome of inappropriate antidiuresis" has been determined to be more accurate

Why is the significance of GRV controversial?

Due to the lack of well powered studies, the relationship of GRV and aspiration pneumonia can not be clarified

Why is the significance of GRV controversial?

Due to the lack of well-powered studies because of this, the relationship of GRV and aspiration pneumonia can not be clarified

Why would SNS be required in hyperemesis gravidarium (HEG)? What are the 5 steps for nutrition treatment?

Due to the likelihood that the patient's nutritional intake has been poor for several weeks due to vomiting, EN or PN may be required. 1. Prior to implementation of nutritional therapy for HEG, fluid and electrolyte imbalances, ketonuria and dehydration would be treated via IV fluid 2. Multivitamins with additional B vitamins are typically added to address suboptimal vitamin intake and prevent complications such as neuropathies (B6 and B12), Wernicke's encephalopathy (thiamine) and neural tube defects (folic acid) 3. Antiemetic treatment would begin and oral intake would temporarily be avoided 4. Initiation of an EN trial for HEG would be appropriate if the patient is still unable to take oral feedings after 24-48 hours of supportive therapy as listed above 5. If the EN trial fails due to exacerbated nausea, vomiting, diarrhea, significant gastric residuals or tube displacement and is associated with clinically significant weight loss (greater than 5% of body weight), it is appropriate to begin PN

When is dumping syndrome most likley to develop?

Dumping syndrome is most likely to develop if all or part of the stomach has been removed

Where are iron and calcium absorbed?

Duodenum

Describe leucine metabolism during a fasting state.

During a fast, leucine levels increase in the bloodstream and within the muscle. Leucine oxidation by the skeletal muscle also increases. Acetyl-CoA is produced as an energy source for the muscle while simultaneously sparing pyruvate oxidation. Pyruvate is reduced to lactate and released by the muscle. Both pyruvate and lactate are returned to the liver to participate in gluconeogenesis. Oxidation of leucine by the skeletal muscle spares essential gluconeogenic precursors.

How does fuel oxidation change during fasting?

During fasting, fuel oxidation gradually shifts from carbohydrates to mainly lipids as oxidative source. Lipolysis increases strongly and provides the body with fatty acids. As a consequence of increased fatty acid oxidation, terminal glucose oxidation is decreased.

During periods of illness and trauma which hormones are increased? Why?

During periods of illness and trauma, there is increased production of the stress hormones, such as epinephrine and cortisol, accompanied by an elevation in growth hormone and glucagon. These counterregulatory hormones all work to oppose insulin action, resulting in increased glucose production by the liver (may exceed 500 grams of glucose day) and decreased utilization of glucose in peripheral tissue. These changes are also responsible for increased protein breakdown from muscle and enhanced fatty acid oxidation, viewed as a metabolic adaptation to provide fuels for heightened demands

Why is feeding even small amounts not indicated in end of life nutrition?

During starvation the body begins to use fat as the predominant energy source leading to increased ketone production with a resulting euphoria. Feeding even small amounts can prevent ketonemia and prolong the sense of hunger

What treatment has been shown to induce remission in up to 85% of children with newly diagnosed Crohn's disease?

EEN - exclusive enteral nutrition

What does NASPGHAN recommend as first line induction therapy in pediatric Crohn's disease? Why?

EEN - exclusive enteral nutrition Has been shown to induce remission in up to 85% of children with newly diagnosed Crohn's disease

When is EFAD usually seen?

EFAD usually results after 4 week of fat-free PN, although signs of deficiency can be seen as early as 10-20 days in adults although deficiency can occur more rapidly in infants and children

What is the benefit of Medicare that primarily covers EN and PN?

EN and PN are primarily covered under the "prosthetic device" benefit under the Medicare Part B program

How should enteral medications be administered? Why?

Each medication should be given separately flushing with at least 15-30 mL of water prior to, between and after administration to prevent potential drug-drug and drug-nutrient interactions

What is the evidence for providing parenteral nutrition support containing both essential amino acids and nonessential amino acids in patients with AKI?

Early clinical studies suggested that patients receiving a parenteral solution of essential amino acids (EAA) and dextrose could reduce need for dialysis. Subsequent studies comparing EAA to a mixture of EAA and nonessential amino acids showed no difference in the rate or frequency of recovery from AKI or survival. Formulations providing only EAA are not recommended. Branched chain amino acids have demonstrated no advantage over standard amino acids in patients with AKI. Several nonessential amino acids, including tyrosine, arginine and glutamine become conditionally essential in AKI.

How should electrolytes be expressed on the PN label?

Electrolytes are to be ordered as complete salt forms as opposed to individual ions

What electrolytes should be closely monitored with nutrition therapy in eating disorders?

Electrolytes including potassium, magnesium and phosphorus should be checked at baseline and routinely with initiation and advancement of enteral feedings for patients with anorexia nervosa due to the high risk of developing refeeding syndrome

What does elevated C-reactive protein indicate?

Elevated C-reactive protein reflects an inflammatory status

What have low plasma choline levels in long term PN patients been associated with?

Elevated liver aminotransferase concentrations

What lab is an indicator of cholestasis?

Elevated serum conjugated bilirubin defined as a concentration > 2 mg/dL

What is the only way to treat galactosemia? What formula should be used in infants with galactosemia?

Eliminate galactose from the diet. Soy based infant formulas are used as substitutes for milk in galactosemia.

What is the role of gluconeogenesis in fasting?

Endogenous glucose production by gluconeogenesis provides the body with sufficient glucose for glucose-dependent processes

How is energy expenditure impacted in liver disease?

Energy expenditure is usually increased in liver disease especially in those patients with infections and ascites

What is a good estimate of nutritional needs of a patient with a bone marrow transplant? (protein and energy)

Energy needs will vary with the individual but usually, energy requirements are estimated at 1.5 x basal energy expenditure (BEE) or approximately 30-35 kcal/kg/day. Protein intake should be aimed at 1.5 g/kg during the first 1-3 months after transplantation

In the terminally ill hospice patient what is the recommendation for EN? Why?

Enteral feeding and hydration do not always ensure comfort. During starvation the body begins to use fat as the predominant energy source leading to increased ketone production with a resulting euphoria. Feeding even small amounts can prevent ketonemia and prolong the sense of hunger.

When should early enteral feeding be initiated in critically ill patients?

Enteral feeding should be delayed until fluid resuscitation is complete

When would enteral feeding cause social embarrassment?

Enteral feedings administered in public may cause social embarrassment

What vitamin supplementation competes with copper for absorption enterally?

Enteral zinc supplementation can compete with copper for absorption

Why are enteric coated or film coated tablets not appropriate to be crushed for administration via enteral feeding?

Enteric coated or film coated tablets do not crush well and tend to clump and increase the risk of clogging the tube

Why are enteric coated and film coated tablets not crushed for administration via an EN feeding tube?

Enteric coated or film coated tablets do not crush well and tend to clump and increase the risk of clogging the tube.

Where is enterokinase secreted from?

Enterokinase is an enzyme secreted from the brush border of the small intestine

How does WHO define persistent diarrhea?

Episodes 14 days or longer in duration

How do some experts define chronic diarrhea?

Episodes longer than 30 days

What is the effect of managing biliary atresia with MCT oil predominantly without LCT formula?

Essential fatty acid deficiency

What happens if the diet is void of linoleic acid and alpha-linolenic acid?

Essential fatty acid deficiency can ensue resulting in metabolic complications

What is the EAR?

Estimated Average Requirement which is defined as the average daily nutrient intake level estimated to meet half the needs of healthy individuals in a particular life stage and gender group

What does the Holliday-Segar method estimate?

Estimates caloric expenditure in fixed weight categories

Other than antimicrobial action for lock solution what is another use of ethanol in the clinical setting?

Ethanol has been used as an anticoagulant in clinical practice

How often should DEXA be performed in long-term PN patients?

Every 1-3 years

How often should open system feeding administration sets be changed?

Every 24 hours and disposable feeding administration sets should not be reused

How often should administration sets for human breast milk be changed?

Every 4 hours

How often should short term (NGT) be changed?

Every 4-6 weeks

How often should short-term feeding tubes be changed?

Every 4-6 weeks

What does evidence show about home enteral feeding schedules?

Evidence demonstrates that patients and their caregivers quickly adapt the prescribed enteral feeding regimen to suit themselves and their home circumstances

What is the development of liver complications with PN usage primarily due to?

Excessive energy intake from dextrose and/or intravenous fat emulsion

What is the usual clinical presentation for buried bumper syndrome?

Excessive pain at the PEG site

What is the usual clinical presentation for buried bumper syndrome? Define the syndrome.

Excessive pain at the PEG site, excessive tightening of the external bolster may lead to ischemic necrosis of the gastric wall and migration of the internal bolster either into the gastric wall, abdominal wall, or even into subcutaneous tissue and skin

What alternative first-line therapy to corticosteroids has been shown shown to induce remission and is recommended by NASPGHAN? How often was it shown effective?

Exclusive enteral nutrition (EEN) has been shown to induce remission in up to 85% of children with newly diagnosed Crohn's disease and NASPGHAN recommends that EEN be supported as a first-line induction therapy in pediatric Crohn's disease

What is the incidence of colocutaneous fistula with PEG tube placement?

Extremely rare, occurring in only 0-0.27% of cases

What has been the result of several reports of systemic toxicity, some resulting in death, published in recent years about using blue dye to detect enteral feeding aspiration?

FDA removed FD&C Blue#1 from the market in 2003

How is the majority of fat digestion accomplished?

Fat digestion begins in the mouth and stomach, but the majority of fat digestion occurs in the duodenum by pancreatic lipase

What vitamins require bile salts for emulsification and integration into the micelle for absorption into the enterocyte?

Fat soluble vitamins (ADEK)

What are the main causes of fatigue in caregivers of enteral nutrition patients?

Fatigue is a result of nocturnal feedings or frequent enteral care during the day that requires additional work for the caregiver

How does beta oxidation compare to carbohydrate oxidation for energy yield?

Fatty acid (and/or lipid) oxidation releases substantially more energy than does oxidation of carbohydrate

Describe the chemistry of fatty acid molecules.

Fatty acid molecules with an acidic carboxyl group at one end followed by a long chain of hydrogenated hydrophobic carbon atoms. Each fatty acid is chemically characterized by the number of carbon toms and double bonds present.

Fatty acids up to what carbon chain length and glycerol can be absorbed directly via the villi of the intestinal mucosa?

Fatty acids up to 10 carbons

What typically interferes with fluid intake in older adults?

Fear of incontinence

Should feeding be delayed in the patient at risk of refeeding syndrome?

Feeding should not be delayed but instead initiated slowly and then advanced based on electrolyte levels and clinical response.

Describe bolus feeding.

Feedings are infused over a short period of time, over as few as 4-10 minutes, 3-6 times daily

How does fermented fiber increase fecal bulk?

Fermented fiber encourages colonic bacterial growth adding to fecal mass

At what FiO2 is the accuracy of indirect calorimetry of mechanically-ventilated patients decreased?

FiO2 >/= 60

What nutrient is fermented by bacteria in the colon into short chain fatty acids?

Fiber

Should fiber be used in abdominal distention?

Fiber may help to promote regular bowel movements in patients receiving enteral nutrition, but may also lead to excess gas production and increased abdominal distention. Providing additional free water flushes may help to decrease distention

What enteral nutrition component may help to promote regular bowel movements in patients receiving enteral nutrition? What is the downside to providing this? What can be done to prevent this?

Fiber may help to promote regular bowel movements in patients receiving enteral nutrition, but may also lead to excess gas production and increased abdominal distention. Providing additional free water flushes may help to decrease distention

What is a strong contributor to stress in the specialized nutrition support patient that is not medical/health related?

Financial concerns

What is the first-line therapy in hyperkalemia? What is the dosage and effective onset time?

First-line therapy in hyperkalemic emergencies consists of calcium gluconate 1-2 grams IV over 10 minutes, which has an effective onset time of 1-2 minutes.

What is the appropriate nutrition therapy for ascites?

Fluid and sodium restriction. Current literature suports the use of protein 0.8-1.2 g/kg/day for maintenance and 1.3-2.0 g/kg/day for repletion. While optimum nutrition support may not be possible, use of maximally concentrated solutions provides the best opportunity to avid further salt and fluid overload while providing necessary substrate for anabolism

What fluid status is most often implicated in difficulty weaning from mechanical ventilation?

Fluid overload (not fluid depletion)

How is folic acid absorbed?

Folic acid is absorbed by a carrier-mediated process, primarily in the proximal part of the small intestine

What is the function of bile salts?

Form micelles in which their hydrophilic portions face out and their hydrophobic portions face toward the center where lipids collect

Is enteral formula covered under Medicare Part B?

Formula is covered under Medicare Part B, but the patient will be financially responsible for 20% of the Medicare approved amount. If the patient has a supplement or secondary insurance, it will usually pick up the 20% that Medicare does not cover

What is Mosteller's formula?

Formula used to calculate BSA(M2). M2: the square root of the following: Height (cm) x weight (kg)/3600 This value is multiplied by maintenance fluid requirement of 1500 mL per day

Why are omega-3 fatty acids indicated in ARDS?

Formulas containing omega-3 fatty acids may down regulate the inflammatory response through the production of less inflammatory prostaglandins and leukotrienes

What is the FIM?

Functional Independence Measure, a tool used to measure functional independence in rehabilitation settings

Why is thiamin deficiency seen in patients with heart failure?

Furosemide and digoxin may decrease thiamin uptake by cardiac cells in patients with heart failure

What is the onset for use of furosemide in the treatment of hyperkalemic emergency?

Furosemide has a 5-15 minute onset

Describe GER.

GER is a frequently encountered problem in infancy and it commonly resolves spontaneously. GER is not associated with significant complications and many times these infants are referred to as "happy spitters"

Why is EN contraindicated in the early post-transplant period in adult patients with hematopoietic cell transplants?

GI toxicities such as nausea, vomiting, delayed gastric emptying and diarrhea seen in the first 2-3 weeks post-stem cell transplant may preclude EN. GI toxicity is most often related to chemotherapy and total body irradiatin, however GI toxicity may also result from other medications or early acute graft-versus-host disease in this patient population.

Describe the digestive processes required for vitamin B12 absorption.

Gastric acid facilitates the proteolytic process that releases vitamin B12 from the proteins in foods. This free vitamin B12 then binds to R-proteins in the stomach and intrinsic factor in order to be absorbed in the terminal ileum

Define bolus feeding.

Generally an amount of 250-480 mL delivered by gravity or a syringe over 15 minutes into the stomach

What is the osmolality of standard infant formulas at a caloric density of 20 kcal/oz?

Generally falls below the limit with a range of 200-380 mOsm/kg

What is the osmolality of hydrolyzed protein and free amino acid containing infant formulas?

Generally have a slightly higher osmolality due to their smaller particle size (330-370 mOsm/kg)

What macronutrient is different in oral nutrition supplements vs. enteral products?

Generally, enteral products designed for oral use contain more sucrose to improve palatability. This translates into a higher carbohydrate to protein and fat ratio.

What is osteogenesis imperfecta? How are routine lab studies impacted?

Genetic disease that is characterized by multiple bone fractures, short stature and is diagnosed by physical exam. Results from routine lab studies are usually within reference ranges.

What is osteogenesis imperfecta? List the characteristics.

Genetic disease that is characterized by: 1. multiple bone fractures 2. short stature on physical exam

What bone age is associated with genetic short stature?

Genetic short stature typically is associated with a bone age similar to their chronological age

What is the function of glucokinase?

Glucokinase is an enzyme involved in the control of the rate of glycolysis and gluconeogenesis

When does gluconeogenesis from amino acid substrate begin?

Gluconeogenesis from amino acid substrate begins within 4-6 hours after the last meal

How does sodium concentration impact glucose absorption?

Glucose and sodium share common co-transporters. High concentrations of sodium in the chyme increase glucose transport. Low concentrations of sodium decrease glucose absorption

What is the electrolyte composition of lactated ringers?

Glucose: 0 Sodium: 130 mEq/L Chloride: 109 mEq/L Potassium: 4 mEq/L Lactate: 28 mEq/L Calcium: 2.7 mEq/L

What is the electrolyte content of D51/2NS?

Glucose: 50 grams/L Sodium: 77 mEq/L Chloride: 77 mEq/L

What is the most abundant amino acid in the body?

Glutamine

What is the principal metabolic fuel for intestinal cells?

Glutamine

What is the function of glutamine?

Glutamine is a non-essential amino acid that is the main fuel for rapidly dividing cells

Which amino acid is the key fuel for the small intestine?

Glutamine is essential for small intestinal structure and function

What is the function of glutamine?

Glutamine is the most abundant amino acid in the body and a vital fuel for rapidly dividing cells such as enterocytes, fibroblasts, reticuloendothelial cells and malignant cells

What is the storage form of glucose in the body?

Glycogen

Where is glycogen present in the body?

Glycogen is present in small amounts in most body tissues but is mainly found in the liver and skeletal muscle

How do Government insurance programs determine coverage for home parenteral nutrition in general?

Government programs (Medicare, Medicaid) have strict coverage criteria and require detailed history, tests and nutritional data to determine elgibility

How do you calculate the nitrogen content of a PN solution?

Grams of protein divided by 6.25 will determine the nitrogen content of protein in a PN solution

When does hypergranulation develop?

Granulation tissue may form within feeding tube tracts and extend out onto the skin surface. Hypergranulation develops when the exit site remains moist or the tube is not stabilized.

What is normally the primary goal in neonatal nutrition?

Growth

What is often the primary goal in neonatal nutrition?

Growth

Can growth occur in neonates during the stress response?

Growth cannot occur until recovery from the stress response has begun

How should human breast milk be prepared?

HBM should be prepared for patient use in a clean environment using aseptic technique by specially trained personnel. The recommendations also support the use of gloves during HBM administration

What is hyperemesis gravidarium (HEG)?

HEG is a severe form of pregnancy-induced nausea and vomiting

What is HIV-associated lipodystrophy syndrome? What is it associated with?

HIV-associated lipodystrophy syndrome is manifested by subcutaneous adipose tissue loss with visceral adipose tissue sparing or accumulation. Subcutaneous tissue loss is often most evident in the face, buttocks and lower extremities. Lipodystrophic patients may also be insulin resistant. Lipodystrophy has been strongly associated with first-generation nucleoside reverse transcriptase inhibitors.

What energy expenditure measurement uses heat released from the subject?

Heat released from the subject is measured by direct calorimetry which requires the subject to remain inside of an enclosed chamber during the measurement

Why should the EN tube be flushed before and after each medication?

Helps to avoid physical interactions both between medications and between medications and formula.

Why is flushing the tube with water before and after each medication (including between each individual medication administered) recommended?

Helps to avoid physical interactions, both between medications and between medications and formula

How does hemodialysis impact indirect calorimetry measurements?

Hemodialysis can alter measurements because of the potential loss of CO2 through the dialysis coil

Why isn't hemodialysis used as first-line therapy for hyperkalemic emergencies?

Hemodialysis has an immediate onset, but feasibility is limited to equipment availability and individuals with existing access

What is the function of hemoglobin?

Hemoglobin, the iron-containing protein of blood, transports oxygen from the lungs to the cells

What is choline supplementation thought to improve?

Hepatic steatosis

What is hepatic steatosis?

Hepatic steatosis may occur as the first stage of hepatic insufficiency as the result of alcohol consumption

How does preterm human milk compare to full term human milk?

Higher concentration of protein

What level of abdominal distention would holding enteral feedings be appropriate?

Holding enteral feedings is generally not indicated unless abdominal girth exceeds the baseline measurement by at least 8 to 10 cm

Is holding enteral feedings indicated with abdominal distention?

Holding enteral feedings is generally not indicated unless abdominal girth exceeds the baseline measurement by at least 8-10 cm

What is the Holliday-Segar method?

Holliday-Segar method estimates caloric expenditure in fixed weight categories; it assumes that for each 100 calories metabolized 100 mL of water will be required. Fluid rates are adjusted based on clinical state (fever, tachypnea)

Describe human milk as a source of iron.

Human milk is low in iron content, it is very efficiently absorbed. The iron content of cow's milk is inadequate and not efficiently absorbed by infants.

Why is human milk the optimal choice over standard formula?

Human milk is the optimal choice over standard formula for any infant due to multiple beneficial components including immunologic properties, growth factors and both pre- and probiotics.

What is recommended for feeding a pancreatic insufficient infant with cystic fibrosis?

Human milk or standard infant formula with appropriate enzyme dosing is recommended. Protein hydrolysate or free amino acid formulas containing MCT are not indicated for infants with cystic fibrosis (CF) unless there is another medical reason such as bowel resection resulting in malabsorption or liver abnormalities

What do parietal cells secrete?

Hydrochloric acid (HCl) and intrinsic factor

What contributes to the risk of PN associated metabolic bone disease that could be a factor for patients with IBD who require long term PN?

Hypercalciuria and aluminum toxicity. Aluminum toxicity is probably a mino contributor to the problem in patients with IBD

How would glucose intolerance present in infants?

Hyperglycemia and/or hypertriglyceridemia

What is the prevalence of hypermaganesemia in home PN patients?

Hypermaganesemia has been reported in > 50% of home PN patients

What strategy may benefit patients on fat free PN?

Hypocaloric PN actually may benefit patient on fat free PN as it is thought that EFA are released as a result of lipolysis of endogenous fat stores in response to reduction in insulin levels

Describe the recommendations for hypocaloric feeding with PN?

Hypocaloric feeding with PN is generally recommended in the critically ill obese patient. For all classes of obseity where BMI is > 30 kg/m2, the goal of the PN regimen should not exceed 60% to 70% of target energy requirements or 11-14 kcal/kg actual body weight/day (or 22-25 kcal/kg IBW/day). Protein should be provided in a range greater than or equal to 2.0 g/kg IBW/day for class I and class II patients (BMI 30-40 kg/m2), greater than or equal to 2.5 g/kg IBW/day for class III (BMI > 40 kg/m2)

Why does hypoglycemia occur in the majority of patients with fulminant hepatic failure?

Hypoglycemia is seen in the majority of patients with fulminant hepatic failure and may result from impaired glycogenolysis, glycogenesis, gluconeogenesis and hyperinsulinemia requiring aggressive glucose administration. Patients are usually in a hypercatabolic state with an increase in energy expenditure and can become rapidly malnourished

Which common metabolic derangements are seen with refeeding syndrome? What is considered the hallmark feature of refeeding syndrome?

Hypophosphatemia, hypomagnesemia and hypokalemia Hypophosphatemia is considered the hallmark feature of refeeding syndrome

How would hypoventilation impact RQ?

Hypoventilation would tend to reduce RQ measurements

Which patients should be given calcium gluconate IV for hyperkalemic emergencies? Why?

IV calcium gluconate should be given to symptomatic patients or those with ECG changes to restore membrane excitability to normal; i.e., act as an antagonist to cardiac conduction abnormalities

Why is IV hydration not recommended in the care of the terminal patient?

IV hydration in the terminal patient can raise the risk of patient discomfort and respiratory distress

What symptom is associated with carnitine deficiency?

Idiopathic encephalopathy

If a patient has REE measured by indirect calorimetry while fasting or feedings are intermittently provided what should be used for energy requirements?

If a patient is measured while fasting or if feedings are intermittently provided, it is reasonable to allow an additional 5% factor to account for thermogenesis

Is a caregiver necessary for home parenteral nutrition (HPN)?

If the patient has the ability to be educated regarding the prescribed therapy, there is no need for a caregiver to be available to the patient at home.

What is considered excessive hypergranulation?

If the tissue is excessive (> 0.25 inch for adults or > 2 mm in pediatric patients)

At what point of total parenteral nutrition should pediatric patients be supplemented with selenium?

If they have been on total parenteral nutrition for > 1 month

Why are resections of the proximal bowel (including duodenum and proximal jejunum) generally better tolerated?

Ileal compensation and adaptation

What specific physical structure predisposes patients to small bowel bacterial overgrowth (SBBO) if removed during intestinal resection?

Ileocecal valve

Where are B12 and bile salts absorbed?

Ileum

Which part of the small intestine has the greater adaptive capacity?

Ileum

Which has greater adaptive capacity the ileum or the jejunum?

Ileum has greater adaptive capacity

What is the electrolyte composition of ileal fluid?

Ileum: Sodium: 110-130 mEq/L Potassium: 10-20 mEq/L Chloride: 90-110 mEq/L Bicarbonate: 20-30 mEq/L

How should immediate release tablets be administered enterally?

Immediate release tablets can be crushed into a fine powder and dissolved or suspended in 30-60 mL water prior to administration

How should immediate release tablets be administered enterally?

Immediate release tablets can be crushed to a fine powder and dissolved or suspended in 30-60 mL water prior to administration

Due to functional age-related changes in the GIT how may the immune function be impacted?

Immune function may be decreased as well, due to slowed immunoglobulin A responsiveness or slowed inflammatory response

What is cyclosporine commonly used for after solid organ transplant?

Immune suppression

How does fecal impaction usually present?

Impaction can be manifested by symptoms of diarrhea. Passage or secretion of fluid around the impaction may be responsible for the loose stool. The patient may intermittently pass small volumes of liquid stool and experience abdominal distention and cramping.

What is the definition of impaired functional status?

Impaired functional status is defined as the inability to perform activities necessary for routine self care

Why does hypophosphatemia result from DKA?

In DKA substantial phosphorus is lost in urine as a result of osmotic diuresis associated with hyperglycemia

What is the main difference between Vitamin D deficient rickets and Vitamin D dependent type 2 rickets?

In Vitamin D dependent type 2 rickets 1,25 (OH) vitamin D levels will be elevated

What is the evidence for support groups in patients receiving home parenteral nutrition HPN?

In a case-control study comparing 2 groups of patients affiliated with a national support or educational organization with nonaffiliated controls, the affiliated patients were found to have a significantly higher QOL, less reactive depression, and a lower incidence of catheter-related sepsis

How should human breast milk be prepared for patient use? How should it be prepared and administered?

In a clean environment using aseptic technique by specially trained personnel. The recommendations also support the use of gloves during HBM administration. Administration sets used for HBM should be di (2-ethylhexyl) phythalate (DEHP) free and changed every 4 hours in an effort to limit adverse complications

What is the evidence showing cancer as a condition highly likely to result in malnutrition?

In a large multicenter cooperative study, over half of cancer patients present with weight loss at diagnosis (range 31-80%). unintentional weight loss is a criterion for diagnosis of malnutrition. The amount and frequency of weight loss varied with type of cancer, location, grade and stage. Type of anti-cancer treatments can also further impact nutritional status

Why is cysteine essential in preterm infants?

In adults cysteine can be synthesized from methionine via a liver-specific trans-sulfuration pathway , the enzyme necessary for this synthesis is not present in adequate amounts in preterm infants there fore cysteine is considered likely to e an essential amino acid for preterm infants

Why is cysteine non-essential in adults?

In adults cysteine can be synthesized from methionine via a liver-specific trans-sulfuration pathway.

Delineate the phases of ketone usage during fasting.

In early phases of fasting, heart and skeletal muscles use ketone bodies as fuel, thereby preserving the limited glucose available for use by the brain. After 1-2 weeks of starvation, the brain adapts to use ketones as a source of energy

Describe the impact of fiber on the upper and lower GI tract.

In general GI transit time in the upper GIT is generally slower (especially with soluble fibers) resulting in delayed gastric emptying. Fiber in the lower GI tract tends to hasten GI transit due to increased stool weight due to fiber and increased water and by increased bacterial mass from fiber fermentation which all can lead to increased propulsion of softer stools.

In general what are centrally-infused protein losses into CRRT effluent? What is the recommendation for protein delivery?

In general centrally infused protein losses into CRRT effluent range from 10-17% and should be taken into consideration when determining protein requirements. Consensus in the literature for daily protein delivery in patients undergoing CRRT is 1.5-2 g/kg/day. While doses as high as 2.5 g/kg/day have been advocated to promote positive nitrogen balance

What does an RQ of 0.82 indicate?

In general, an RQ < 0.82 suggests underfeeding or lipid catabolism, indicating the need to increase caloric delivery

When would protein restriction be an appropriate treatment for the patient with cirrhosis?

In patients with cirrhosis with acute encephalopathy a temporary protein restriction may be utilized until cause of the encephalopathy is diagnosed and eliminated. In hepatorenal syndrome a modest reduction in protein can be made on a temporary basis until renal function improves

How do predictive equations compare to measured energy expenditure in pediatric ICU patients? How is nutrition support impacted?

In pediatric ICU patients predictive equations for energy expenditure yield results that are not consistent with measured energy expenditure. Provision of nutrition support based on inaccurately estimated energy requirements has been shown to result in significant under or overfeeding

Why is glutamine considered conditionally essential?

In some conditions, such as trauma, sepsis and exercise the body's glutamine requirement exceeds the rate of synthesis leading to a decrease in plasma and intracellular glutamine

What are the most common surgical techniques used in the treatment of severe reflux?

In the United States are the Thai and Nissen fundoplications which are performed via open or laporoscopic approach

When would elevated catecholamines and elevated or normal plasma insulin be observed following a burn injury?

In the acute phase of the flow response

How should home enteral feeding schedules be prepared?

In the home, enteral feeding should be integrated into the patient's and family's typical way of living. Evidence demonstrates that patients and their caregivers quickly adapt the prescribed enteral feeding regimen to suit themselves and their lifestyle

How should enteral feeding schedules be designed for the home?

In the home, enteral feeding should be integrated into the patient's and family's typical way of living. Separation of the patient from the family during meal times may have a negative impact on the family structure, although the administration of tube feeding may not be accepted by some at the dinner table. A compromise may be necessary to meet all the family members' needs. Participation in conversations and socialization at the dinner tale is encouraged. When possible in the home setting, the administration schedule should be structured to simulate normal meal times

When is it within the scope of practice for registered nurses to insert nasogastric feeding tubes?

In the uncomplicated patient on the inpatient floor

Why would metabolic alkalosis be expected in a patient awaiting liver transplant and has been taking a diuretic to control ascites and peripheral edema?

In this patient, metabolic alkalosis (saline-responsive) is a consequence of chronic diuretic therapy used to control ascites and peripheral edema. These agents cause a loss of bicarbonate-poor, chloride rich extracellular fluid leading to contraction of extracellular fluid volume. Since the original bicarbonate mass is now dissolved in a smaller fluid volume, an increase in bicarbonate concentration occurs

What other body mass alteration do many older persons also experience in addition to sarcopenia?

Increase in total body fat

Do gastric residual volumes correlate to increased risk of aspiration?

Increased gastric residuals have not been linked to an increased risk for aspiration

What disease has hyperhomocysteinemia been linked to?

Increased risk for coronary atherosclerosis. It is not known whether hyperhomocysteinemia is a causative factor of atherosclerosis or simply a marker of vascular disease

Why is creatine taken as a food supplement?

Increases lean body mass

What happens to dietary fiber that is not degraded or fermented in the colon?

Increases stool bulk and weight. Unfermented fiber in the colon creates a gel which holds water. This results in increased stool water content and softened stool consistency to ease evacuation.

How should energy prescriptions be calculated in critically ill and postoperative neonates?

Indirect calorimetry (IC) is recommended when possible, if IC Is not available the basal energy/resting energy expenditure REE should be used for nutrition support provision (55-60 kcal/kg/day)

How should energy needs be estimated in critically ill and postoperative neonates?

Indirect calorimetry is recommended when possible, but if IC is not available the basal energy/resting energy expenditure should be used for nutrition support provision (55-60 kcal/kg/day)

When do breastfed infants require iron supplementation?

Infants exclusively fed human milk require an iron supplement starting at 4-6 months of age

How does chronic lung disease impact calorie needs in infants?

Infants with chronic lung disease often have high calorie needs

What is foul-smelling drainage around the tube exit site a sign of?

Infection

What metabolic molecules are present in both acute lung injury ALI and ARDS?

Inflammatory mediators, including prostaglandins and leukotrienes derived from arachidonic acid metabolism

Why are formulas containing omega-3 fatty acids recommended in ALI and ARDS?

Inflammatory mediators, including prostaglandins and leukotrienes derived from arachidonic acid metabolism have been implicated in both ALI and ARDS. Formulas containing omega-3 fatty acids may down regulate the inflammatory response through the production of less inflammatory prostaglnadins and leukotrienes

What is the onset for use of regular insulin and dextrose in the treatment of hyperkalemic emergencies?

Infusion of regular insulin with dextrose has a 15-45 minute onset

What is the recommended infusion rate for phosphate? Why?

Infusion rates of phosphate should not exceed 7 mmol/hour because faster infusion rates can often cause thrombophlebitis (ie potassium phosphate) and metastatic calcium-phosphate deposition with potential resultant organ dysfunction

What order should PN Ingredients be expressed on the PN label?

Ingredients are to be expressed on the PN label in the same sequence and units of measure as the PN order

What is the recommended intervention to prevent tube occlusion associated with GRV assessment? Why?

Injecting 30 mL of air into the tube prior t, and flushing the feeding tube with 30 mL of water following GRV assessment is the recommended intervention Enteral intact protein formulations may coagulate with contact with an acidic pH

How does insulin impact potassium and phosphorus?

Insulin is an anabolic hormone that drives potassium and phosphorus into cells and results in serum depletion

What is required for insurance coverage of home parenteral and enteral nutrition?

Insurance coverage for EN and PN varies by type of program as well as individual plans. Government programs (Medicare and Medicaid) have strict coverage criteria and require detailed history, tests and nutritional data to determine eligibility. Coverage policies and reimbursement for EN and PN also vary with private payers and managed care organizations and frequently require preauthorization or pre-certification. Most require that the therapy be medically necessary and the sole source of nutrition. Many insurance policies establish their own criteria for EN and PN, while others follow the guidelines for coverage set forth by Medicare

What types of feeding schedules may cause fluctuations in blood glucose concentrations, placing patients at risk for hypoglycemic and hyperglycemic complications?

Intermittent feeding schedules (bolus, gravity drip, or nocturnal infusion)

Describe intermittent feeding.

Intermittent feedings are commonly delivered by enteral pump or gravity drip method over a period of 20-60 minutes 4-6 times daily

Define intermittent feeding.

Intermittent feedings are generally an amount of 240-480 mL administered over 45 minutes several times daily with or without feeding pump

Define intermittent feedings.

Intermittent feedings are generally an amount of 240-480 mL administered over 45 minutes several times daily with or without feeding pump

What is the evidence for choline supplementation in steatosis?

Investigations reported that steatosis resolved following choline supplementation. Further studies to evaluate choline supplementation to prevent and treat PN associated liver disease are needed

What is the most common nutritional deficiency in childhood?

Iron deficiency anemia

Why is iron the most likely trace element deficiency to occur in long term parenteral nutrition-dependent patients?

Iron is not a component of the PN formulation in part to avoid potential contribution to microbial growth and damaging oxidative reactions.

How does the Holliday-Segar method work?

It assumes that for each 100 calories metabolized 100 mL of water will be required. Fluid rates can be adjusted based on clinical state (fever, tachypnea)

What dose and type of cysteine can be used for parenteral nutrition in preterm infants to circumvent the the solubility concerns?

It can be added as cysteine HCl at a dose of 40 mg per gram of amino acids

What is the main concern when granulation occurs?

It can cause more moisture accumulation under the external bolster, increasing the risk for skin breakdown

What is SIAD?

It is a disorder of sodium and water balance caused by the inappropriate release of antidiuretic hormone (ADH).

What does decreased serum albumin indicate?

It is a good indicator of clinical outcome, it does not always reflect nutritional status

What is the origin of the Fenton growth chart?

It is an update from data previously collected by Babson and Benda, data was collected from a large sample size and validation of the chart occurred by using data from the National Institute of Child Health and Human Neonatal Research Network, CDC growth charts, intrauterine growth data and postnatal growth data. The data is cross sectional and is best used to assess growth over time

What is the appropriate education to provide to family members regarding the dying process?

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

Why is cysteine not included in standard parenteral amino acid solutions? How is it provided for infants?

It is not a component of standard parenteral amino acid solutions because it is unstable in aqueous solution Cysteine is considered an essential amino acid for infants but is unstable in aqueous solution so it is therefore added immediately prior to administration

How is cysteine added to TPN (what form and dosage)?

It is not included in usual amino acid solutions because of solubility concerns, however, it can be added as cysteine HCl at a dose of 40 mg per gram of amino acids

How is cysteine (an essential amino acid in infants) added to PN? Why?

It is unstable in aqueous solutions so it is added immediately prior to administration

What is the scope of practice for registered nurses in NGT placement?

It is within the scope of practice for registered nurses to insert nasogastric feeding tubes in the uncomplicated patient on the inpatient floor

What is the electrolyte composition of jejunal fluid?

Jejunum: Sodium: 95-120 mEq/L Potassium: 5-15 mEq/L Chloride: 80-130 mEq/L Bicarbonate: 10-20 mEq/L

Define the ethical principle of justice.

Justice is related to the fair distribution of resources.

What is the Katz ADL?

Katz Index of Independence in Activities of Daily Living, tool measures activities of daily living

Define Kwashiorkor?

Kwashiorkor is associated with visceral protein wasting, causing hypoalbuminemia, with preservation of fat and somatic muscle

Why is zinc deficiency difficult to assess and detect?

Laboratory limitation

What is the usually cause of challenges in early delivery of EN in the critically ill patient?

Lack of standardized procedures

Why is early delivery of EN in the critically ill patient is extremely challenging in many cases?

Lack of standardized procedures. Centers that use enteral feeding protocols provide more EN, use less parenteral nutrition, start EN sooner and provide a grater percentage of the goal calories compared to centers that do not have a EN feeding protocol in place

What result of thiamin deficiency can be fatal? What nutrition support method increases risk? Why?

Lactic acidosis The relatively high glucose loads of parenteral nutrition exacerbate the risk, despite adequate supplies of adult parenteral multivitamin preparations since 1999 suboptimal dosing practices have persisted

What is Lactobacillus GG?

Lactobacillus GG is a component of normal human intestinal flora which has ben studied frequently in regard to its potential antidiarrheal properties

What is the Lawton-Brody's IADL?

Lawton-Brody Instrumental Activities of Daily Living Scale, tool measures instrumental activities of daily living

What is another common complication with gastrostomy sites (aside from peristomal infection)? How can this be prevented/reduced?

Leakage around the gastrostomy site Exit site care, proper outer bumper placement and prevention of tension on the tube help reduce gastrostomy exit site leakage

What is used as an index of stunting due to chronic malnutrition in children?

Length for age

What should be the dose limit on pancreatic enzymes?

Less than 10,000 units of lipase/kg/day

What is the WHO definition of acute diarrhea?

Less than 14 days in duration

What is the osmolality recommendation for infant formulas?

Less than 460 mOsm/kg

What type of medication form is preferred for enteral medication administration?

Liquid mediations (non-acidic elixirs and suspensions) are preferred over solid dosage forms

What type of medications are preferred for enteral administration?

Liquid medications (non-acidic elixirs and suspensions) are preferred over solid dosage forms

What is the only site for oxidation of essential amino acids?

Liver

Where are bile acids secreted from?

Liver

Where are free fatty acids converted to ketone bodies?

Liver

How many grams of glycogen are stored in the liver?

Liver glycogen stores 100 grams have the potential to provide 390 kcal of energy

Where are both lactase and maltase located? What is their function?

Located i the brush border cells of the small intestine, are important in intraluminal carbohydrate digestion

For fatty acids greater than 10 carbons in chain length what is required for digestion and absorption?

Long chain triglycerides require bile salts for both enzymatic digestion and formation of micelles

What type of fatty acid is stearic acid?

Long chain, 18 carbons

What deficiency syndrome may result from long-term alcohol abuse?

Long-term alcohol abuse may lead to Wernicke-Korsakoff syndrome, which is associated with thiamin deficiency

Why does furosemide contribute to hyponatremia?

Loop diuretics (such as furosemide) cause an increased excretion of both sodium and water. Patients may experience a lower serum sodium when taking this medication; however, the observed hyponatremia is often asymptomatic.

What electrolyte/metabolic abnormalities can be expected with the use of loop diuretics?

Loop diuretics are known to cause electrolyte abnormalities as a result of increased urine output. Specific disturbances include excess potassium and magnesium excretion which can result in hypokalemia and hypomagnesemia. Patients are not known to become hypoglycemic. Azotemia can occur related to volume depletion

When are lower glucose targets (less than the recommended 140-180 mg/dL) recommended?

Lower glucose targets (110 mg/dL to 140 mg/dL) may be appropriate for some patients, but this is only appropriate when this can be safely achieved. Targets less than 110 mg/dL are not recommended due to the adverse effects of hypoglycemia

Wha do low muscle mass and low fat mass indicate in the hemodialysis patient? What BMI is recommended?

Lower muscle mass reflects poor nutrition status and inflammation Low fat mass reflects low body stores of energy and demonstrates poor coping with catabolic stress as caused by dialysis A BMI between 30 kg/M2 and 34.9 kg/M2 as demonstrated by Dialysis Outcomes and Practice Patterns Study is considered protective in dialysis patients. A BMI of less than 25 kg/M2 is not considered beneficial for patients on HD.

What is the first step in treating hepatic encephalopathy?

Lowering blood ammonia concentrations with medications, such as lactulose and/or rifaximin

What nutrient can be used to provide a concentrated source of energy to patients with fat malabsorption or damage to lymphatic vessels? Why?

MCT MCT are absorbed directly into the bloodstream and enter portal circulation bypassing the need for pancreatic enzymes, bile, bile transport in the lymphatic system and carnitine dependent transport into the mitochondria.

What is the advantage of MCTs in fat malabsorption?

MCT are absorbed directly into the bloodstream and enter portal circulation bypassing the need for pancreatic enzymes, bile, bile transport in the lymphatic system and carnitine dependent transport into the mitochondria. Because of this, MCT can be used to provide a concentrated source of energy to patients with fat malabsorption or damage to lymphatic vessels

How are MCTs absorbed?

MCTs are hydrolyzed and pass through the enterocytes directly into the portal circulation

What is the most important nutrition intervention to prevent nephrolithiasis?

Maintaining adequate hydration to support a urine output > 1200 mL/day is the most important intervention to prevent this complication

What is the Mifflin-St. Jeor equation?

Males: ABW (kg) x 9.99 x Ht (cm) x 6.25 - Age (years) x 4.92 + 5 Females: ABW x 9.99 x Ht (cm) x 6.25 - Age (years) x 4.92 - 161

Is the removal of what trace elements is warranted in PN patients with elevated bilirubin?

Manganese and copper may need to be reduced or eliminated, the removal of all trace elements is not warranted

What is the aluminum labelling requirement for PN?

Manufacturers of large volume, small volume and pharmacy bulk packages of components for PN must label each with the amount of aluminum anticipated to be in the product when the product expires. Pharmacies are required to list the aluminum content on each patient's PN bag

What is the risk of feeding a patient before hemodynamic stability has been achieved?

May increase the risk of intestinal ischemia as blood perfusion of the gut may be compromised in a patient who is still requiring high doses of vasopressor drugs to maintain blood pressure

Why is feeding a patient before hemodynamic stability has been achieved not recommended?

May increase the risk of intestinal ischemia. Blood perfusion of the gut may be compromised in a patient who is still requiring high doses of vasopressor drugs to maintain blood pressure.

What may be required with liquid enteral medication administration to minimize tube occlusion and adverse effects?

May require additional dilution

What complication can result with high dose pancreatic enzyme usage?

May result in strictures of the ascending colon (fibrosing colonopathy)

Measurement of what lab is reflective of the functional or long-term status of selenium?

Measurement of plasma glutathione peroxidase is reflective of the functional or long-term status of selenium

What is the ideal environment for indirect calorimetry measurement?

Measurements should be made in a quiet, thermoneutral environment and routine care during the study should be avoided.

How does indirect calorimetry calculate resting energy expenditure (REE) and respiratory quotient (RQ)?

Measuring whole body oxygen (VO2) and carbon dioxide (VCO2) gas exchange using the abbreviated Weir equation.

What is meconium ileus?

Meconium ileus is a bowel obstruction that occurs when the meconium in your child's intestine is even thicker and stickier than normal meconium, creating a blockage in a part of the small intestine called the ileum. Most infants with meconium ileus have a disease called cystic fibrosis

Is medical therapy useful in neurologically impaired children with severe gastroesophageal reflux?

Medical therapy for these children is not very effective, however vigorous trials of aggressive medical therapy (anti-reflux medications, proton pump inhibitors, dietary adjustments and positioning) should be tried before a child undergoes an anti-reflux procedure

What part of medicare covers home enteral nutrition?

Medicare Part B

How does Medicare define eligibility for coverage of home enteral nutrition?

Medicare Part B benefit for patient who has a permanent non-function or disease of the structures that normally permit food to reach the small bowel or for a disease of the small bowel that impairs digestion and absorption of an oral diet. The beneficiary must require tube feeding to provide sufficient nutrients to maintain weight and strength commensurate with their overall health status. The patient's condition could be either anatomic (obstruction, head and neck cancer or reconstructive surgery) or due to a motility disorder (severe dysphagia)

What consistency of medications should be used with enteral feedings?

Medications in liquid form are less likely to clog than crushed pills and should be used if available

How does megastrol acetate impact diabetes?

Megestrol acetate can exacerbate underlying diabetes

What is megastrol acetate and its function?

Megestrol acetate is a synthetic progestational agent that promotes weight gain and helps to stimulate appetite. Progestagens induce the release of neuropeptide Y from the hypothalamus and downregulate the synthesis and release of proinflammatory cytokines. The change in weight is thought to be largely due to increased adipose tissue and edema

Why is 30-35 kcal/kg the recommended energy intake for adults over 60 on hemodialysis or peritoneal dialysis?

Metabolic balance studies of people undergoing maintenance hemodialysis indicate that the total daily energy intake of 35 kcal/kg/day induces neutral nitrogen balance and is adequate to maintain serum albumin and anthropometrics indices. Because individuals more than 60 years of age tend to be more sedentary, a total energy intake of 30-35 kcal/kg is acceptable according to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative Guidelines

What are bile acids?

Metabolites of cholesterol

What is the most serious complication of hyperphosphatemia? How does this occur?

Metastatic and vascular calcification of non-skeletal tissues. This occurs when the calcium-phosphorus product exceeds 55 mg2/dL2

What is methotrexate and how does it work?

Methotrexate is a chemotherapeutic drug that became available in the early 1950s, it works as a folate analogue Methotrexate is structurally similar to folate. It competitively inhibits dihydrofolate reductase, an enzyme that catalyses the conversion of dihydrofolate to tetrahydrofolate, a cofactor in the synthesis of purine nucleotides and thymidylate. Therefore methotrexate impairs malignant growth by interfering with DNA synthesis, repair and cellular replication

What is the usual treatment for mild hypercalcemia?

Mild hypercalcemia usually responds to hydration and ambulation and requires no further intervention

What deficiency risk increases in children with increased intake of juices, sodas and sweetened beverages according to studies? Why?

Minerals such as magnesium and calcium Corresponding decrease in consumption of beverages like milk that promote bone health

What is the MDS?

Minimum Data Set (MDS) - a core set of clinical and functional status elements, and it forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare and Medicaid. The MDS is part of the Resident Assessment Instrument (RAI)

What are glucose, fructose and galactose all examples of?

Monosaccharides

Why is it not surprising that zinc is the most commonly suspected trace element abnormality in long-term PN patients?

Most patients who require long-term PN have a dysfunctional gastrointestinal (GI) tract that can contribute to increased GI losses. These GI losses can increase zinc losses and thus increase znc requirements

What is the etiology of parenteral nutrition-associated bone disease?

Multifactorial and aluminum toxicity is only one of the many potential contributors

What types of medications are documented to result in constipation?

Narcotics or diphenhydramine have well documented anticholinergic effects often resulting in constipation

What is important about FiO2 during measurement of indirect calorimetry?

Needs to remain constant during the measurement

What type of acute phase proteins are albumin and prealbumin?

Negative

What population is the Holliday-Segar method of estimating fluid needs not suitable in?

Neonates < 14 days old

What is the cause of nephrolithiasis from calcium oxalate stones?

Nephrolithiasis from calcium oxalate stones is multifactorial but is primarily due to accelerated oxalate absorption in the colon

What are the clinical manifestations of aluminum toxicity?

Neurological, hepatic, hematologic and skeletal and are neither specific nor sensitive for aluminum toxicity

What are the clinical manifestations of aluminum toxicity?

Neurological, hepatic, hematologic and skeletal but are neither specific nor sensitive for aluminum toxicity

Under what conditions may arginine supplementation be harmful?

Nitric oxide can be detrimental by leading to coagulation abnormalities and altered hemodynamic status. In this case, arginine could be considered harmful. Because of these effects, there is still much debate over the value of arginine in nutrition support for critically ill patients

According to safe enteral nutrition guidelines can disposable feeding administration sets be reused?

No

Are bowel sounds/evidence of bowel function needed prior to the initiation of enteral nutrition?

No

Are powdered formulas considered sterile?

No

Are teenagers considered high risk for problems when PN is initiated in the home setting?

No

Are the overt signs of EFAD common in CF?

No

Do GRVs correlate with incidence of regurgitation, aspiration or pneumonia?

No

Do current PN admixtures contain choline?

No

Do enteral feeding and hydration ensure comfort in the end of life?

No

Do gastric residual volumes correlate with incidence of regurgitation, aspiration or pneumonia?

No

Do standard infant and pediatric trace element commercial products contain selenium?

No

Do standard infant formulas and pediatric trace element products contain selenium?

No

Does indirect calorimetry measure heat released from the subject?

No

Does indirect calorimetry measure nitrogen balance?

No

Does indirect calorimetry measure total energy expenditure?

No

Does infantile anorexia follow a traumatic event?

No

Has an association between gastric residual volume amount and aspiration risk been validated?

No

Has fiber been shown to affect absorption of calcium, zinc or magnesium significantly?

No

Have increased gastric residuals been linked to an increased risk for aspiration?

No

Is gastrointestinal surgery a contraindication to early enteral nutrition?

No

Is head trauma a contraindication to early enteral nutrition?

No

Is infantile anorexia due to an associated gastrointestinal disorder or other medical condition?

No

Is pancreatitis a contraindication to early enteral nutrition?

No

Is professional intervention/monitoring for home parenteral nutrition patients by a registered dietitian a covered benefit under Medicare?

No

Is routine use of antibiotic ointments advisable for the care of feeding tube sites?

No

Is starting parenteral nutrition appropriate for an infant who is mildly dehydrated from viral gastroenteritis?

No

Is there a need for routine cultures in the uncomplicated enterally fed patient?

No

Is there clear indication for increasing the intake of dietary fiber to resolve constipation?

No

Should antidiarrheal medications be used in C.difficile patients?

No

Should fresh formula be added to already hanging formula if needed?

No

Should medications be mixed directly into the enteral formula for administration?

No

Was there sufficient evidence in the 2010 IOM review of calcium and vitamin D needs to support a cause-and-effect relationship between calcium and vitamin D and extraskeletal outcomes (cancer, cardiovascular disease, diabetes and autoimmune disorders)?

No

Would a patient with a functioning GI tract that is unable to meet nutrition needs due to anorexia or nausea be eligible for Medicare coverage of home enteral nutrition?

No

Would enteral nutrition be covered for anorexia?

No

Would enteral nutrition be covered for nausea?

No

Would hepatic encephalopathy, jaundice and elevated LFTs be considered markers of malnutrition?

No

is a soy formula recommended in infants with acute diarrhea associated with gastroenteritis who develop secondary lactase deficiency?

No

Is an isolated infusion area and dedicated refrigerator required for home infusion? What is required in the home?

No An area that can be used for supply storage

Is parenteral nutrition with BCAAs recommended in AKI?

No BCAA have demonstrated no advantage over standard amino acids in patients with AKI.

Can Cisapride be used for increased motility?

No as the agent was withdrawn from the US market in 2000 due to increasing reports of cardiac dysrhythmias

Is cisapride useful in patients with high GRVs?

No cisapride would not be a good choice as this agent was withdrawn from the US market in 2000 due to increasing reports of cardiac dysrhythmias

Is cysteine a component of standard TPN? Why?

No it is not a component of standard parenteral amino acid solutions as it is unstable in aqueous solutions.

Does Medicare cover professional intervention/monitoring for home parenteral nutrition?

No it is not a covered benefit under Medicare

Would a back-up electrical generator be needed in the home environment for a patient receiving parenteral nutrition?

No it is not required

Are laboratory values a good assessment of micronutrient status?

No lab values are not always reliable indicators, normal levels can give a false sense of security when the patient is deficient or toxic

What is the hang time of canned, ready-to-use formula?

No longer than 12 hours

Would low carbohydrate formula, hydrolyzed protein formulas or MCT oil predominant formulas be indicated for use in the treatment of chronic lung disease?

No none of these would be indicated

Is patient harm typically a concern in EN administration?

No patient harm is not typically a significant concern in EN since administration and care are relatively simple

Can patients be sent home with a temporary catheter for HPN use?

No patients should not be sent home with a temporary catheter for HPN

Is antibiotic ointment recommended with feeding tube site care?

No routine use of antibiotic ointments is not advised

Is there currently a reimbursement structure for compensation of phone consultations?

No there is currently no reimbursement structure for compensation of phone consultations in the US

Would primary sclerosing cholangitis, alcoholic liver disease and hepatocellular carcinoma be reasons for protein restrictions?

No they do not require protein restrictions

Can children with burns covering > 20% TBSA have nutrition support by oral intake?

No they generally cannot meet their nutrient needs by oral intake alone

Is HPN covered for ESRD? Why?

No, ESRD is not an indication for PN in and of itself as ESRD is not a diagnosis involving the small bowel or the bowel's ability to absorb nutrients?

Do vitamins compose a large percentage of oral nutrition supplements?

No, although an important part of enteral products they are generally a very small percentage of the total formula

Is there a clear indiction that existing constipation can be effectively resolved by increasing the intake of dietary fiber?

No, although there are reports that constipation is relieved by fiber intake, there is no definitive or consistent evidence to confirm this finding

Should antidiarrheal medications be ordered in patients with diarrhea prior to receiving Clostridium difficile test results?

No, antidiarrheal medications are not indicated in those with Clostridium difficle

Are clinically significant protein deficiencies common?

No, clinically significant protein deficiencies secondary to enterocyte amino acid transport abnormalities are very unusual. Both inherited and acquired defects exist

Is expressed human milk sterile?

No, expressed human milk is never sterile and contains a variety of normal skin flora.

Do fluid balances need to be even daily?

No, fluid gains should be in balance with fluid losses over a period of several days

Should a smaller syringe be used for feeding tubes? Why?

No, increased pressure exerted by a small syringe may cause feeding tube rupture

Should small syringes be used for feeding tube flushes? Why?

No, increased pressure exerted by a small syringe may cause feeding tube rupture

Is soy formula recommended in acute diarrhea due to gastroenteritis? Why?

No, infants with acute diarrhea associated with gastroenteritis can develop secondary lactase deficiency which would not be benefited by soy formula but rather lactose-free

Is it necessary for the patient to know the protein and calorie provision of enteral feeding prescription at discharge?

No, it can be provided if the patient wishes to have the information

Is expressed human milk sterile?

No, it is never sterile and contains a variety of normal skin flora. Contamination can occur during milk espression and storage, during the preparation and mixing of ingredients, and while assembling and handling feeding systems

Does protein and calorie provision need to be included in enteral nutrition discharge instructions?

No, it is not necessary for the patient to know the protein and calorie provision. It can be provided if the patient wishes to have this information.

Are midline catheters an approved VAD for HPN? Why?

No, midline catheters are short-term VADs typically used for therapies lasting 2-4 weeks

Is an isolated infusion area and dedicated refrigerator needed for home parenteral nutrition?

No, neither of these areas are required

Should you change to an elemental formula in patients with C.difficile?

No, once a patient is treated for C. difficile the diarrhea quickly resolves. There is no need to change to an elemental formula if there are no other indications for an elemental diet.

Should elemental formula be used with C.difficile?

No, once a patient is treated for C.difficile, the diarrhea quickly resolves. There is no need to change to an elemental formula if there are no other indications for an elemental diet.

Do all patients with wounds require zinc supplementation?

No, patients with wounds of any and all types do not necessarily require zinc supplementation but only those with a suspected zinc deficiency

Is regurgitation rare in infants?

No, regurgitation is very common in infants and does not necessarily signify a problem

Is adding fresh formula to formula already hanging in an administration set recommended?

No, should be avoided

Is soy formula recommended in children who have a cow's milk protein allergy?

No, since a high percentage of children who are allergic to cow's milk protein will also be allergic to soy protein, the AAP now recommends a trial use of either a hydrolyzed or free amino acid-containing formula

Are teenagers considered high-risk for home parenteral nutrition?

No, teenagers are typically not thought to be at high risk for problems when PN is initiated in the home setting

Are home infusion providers responsible for physical therapy?

No, while physical therapy is often appropriate for a homebound patient it is not typically the responsibility of the home infusion company

Would the diagnosis of partial small bowel obstruction qualify a person for HPN under present Medicare guidelines? Why?

No. Medicare has stringent guidelines for the use of HPN. The diagnosis of nonfunctional gastrointestinal tract is critical to ensure coverage

Is there an association between gastric residual volumes and aspiration risk?

None has been validated

Define the ethical principle of nonmalfeasance.

Nonmalfeasance relates to health care providers actively seeking to avoid harming the patient.

Does body weight below ideal indicate malnutrition?

Not necessarily

Are dressings needed for the care of feeding tube sites?

Not unless there is drainage

What is one major advantage of human milk over formula?

Nutrients in human milk (fortified or unfortified) are more readily absorbed than nutrients in preterm or term formula

Which is more readily absorbed in preterm infants human milk (fortified or unfortified) or formula (preterm or standard)?

Nutrients in human milk (fortified or unfortified) are more readily absorbed than nutrients in preterm or term formula

What is the NRI? What 2 objective criteria are used?

Nutrition Risk Index 1. Serum albumin 2. Ratio of current weight to usual weight

what should not be used to manage hypergranulation? Why?

Occlusive dressing should not be used to manage hypergranulation, may promote the retention of moisture at the exit site

What is the incidence of buried bumper syndrome in PEG tube placement?

Occurs in 0.3-2.4% of patients

How does octreotide benefit refractory diarrhea?

Octreotide reduces the production of a variety of GI secretions and slows jejunal transit

Why are older adults at increased risk of zinc deficiency? What can exacerbate this loss after a colectomy?

Older adult patients are at an increased risk of zinc deficiency at baseline primarily due to decreased intake and absorption. The insult of recent surgery and the patient's output losses via ileostomy will increase risk of zinc deficiency after a colectomy

What population is at higher risk for vitamin D deficiency? List 4 reasons why.

Older adults 1. More likely to stay indoors 2. Have reduced ability to synthesize vitamin D in the skin when exposed to sunlight 3. Use of sunscreens 4. Inadequate vitamin D intake

What population has a lower tolerance of alcohol?

Older adults have a lower tolerance of alcohol due to the effects of aging

What is the Oley Foundation?

Oley Foundation is a national, independent, non-profit organization that distributes information, organizes conference activities and provides emotional support for patients and caregivers. Families may avail themselves of the Foundation's many resources including bimonthly newsletters (Lifeline Letter), videos, regional coordinators, and an information clearinghouse

How do energy needs change with age? Why?

On average, adult energy needs decline an estimated 5% per decade. The lower energy expenditure of older adults requires that they eat less food to maintain their weights. Accordingly, the energy RDA for adults decreases slightly after age 50. Reasons: 1. People usually reduce their physical activity as they age, although they do not do so 2. Lean body mass diminishes, slowing the basal metabolic needs

When medically possible when can enteral feeds begin in neonates? What is the preferred formula?

On the day of birth, with the preferred feeding being human milk

What bone age to children with short stature typically have?

One similar to their chronological age

How much formula should be poured into an open administration set?

Only an 8-12 hour supply

Which type of medication should be crushed for administration via enteral feeding tube? Why?

Only immediate release tablets Enteric coated or film coated tablets do not crush well and tend to clump and increase the risk of clogging the tube. Modified release dosage forms (often designated with abbreviations sucha s XL, XR, SR, CD, etc) are inappropriate to crush and give via enteral feeding tube because crushing these dosage forms destroys their modified releasing properties

What type of tablets should be crushed for administration via an enteral feeding tube?

Only immediate release tablets should be crushed fro administration via an enteral feeding tube.

What type of fat is contained in standard infant formulas?

Only long chain fatty acids

Why is the hang time shorter for open system enteral feedings?

Open system enteral feeding containers are more likely to be exposed to contaminants

Which type of enteral system has a higher risk for contamination?

Open systems provide more opportunity for contamination due to nursing manipulation when adding more formula to the bag

Which type of system provides the most opportunity for contamination? Why?

Open-system due to nursing manipulation when adding more formula to the bag

What is the nutrition therapy for pediatric patients with small burns (< 20% TBSA) not complicated by facial injury, psychologic problems, inhalation injury or pre-burn malnutrition?

Oral high protein, high calorie diet

What 2 nutrients should oral rehydration fluids include?

Oral rehydration fluids used to treat diarrhea should contain both NaCl and glucose

What are metabolic bone disease complications associated with inflammatory bowel disease? Why?

Osteopenia and osteoporosis Although it is controversial whether or not the primary contributor is corticosteroid therapy, a correlation has been shown between corticosteroid dose and degree of osteopenia

Can other blue dyes such as methylene blue and FD&C Blue #2 be used in place of FD&C Blue#1 to detect aspiration in the enterally fed patient?

Other blue dyes such as methylene blue and FD&C Blue#2 may have similar or greater toxicity than Blue#1 and are not suitable alternatives

How does the protein concentration in preterm milk change?

Over time, the protein concentration decreases by 28 days of lactation

How should PN ingredients be ordered for adults?

PN ingredients shall be ordered in amounts per day for adults

How should PN ingredients be ordered for pediatric and neonatal patients?

PN ingredients shall be ordered in amounts per kilogram per day for pediatric and neonatal patients

What type of fistula is an indication for PN?

PN is indicated in patients with a high output fistula (> 500 mL/day)

Where are lipase and colipase produced?

Pancreas

What is the purpose of pancreatic enzyme therapy?

Pancreatic enzymes are used to increase nutrient absorption and decrease the presence of steatorrhea

What are pancreatic lipase, cholesterol ester hydrolase and phospholipase? What is their function?

Pancreatic enzymes involved in fat digestion. These enzymes hydrolyze triglycerides, phospholipids, cholesterol esters and fat-soluuble vitamins in the duodenum

What form of glutamine supplements are most beneficial? Why?

Parenteral glutamine supplementation is more beneficial than enteral supplementation. Enteral glutamine is protein bound and is difficult to determine the exact glutamine content

What nutrition support can increase the metabolic demand for thiamin?

Parenteral nutrition due to the glucose load

At what level of parenteral zinc dosage have adverse effects and toxicity been seen?

Parenteral zinc doses of 30 mg and greater have been shown to produce adverse effects and toxicity

What cells in the stomach are responsible for producing intrinsic factor?

Parietal cells

What patients qualify for Medicare Part B benefit for home enteral nutrition?

Patient who has a permanent non-function or disease of the structures that normally permit food to reach the small bowel or for a disease of the small bowel that impairs digestion and absorption of an oral diet. The beneficiary must require tube feeding to provide sufficient nutrients to maintain weight and strength commensurate with their overall health status. The patient's condition could be either anatomic (obstruction due to head and neck cancer or reconstructive surgery) or due to a motility disorder (dysphagia following a stroke)

Why should patients considered not-at-risk be included in the protocol for refeeding syndrome?

Patients considered not-at-risk should also be included since methods for screening "at-risk" are inadequate

What is the generally accepted treatment plan for eating disorders?

Patients require medical stabilization and nutrition rehabilitation

Which patient population cope more effectively with HPN?

Patients with chronic bowel disease seem to cope more effectively since they often see relief from frequent hospitalizations and abdominal discomfort

How do patients with compensated viral diseases, such as hepatitis B and C compare to those with ETOH disease/cirrhosis in nutrition status?

Patients with compensated viral diseases, such as hepatitis B and C are usually not severely malnourished in contrast to those with alcoholic liver disease/cirrhosis

In what patients should Clostridium difficile be ruled out in?

Patients with diarrhea who have been recently receiving antibiotic therapy

Describe the usual nutrition status in patients with nonalcoholic steatohepatitis?

Patients with nonalcoholic steatohepatitis are usually obese and malnutrition is much less common

According to safe enteral nutrition guidelines how long can a closed administration set hang?

Per manufacturers

Currently what is the most practical approach to managing micronutrients?

Perform a micronutrient assessment every 6 months

How long is recommended for peripheral PN? Why?

Peripheral PN is discouraged for use longer than 2 weeks due to the difficulty in providing adequate protein and calories and because of the difficulty in maintaining peripheral access

What is the most common complication following gastrostomy placement?

Peristomal infection

Name a relatively common post-procedural complication reported in up to 30% of tubes placed?

Peristomal infection (infection around the insertion site)

What is the most common post-procedural complication with PEG tube placement? What is the rate of occurrence?

Peristomal infection - infection around the insertion site 30% of tubes placed

How does persistent hyperglycemia in patients with type 2 diabetes lead to glucolipotoxicity?

Persistently elevated hyperglycemia affects insulin secretion. Glucotoxicity and glucolipotoxicity are closely interrelated in the sense that glucolipotoxicity does not exist without chronic hyperglycemia and chronically elevated fatty acid levels do not harm beta-cell function as long as blood glucose levels are normal

Why are cations especially Iron dextran destabilizing to total nutrient admixture (TNA)?

Phase separation and the liberation of free oil from the destabilization of TNAs can result over time when an excess of cations is added to a given formulation. The higher the cation valence, the greater the destabilizing power; thus, trivalent cations such as Fe 3+ (from iron dextran) are more disruptive than divalent cations such as calcium and magnesium. Monovalent cations such as sodium and potassium are least disruptive to the emulsifier, yet when given in sufficiently high concentrations, they may also produce instability. There is no safe concentration of iron dextran in any TNA

What is the deficiency in classic PKU? What is the consequence of this deficiency?

Phenylalanine hydroxylase, prevents the hydroxylation of phenylalanine to tyrosine which causes a build up to phenylalanine in the blood and a subsequent deficiency of tyrosine

Is physical therapy provided by the home infusion company?

Physical therapy, while often appropriate for a homebound patient, is not typically a responsibility of the home infusion company

What is a phytobezoar?

Phytobezoars may consist of indigestible plant material such as fiber, skins and seeds

What procedure is essential prior to discharging a patient on home parenteral nutrition (HPN)?

Placement of a permanent vascular access device (VAD) is essential prior to discharging a patient on HPN. Patients should not be sent home with a temporary catheter for HPN use.

What procedure is essential prior to discharging a patient on HPN therapy?

Placement of a permanent vascular access device VAD

What is the PDSA cycle?

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

What type of acute phase protein is C-reactive protein?

Positive

What is the advantage of open enteral feeding systems?

Potential for less formula wastage due to the ability to customize perparation

What is the physiological function of chromium?

Potentiates the action of insulin and has a role in glucose, protein and lipid metabolism

Why are powdered infant formulas only used in health care facilities when clinically necessary and when alternative commercially sterile liquid products are not available?

Powdered formulas are not sterile, when there are no other alternatives to infant formula powder, clinicians need to be aware of potential risks with use of powdered formulas for immunocompromised patients

How should powdered formulas be prepared? What is their shelf life? How long can they be exposed to room temperature?

Powdered formulas reconstituted in advance should be refrigerated immediately after preparation and discarded within 24 hours of preparation if not used. They should also be exposed to room temperature for no longer than 4 hours.

What are the preparation guidelines for powdered formulas? How long can they be at room temperature?

Powdered formulas reconstituted in advance should be refrigerated immediately after reparation and discarded within 24 hours of preparation if not used. they should also be exposed to room temperature for no longer than 4 hours.

When should powdered formulas be used in health care facilities?

Powdered infant formulas should only be used in health care facilities when clinically necessary and when alternative commercially sterile liquid products are not available. When there are no other alternatives to infant formula powder, clinicians need to be aware of potential risks with use of powdered formulas for immunocompromised patients.

What bone age is associated with precocious puberty?

Precocious puberty is usually associated with an advanced bone age

Define precocious puberty.

Precocious puberty is when a child's body begins changing into that of an adult (puberty) too soon. Puberty that begins before age 8 in girls and before age 9 in boys is considered precocious puberty.

What is the "ileal brake"?

Presence of fat in the distal ileum produces an inhibitor feedback effect called the "ileal brake" which slows gastric emptying and intestinal transit

What type of fat is in preterm formulas compared with standard infant formulas? Why?

Preterm formulas contain 40-50% of fat calories as MCT which are easier to absorb than long chain fatty acids as they do not require pancreatic lipase or bile salts for digestion or absorption. Standard infant formulas contain only long chain fatty acids.

What types of fat are contained in preterm infant formulas? Why?

Preterm formulas contain 40-50% of fat calories as MCTs because they are easier to absorb than LCFA as they do not require pancreatic lipase or bile sats for digestion or absroption

How does the carbohydrate content of preterm formulas compare to standard term infant formulas?

Preterm formulas contain 40-50% of the carbohydrate calories as lactose (50-60% as glucose polymers) which is a lower load of lactose to the premature infant compared to standard term infant formulas (100% lactose)

How doe premature infant formulas compare to standard term infant formulas in lactose content?

Preterm formulas contain 40-50% of the carbohydrate calories as lactose which is a lower load of lactose compared to standard term infant formulas which are 100% lactose

What percentage of carbohydrate calories are lactose in preterm formulas? What makes up the rest of carbohydrate calories?

Preterm formulas contain 40-50% of the carbohydrate calories as lactose, the remaining 50-60% are glucose polymers

Describe preterm human milk's protein concentration? What is necessary due to this?

Preterm human milk often contains a higher concentration of protein. However, the protein concentration decreases by 28 days of lactation. Human milk fortifiers should be added to human milk to meet the protein, calcium, phosphorus and sodium needs of the rapidly growing premature infant

What preventative education should be done to help prevent hypergranulation?

Preventative education should stress the need for keeping the area dry and the tube stabilized

How is tube feeding syndrome prevented and/or treated?

Prevention and treatment requires the provision of adequate fluid (30-40 mL/kg/day). A reduction in protein loads may be necessary if the ability to excrete byproducts of protein metabolism during adequate fluid provision is compromised.

Why do effects of fiber in the upper intestinal tract differ from those in the colon?

Primarily because of partial or complete fiber degradation and fermentation by colonic bacterial enzymes

What is mortality from acute diarrhea due to?

Primarily due to fluid loss and dehydration

What is mortality from acute diarrhea usually a result of?

Primarily due to fluid loss and dehydration.

What is the PINI? What 4 objective criteria are used?

Prognostic Inflammatory and Nutrition Index Inflammatory response markers: 1. Alpha-1 acid glycoprotein 2. C-reactive protein 3. Albumin 4. Prealbumin

What is the PNI? What 4 objective criteria are used?

Prognostic Nutrition Index 1. Tricep skin fold thickness measurement 2. Serum albumin 3. Serum transferrin 4. Delayed hypersensitivity skin test reactivity

Which medications (2) may be beneficial in post-operative patients with high GRVs?

Prokinetic agents (metoclopramide and erythromycin) to increase motlitiy

What medication may be used in patients with increased GRVs to help with tolerance?

Prokinetic agents such as metoclopramide and erythromycin to increase motility

What Medicare act is home parenteral nutrition (HPN) covered under?

Prosthetic device act

What do 2000 KDOQI guidelines recommend for protein delivery in peritoneal dialysis patients? Why?

Protein losses through the peritoneum take place routinely while on PD, KDOQI guidelines recommend 1.2-1.3 grams protein/kg/day in clinically stable patients Unless the patient has demonstrated stable protein status with 1.2 g/kg/d, 1.3 g/kg per day must be used

How should protein requirements be determined for parenteral nutrition

Protein requirements can be estimated initially and adjusted based on nitrogen balance studies and clinical response.

Is protein restriction a management strategy to reduce risk for developing hepatic encephalopathy?

Protein should not be restricted as a management strategy to reduce risk of developing hepatic encephalopathy. Protein requirements for the patient with hepatic failure should be determined in the same manner as for the the general intensive care unit patient per the ASPEN guidelines

How do proton pump inhibitors impact the absorption of vitamin B12? When can a deficiency be expected?

Proton pump inhibitors decrease gastric acidity and may interfere with the absorption of protein-bound dietary vitamin B12. Long term use (> 3 years) of proton pump inhibitors may cause a fall in circulating levels of vitamin B12

What is the nutrition therapy for phenylketonuria (PKU)?

Provision of a phenylalanine restricted, tyrosine supplemented diet has been shown to improve outcomes in people with this hereditary metabolic disorder

What is the treatment for PKU?

Provision of a phenylalanine restricted, tyrosine supplemented diet has been shown to improve outcomes in people with this hereditary metabolic disorder

What portion of the small bowel is dietary fat absorbed in?

Proximal small bowel: duodenum and proximal jejunum

How does psyllium impact IBS?

Psyllium (soluble fiber) has been shown to reduce incidence of involuntary stool leakage

What nutrition supplement has been shown to reduce the incidence of involuntary stool leakage?

Psyllium fiber and gum arabic supplements

What does the research say about the use of BCAA enriched formulas for refractory encephalopathy?

Published randomized trials have shown mixed results in patients with hepatic failure receiving these formulas. Due to the lack of evidence supporting their use and the increased cost of such products, it has been suggested that the use of these hepatic formulas be limited to patients with encephalopathy to standard medical therapy (i.e. lactulose, non-absorbed antibiotics)

Why is aspiration more of a concern as a complication of EN in the older adult than diarrhea, abdominal distention and leaking around the enterostomy tube insertion site although all may occur?

Pulmonary aspiration may result from reflux and is one of the most serious complications of EN. It can lead to pneumonia or death. While diarrhea, abdominal distention and leaking are undesirable, their overall impact on morbidity and mortality are not as great as that of aspiration.

What type of water is recommended for formula reconstitution? Why?

Purified/sterile water to minimize the potential of tap water as a source of contamination

How has the vitamin B6 been shown to interact with levodopa?

Pyridoxine (vitamin B6) has been shown to reverse the effects of levodopa by increasing the rate of aromatic amino acid decarboxylation. Patients who require this medication, such as patients with Parkinson Disease, should use care in selecting foods or vitamin supplements that may contain vitamin B6. These foods should not necessarily be eliminated but should possibly be restricted below usual recommendations

Based on bone health evidence what is the RDA for calcium in children 4-8 years of age?

RDA is 1000 mg/day

Based on bone health evidence what is the RDA for calcium in children and adolescents 9-18 years of age?

RDA is 1300 mg/day

Based on bone health evidence what is the RDA for calcium in children 1-3 years of age?

RDA is 700 mg/day

Why should REE measured by indirect calorimetry be used as the caloric target without addition of stress or activity factors?

REE measured under steady state conditions closely approximates true 24 hour energy expenditure. The addition of a stress or activity factor may not be necessary and could result in overfeeding

What is the formula for RQ?

RQ = CO2 produced / O2 consumed

What special requirement is needed when replacing/placing jejunostomy tubes?

Radiographic verification with contrast medium

What is the preferred treatment in an otherwise healthy infant who is mildly dehydrated from diarrhea?

Receive adequate fluid and electrolyte replacement from an oral rehydration solution. A short course of oral rehydration therapy is the preferred treatment

What does the American Academy of Pediatrics recommend in infants with acute diarrhea associated with gastroenteritis? Why?

Recommend a trial use of either a hydrolyzed or free amino acid-containing formula since a high percentage of children who are allergic to cow's milk protein will also be allergic to soy protein

What GI function may be slower than return of small bowel motility in post-operative patients?

Recovery of gastric emptying may be lower than return of small bowel motility in post operative patient

Why might small bowel feeding increase the amount of feeding delivered in postoperative patients with high GRVs?

Recovery of gastric emptying may be slower than return of small bowel motility in post-operative patients

Older adults, particularly women with reduced olfaction (sense of smell) may have what nutritional concern?

Reduced interest in cooking and consuming a variety of foods

What is the possible benefit of using soluble fiber in tube feeding?

Reducing diarrhea

How should manganese (Mn) be adjusted in TPN patients with hepatobiliary disease such as cholestatic liver disease?

Reductions in Mn should be considered. Supplemental Mn may ned to be removed from the PN solution in long-term PN patients

Define refeeding syndrome. Which electrolytes need to be closely monitored?

Refeeding syndrome describes the occurrence of electrolyte disturbances when attempting to initially feed the undernourished patient. Potassium, magnesium and phosphorus need to be closely monitored

What is refeeding syndrome?

Refeeding syndrome describes the occurrence of electrolyte disturbances when attempting tp initially feed the undernourished patient. Potassium, magnesium and phosphorus need to be closely monitored (calcium does not)

What is refeeding syndrome characterized by? When is it expected?

Refeeding syndrome is characterized by a serum depletion of phosphorus, magnesium and potassium as a result of aggressively refeeding malnourished patients

Which type of insulin should be used when initiating enteral nutrition in a diabetic patient? Why?

Regular insulin Use of short-acting (regular insulin) is typically used as tolerance and titration may be unpredictable. This type of insulin may minimize the risk of hypoglycemia resulting from continued absorption of insulin from an intermediate (premixed NPH/regular insulin, NPH insulin) or long-acting (insulin glargine) insulin product in the even that enteral nutrition is interrupted for any reason

When does regurgitation usually resolve in children? Why?

Regurgitation usually will resolve around 7-12 months of age with maturation of the lower esophageal sphincter

Under what circumstance should selenium supplementation be reduced in TPN dependent neonates?

Renal dysfunction

When would vitamin A supplementation be contraindicated? (3 patient populations)

Renal or liver failure and it should be used cautiously in the older adult.

What is the requirement for replacement of jejunostomy tube?

Replacement of a jejunostomy tube requires radiographic verification with contrast medium

Why is access to telephone required in the home environment for a patient receiving parenteral nutrition?

Require a home/cellular telephone or other means of contacting someone outside of the home in the event of a medical emergency. The appropriate health care personnel or emergency center must be contacted as soon as possible

What process has been shown most effective for understanding of discharge teaching?

Research shows that one of the most effective ways to improve understanding of discharge teaching while simultaneously addressing health literacy is the "teach-back" process

Why can resection of the ileocecal valve lead to malabsorption?

Resection of the ileocecal valve leads to decreased transit time and influx of nutrients in the large intestine which can result in malabsorption

What is the RAI?

Resident Assessment Instrument - a problem identification model used for Medicare and Medicaid certified long-term care facilities

What is RQ?

Respiratory quotient, defined as the ratio of CO2 production to O2 consumption

What is the result of prolonged nasogastric output? What is the most common electrolyte abnormality? Why?

Results in a loss of gastrointestinal secretions primarily from the stomach. Hypokalemia is a common issue with continued nasogastric output as the normal potassium concentration of gastric fluid is 10 mEq/L

What clinical presentation does SIADH cause?

Results in an increased total body water which causes a dilutional hyponatremia. Increased sodium concentrations and osmolality are seen in the urine due to excessive water reabsorption. To compensate for expansion of extracellular fluid, aldosterone secretion is inhibited while atrial natriuretic peptide (ANP) increases. These compensative responses serve to maintain euvolemia, but at the same time further worsen hyponatremia

What compounds are included in the vitamin A family?

Retinoid compounds and carotenoids

How should nutrition be continued during treatment of diarrheal illness in an infant?

Return to an age-appropriate and healthy diet early in the course of diarrheal illness is superior to providing diluted formula or clear liquids. Infants provided human milk ad lib should continue to be fed the human milk

What is the treatment for idiopathic encephalopathy associated with carnitine deficiency? What happens if it is left untreated?

Reversed with L-carnitine supplementation and restoration of carnitine serum levels. Fatalities have been reported in untreated carnitine deficiency.

What enzymes hydrolyze RNA and DNA to form mononucleotides during the digestion of nucleic acids?

Ribonuclease and deoxyribonuclease

How does small bowel bacterial overgrowth SBBO lead to fat malabsorption?

SBBO results in deconjugation of bile salts and impaired micelle formation resulting in fat malabsorption

What should be recommended in short bowel syndrome patients who have a colon to decrease risk of oxalate nephropathy?

SBS patients who have a colon should restrict dietary oxalate intake and consume high calcium foods or calcium citrate supplements

What is one of the most common cause of hyponatremia?

SIAD

Why does cystic fibrosis related diabetes occur?

Secondary to mucus obstruction of pancreatic beta cells, which prevents insulin secretion and may lead to beta cell destruction

Of the 2 options for iron deficiency anemia screening offered by the AAP (Universal screening and Selective screening) which is a better option for communities with a historically low incidence of anemia and where there are generally good infant dietary practices related to iron nutrition?

Selective Screening

What is selenium?

Selenium is active as an antioxidant and is also vital in central nervous system development in the infant

When is selenium supplementation recommended in the pediatric PN patient?

Selenium supplementation is recommended when a pediatric patient is on TPN > 1 month

In most cases what accounts for the majority of fluid losses?

Sensible losses from the GIT and kidneys

Should the home enteral nutrition patient be separated from the family during meal times?

Separation of the patient from the family during meal times may have a negative impact on the family structure, although the administration of tube feeding may not be accepted by some at the dinner table. A compromise may be necessary to meet all the family members' needs. Participation in conversations and socialization at he dinner table is encouraged. When possible in the home setting, the administration schedule should be structured to simulate normal meal times

What lab can be used to determine vitamin D adequacy? How should this lab be interpreted?

Serum 25, hydroxyvitamin D (25(OH)D) values between 21-29 ng/mL signifies vitamin D insufficiency, < 20 ng/mL is indicative of vitamin D deficiency, a level >/= 30 ng/mL is representative of adequate vitamin D stores

How often should serum iron and ferritin levels be monitored with PN supplementation for iron deficiency anemia?

Serum iron and ferritin levels should be monitored routinely every 1 to 3 months if a repletion dose is added to the PN solution to prevent iron overload

What test is used for assessing vitamin A status? Why?

Serum retinol concentration is a test used for assessing vitamin A status as it correlates well with dietary intake of vitamin A

Can serum zinc be used to diagnose zinc deficiency? Why?

Serum zinc is not a reliable indicator of zinc status. It can be within normal limits, and the patient may be in a negative zinc status. Conversely, in the setting of systemic inflammatory response syndrome zinc levels will decline and remain low until resolution of the acute phase reaction. Zinc is dependent on adequate albumin levels, so caution should be used when interpreting zinc levels in the setting of hypoalbuminemia

What is the lab marker for zinc deficiency? What can complicate its use?

Serum zinc levels are used to assess zinc status, however serum zinc levels fall in the presence of inflammation, as albumin is the primary transporter of zinc and interpretation of serum zinc levels are difficult

What does the evidence show is the preferred mode for feeding in eating disorders?

Several reviews have indicated that in the US oral refeeding is the preferred modality for nutritional rehabilitation. Enteral feeds, however, have been helpful for patients who are unable to eat, or have been unwilling to eat. In some cases, TF have been shown to significantly increase both weight and show improvement in BMI compared to oral refeeding therapy alone

What does the evidence show about wheat bran supplements in IBS?

Several studies have shown that the addition of wheat bran causes increased IBS symptoms of abdominal bloating, pain, and altered bowel habits

What does the evidence show about enteral vs. parenteral feeding strategies in severe, acute pancreatitis?

Severe acute pancreatitis has historically been considered an indication for parenteral nutrition in an effort to avoid enterally induced pancreatic stimulation; however, more recent research has demonstrated that enteral nutrition is well tolerated in severe acute pancreatitis. In a study of 38 patients with severe acute pancreatitis, enteral nutrition beyond the ligament of Treitz was compared with parenteral nutrition. Those who received enteral nutrition were less likely to develop infectious complications, maintained equal nitrogen balance and had a reduced incidence of hyperglycemia compared to those who received parenteral nutrition. The enteral feedings were well tolerated without adverse effects on the disease course. It is suggested that the enteral route be used preferentially rather than parenteral nutrition, for the patient with severe acute pancreatitis. The 2013 American College of Gastroenterology Guidelines for Management of Acute Pancreatitis recommends administration of enteral nutrition as the preferred route of nutrition support to prevent infectious complications, unless EN is not available, tolerated or patient is not meeting nutritional requirements via EN alone

What are neurologically impaired children at risk for aspiration and pneumonia from? Is medical therapy effective?

Severe gastroesophageal reflux Medical therapy for these children is not very effective, however vigorous trials of aggressive medical therapy including anti-reflux medication, proton pump inhibitors, dietary adjustments and positioning should be tried before a child undergoes an anti-reflux procedure

How is severe hypercalcemia treated?

Severe hypercalcemia is treated with saline hydration and furosemide

What should be done for any new occurrence of pain at or near the tube site?

Should be promptly evaluated by the patient's gastroenterologist or enterostomal nurse, tube complications can be a serious problem if not managed in a timely manner

When should C.difficile be sent?

Should be ruled out in any patient recently receiving antibiotic therapy, this should be done prior to ordering antidiarrheal medication since antidiarrheal medications are not indicated in those with C.diff

What nutrition should be provided to infants who are normally provided human milk ad lib?

Should continue to be fed the human milk

How should NGT be placed in a patient with head or neck pathology?

Should have direct visualization by pharyngoscopy or have the tube placed with surgeon assistance

Who should place a tube in a patient with head or neck pathology?

Should have direct visualization by pharyngoscopy or have the tube placed with surgeon assistance

Describe cyclic feeding.

Similar to the continuous infusion method, except that the rate of formula delivery increases allowing patients to meet nutrient goals with an infusion period less than 24 hours down to as few as 8 hours

What are simple carbohydrates?

Simple carbohydrates include monosaccharides (one sugar unit) and disaccharides (two sugar units)

Why is malnutrition most common in Crohn's disease vs ulcerative, microscopic or collagenous colitis?

Since Crohn's disease usually involves the small intestine, malnutrition and micronutrient deficiencies. Depending on the severity of disease, weight loss has been reported in 20-85% of those with Crohn's disease. Possible mechanisms for malnutrition in Crohn's disease include malabsorption from diseased small bowel mucosa, increased nutrient requirements from active inflammation, and reduced oral food intake due to abdominal discomfort and diarrhea

Why is liver failure associated with copper toxicity?

Since about 80% of copper is excreted in the bile, patients who have liver disease should be monitored and supplementation reduced or eliminated

How should skin care around a feeding tube site be done?

Skin care around a feeding tube site should be accomplished by cleaning with mild soap and water, rinsing and drying thoroughly. Patients should be taught to clean carefully under external bolsters to remove debris and check for excessive pressure

What is the osmolality of hydrolyzed protein and free amino acid containing infant formulas?

Slightly higher than standard due ot heir smaller particle size 330-370 mOsm/kg

What strategy may increase the amount of feeding delivered in patients with high GRVs?

Small bowel feeding

What type of long term enteral access is preferred in patients at increased risk for aspiration? Why?

Small bowel feedings are the preferred choice in patients at increased risk for aspiration. PEJ tube placement would allow delivery of nutrients into the jejunum, which may minimize the potential for reflux and aspiration. PEG feedings are an option, but aspiration risk is greater than with PEJ feedings.

What type of burns can usually be supported by an oral high protein, high calorie diet in children?

Small burns (< 20% TBSA) not complicated by facial injury, psychologic problems, inhalation injury or pre-burn malnutrition can usually be supported by an oral high protein, high calorie diet

What is the primary complication of hyperphosphatemia?

Soft tissue and vascular calcification

What can occur with long term vitamin D toxicity?

Soft tissue calcification

How does soluble fiber impact blood glucose?

Soluble fiber has been shown to have a slight decrease on plasma glucose and hemoglobin A1c

What is the evidence based recommendation for initiating enteral feeds in neonates based on the risk of NEC?

Some studies not refute the practice of withholding enteral feeds by demonstrating that early initiation of minimum enteral feeds does NOT increase the risk of NEC and shows several benefits. When medically possible, minimum enteral feeds can begin on the day of birth with the preferred feeding being human milk.

What electrolyte abnormality can occur with sorbitol administration?

Sorbitol induces hypokalemia by promoting excess potassium loss in the stool

Do soy protein-based formulas have a role in preventing allergy or managing GIT symptoms?

Soy protein-based formulas have no role in preventing allergy or in management of non-specific gastrointestinal symptoms e.g. infantile colic and regurgitation

What is the breakdown of linoleic acid to alpha-linolenic acid in soy-bean based IVFE?

Soybean oil-based emulsions contain approximately 55-60% of total calories as linoleic acid and 3-4% of calories as alpha-linolenic acid

What is the usual osmolality of standard infant formulas?

Standard infant formulas at a caloric density of 20 kcal/oz generally have a range of 200-380 mOsm/kg

What is the AAP recommendation for infants beginning at 4-8 weeks for infants not receiving human milk?

Start an iron fortified formula

Is TPN appropriate for treating mild dehydration due to diarrhea in an infant?

Starting parenteral nutrition is not an appropriate treatment option

What type of malnutrition are hypoglycemia, ketosis and lipolysis characteristics of?

Starvation-related malnutrition

Why is the metabolic response to sepsis and stress characterized by an increase in glucose production and a decrease in glucose uptake? What is recommended?

Stress hormones induce insulin resistance and hyperglycemia is commonly observed with nutrition support. It is recommended that glucose levels be adequately controlled to avoid polyuria and electrolyte disturbances

What type of malnutrition are hyperglycemia, hypermetabolism and lipolysis characteristics of?

Stress-related malnutrition

What may result with high dose pancreatic enzyme therapy?

Strictures of the ascending colon, also known as fibrosing colonopathy

What is the evidence for fiber usage to resolve diarrhea in tube fed patients?

Studies lack clear definitions of diarrhea and its incidence to conclude that dietary fiber reduces diarrhea in tube-fed patients

What does length for age in the Waterlow criteria represent?

Stunting due to chronic malnutrition

What was the conclusion of the IOM thorough review of the evidence for both skeletal and extraskeletal outcomes in an effort to determine population needs for calcium and vitamin D?

Sufficient evidence exists to support a cause-and-effect relationship between calcium and vitamin D and skeletal health. Evidence was inconsistent for extraskeletal outcomes, including cancer, cardiovascular disease, diabetes, and autoimmune disorders

What can be done for bezoar if they do not respond to treatment?

Surgery can be performed to remove the bezoar

In a 50 year old male weighing 80 kg how do you calculate the fluid in each compartment?

TBW: 48 L (80 x .6) Extracellular fluid: 16L (1/3 x 48) Intravascular space: 4L (1/4 x 16)

What does research show is the most effective way to improve understanding of discharge teaching while simulatenously addressing health literacy?

Teach back process

What do more recent studies on caloric beverages (milk, juice, sweetened beverages) consumed by children show?

That these beverages were complementary to each other and that more of a focus needs to be on total caloric intake for weight management and promoting balanced nutrient intake. Other recent findings claim that over consumption of juice in particular is not necessarily associated with decreased intake of milk and other food groups, however it remains important to adhere to age appropriate recommendations for such beverages to ensure that proper nutrition is practiced.

What have studies int he past indicated is a result of increased intake of juices, sodas and sweetened beverages by children?

That they are at higher risk for deficiencies in mineral such as magnesium and calcium due to the corresponding decrease in consumption of beverages like milk that promote bone health. Increased consumption of these caloric beverages has also been associated with obesity risk in the population.

What has evidence shown about glutamine supplementation?

The "reducing deaths due to oxidative stress" (REDOX) trials did not provide evidence supporting glutamine supplementations effectiveness to reduce mortality and nosocomial infections in critically ill patients. A recent meta-analysis investigated the impact of glutamine-supplemented nutrition on the outcomes of critically ill patients and found that glutamine supplementation conferred no overall mortality and length of hospital stay benefit in critically ill patients. However, glutamine supplementation did reduce nosocomial infections among critically ill patients

What is the AAP recommendation for milk intake?

The AAP also states that drinking 3 8 ounce glasses of milk per day (or equivalent in other non-dairy sources) will achieve the recommended adequate intake of calcium in children 4-8 years of age and four 8-10 ounce glasses of milk (or equivalent) will provide the adequate calcium intake for adolescents

How much milk (or milk equivalents) does the AAP recommend in children 4-8 years old to provide adequate calcium? How much is recommended in adolescents?

The AAP also stats that drinking 3 8 ounce glasses of milk per day (or equivalent in other non-dairy sources) will achieve the recommended adequate intake of calcium in children 4-8 years of age and 4 8-10 ounce glasses of milk or equivalent will provide the adequate calcium intake for adolescents

What does the AAP recommend as an initial step in an infant who is showing sings of intolerance on an exclusively cow's milk based formula? Why?

The AAP now recommends a trial use of either a hydrolyzed or free amino acid containing formula. Since the child could have a cow's milk protein allergy, a correct initial response would be to switch to a protein hydrolysate or free amino acid formula since a percentage of children who are allergic to cow's milk protein will also be allergic to soy protein

What are the age appropriate recommendations for juice in children 1-6 years of age? 7-18 years of age?

The AAP suggests 4-6 ounces of 100% juice per day in children 1-6 years of age, and up to 12 ounces per day in children ages 7-18 years old

What is the acceptable macronutrient distribution range (AMDR)?

The AMDR is defined as a range of intake for a particular energy source that is associated with a reduced risk of chronic disease while providing adequate intakes of essential nutrients

What is the AAP recommendation for juice intake?

The American Academy of Pediatrics (AAP) suggests 4 to 6 ounces of 100% juice per day in children one to six years of age and up to 12 ounces per day in children ages seven to eighteen years old

What is the body surface area (BSA) method for calculating fluids based on?

The BSA is based on the assumption that caloric expenditure is proportional to BSA

What is the BSA method for calculating fluid needs based on?

The BSA method is based on the assumption that caloric expenditure is proportional to BSA.

What is the law behind SNS provision?

The Cruzan case, the US Supreme Court assumed that a competent individual has the same right to refuse life-sustaining treatment (including nutrition and hydration by medical means) as to refuse any other kind of medical intervention. Where evidence of an incompetent person's previously expressed wish not to be kept alive by medical technologies meets state evidentiary standards, the exercise of that choice by a surrogate decision-maker must also be honored

How was the 2010 Institute of Medicine recommendation that available scientific evidence supports a key role of calcium and vitamin D in skeletal health developed?

The IOM conducted a thorough review of the evidence for both skeletal and extraskeletal outcomes in an effort to determine population needs for calcium and vitamin D. The committee concluded that sufficient evidence exists to support a cause-and-effect relationship between calcium and vitamin D and skeletal health. Evidence was inconsistent for extraskeletal outcomes

What is the Mini Nutritional Assessment (MNA)?

The MNA fulfills many criteria for both screening and diagnostic measures, having been developed and validated on large representative groups of older adults worldwide. It is complex and lengthy (18 items and special anthropometric measures required)

Why was the MNA-SF developed?

The MNA's complexity and length (18 items, special anthropometric measures required) impede its use as a brief screening tool. The shortened version of the MNA (MNA-SF) eliminates time-consuming and subjective items and can be administered in less than 5 minutes, while preserving the high diagnostic accuracy relative to clinical nutrition status and high correlation with the MNA

Who is the MNA-SF recommended for?

The MNA-SF is recommended for widespread screening of undernutrition in older adults, with those identified "at risk" receiving additional assessment for diagnosis confirmation and appropriate interventional planning

Which predictive equation is shown to be the most accurate?

The Mifflin-St Jeor equations have demonstrated the greatest accuracy with healthy obese and non-obese people when compared to the Owen equations and Harris-Benedict equations using either adjusted or actual body weight

What is the RDA for vitamin D based on?

The RDA for vitamin D was determined based on conditions of minimal sun exposure due to the variability of vitamin D synthesis in the skin from ultraviolet light and the risks of skin cancer

Describe the Swinamer Equation.

The Swinamer Equation uses body surface area to predict resting metabolic rate RMR = EE = 945 (BSA) - 6.4 (age) + 108 (T) + 24.2 (breaths/min) + 81.7 (VT) - 4349 EE = energy expenditure BSA = body surface area T = temperature in degrees Celsius VT = tidal volume

Due to functional age-related changes in the GIT absorption of which nutrients may be reduced?

The absorption of certain nutrients such as calcium, iron, vitamin D and others may be reduced

What is the incidence of aspiration caused by enteral nutrition in critically ill children?

The actual incidence of aspiration directly caused by enteral nutrition is difficult to determine because there have not been standardized definitions of what constitutes aspiration, nor have there been adequate descriptions in all studies of the actual cause of aspiration in each particular patient

How does the acute phase response impact iron transport?

The acute phase response to injury and infection suppresses iron transport

What is the purpose of ketone metabolism in starvation?

The adaptation to starvation with a ketone-based fuel system minimizes gluconeogenesis and further protein breakdown

Should recommendations for laboratory monitoring be included on the PN order form?

The addition of recommended laboratory monitoring to PN order forms is strongly recommended, but it is not required

How does the labeled amount of aluminum on PN products compared to the measured amount?

The amount on the label has been shown to be approximately 10 times more than what was actually measured in a PN bag prepared according to a patient's prescription

When does the anabolic phase of the metabolic response to critical illness occur? How long does it last?

The anabolic phase of the stress response occurs after the acute phase response has resolved and can last for months

How much fluid does the average health adult require to maintain fluid balance?

The average healthy adult will require 30-40 mL/kg/day

What is the average nitrogen content of protein?

The average nitrogen content of protein was determined to be 16%

How is bone age evaluated?

The bone age is evaluated by a radiography of the patient's knees or left wrist. Using established norms for different ages and sexes, a trained observer can estimate the degree of maturation of the bones

After approximately 2 days of starvation what important metabolic adaptation occurs?

The brain switches its fuel source from glucose to ketone bodies

When does glycogenolysis begin?

The breakdown of hepatic glycogen stores (glycogenolysis) for glucose production begins within 2-3 hours of fasting, but its stores are depleted within 24 hours

When does the catabolic phase of the metabolic response to critical illness occur? What is the usual duration?

The catabolic phase occurs after resuscitation and usually lasts for 7 to 10 days

How does the colon produce short chain fatty acids?

The colon can convert by fermentation complex carbohydrates to short chain fatty acids

Why are patients lacking a colon at a greater risk of dehydration?

The colon has critical roles in fluid and nutrient absorption

How does the colon salvage calories?

The colon is capable of salvaging calories through anaerobic bacterial fermentation of undigested carbohydrates into absorbable short-chain fatty acids (SCFAs)

Why does sorbitol ingestion lead to diarrhea in enterally fed patients when it is not an ingredient of enteral products?

The cumulative daily dose of sorbitol from liquid medications can easily equal purgative dosages

What is the purpose of cyclic feeding regimens?

The cycle allows freedom from the feeding equipment for a few hours each day and ensures that nutrient requirements are met. Cyclic feedings during the night are frequently used as patients are transitioning from Enteral feeds to oral intake. Time off the tube feeding during the day often increases appetite.

What was the Waterlow criteria developed to determine?

The degree of malnutrition in children

Why is a main strategy for reducing the risk of NEC to withhold enteral feeds for prolonged periods of time?

The development of necrotizing enterocolitis (NEC) is a concern in the neonate, although the etiology of NEC remains unclear it often occurs in infants who are being fed via the gastrointestinal tract

What is the preferred iron formulation for PN dosage? What should be done before it is administered?

The dextran formulation, or bound iron, is preferable to other forms of IV iron to add to PN. Iron dextran may be added to dextrose and amino acid PN solutions only after the patient has been given a test dose of iron dextran to evaluate tolerance and avoid anaphylactic reactions

What must be documented in the medical record to qualify a patient for HPN under present Medicare guidelines?

The diagnosis of nonfunctional gastrointestinal tract, an enteral tube feeding trial must be attempted and shown to fail or explain why a feeding tube is not an option

What can the dietitian recommend in the event the patient cannot afford the cost of their enteral formula?

The dietitian may be able to recommend an alternate formula or store brand that is less expensive. Other options for financial assistance include nonprofit organizations or indigent care.

Where are the primary sites of cholecystokinin and secretin secretion?

The duodenum and jejunum

Describe the ebb response following burn injury.

The ebb response following burn injury lasts 3-5 days and includes depressed energy expenditure, hyperglycemia, low plasma insulin, loss of plasma volume, decreased oxygen consumption, decreased blood pressure, reduced cardiac output and decreased body temperature

What is the risk of enamel fluorosis in infants drinking reconstituded infant formula related to?

The estimated risk of enamel fluorosis related to fluoride intake from reconstituted infant formula is positively associated with the fluoride concentration in the drinking water

What is the etiology of NEC?

The etiology of NEC remains unclear, it often occurs in infants who are being fed via the gastrointestinal tract

What PN associated disease is thought to have a component of aluminum toxicity?

The etiology of PN associated bone disease is multifactorial and aluminum toxicity is only one of many potential contributors

Who should perform the first replacement of gastrostomy and PEG tubes? What about subsequent replacements?

The first replacement should be typically performed by the physician who inserted the tube after that, it is appropriate for trained nurses to replace these tubes

Why is soy or hyoallergenic formula recommended in galactosemia vs. lactose-free cow's milk?

The galactose content (approximately 20 mg/L) of lactose-free cow's milk infant formula is considerably higher than soy and hypoallergenic formulas; therefore lactose-free cow's milk formula is not recommended for treatment of galactosemia

How does location in the GI impact fistula output?

The higher the fistula occurs in the gastrointestinal tract, the greater the output and the higher the risk of metabolic derangements, as seen with proximal high output fistulas.

What is the Tolerable Upper Intake Level?

The highest level of daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population

What is the function of glucose-dependent insulinotropic polypeptide (GIP)?

The hormone GIP stimulates insulin secretion from the pancreas

How can refeeding syndrome impact weaning from mechanical ventilation?

The hypophosphatemia associated with refeeding syndrome can intensify respiratory dysfunction and diaphragmatic weakness, leading to difficulty in ventilator weaning

What is the purpose of the EN formula label requirements?

The importance of providing this information ensures the patient is receiving the formula ordered and that the infusing formula is not expired or exceeding the recommended hang time

How does overfeeding in pulmonary insufficiency lead to respiratory acidosis?

The increased metabolism of glucose (oxidation and lipogenesis) increases CO2 production. This may result in increased blood pCO2 if pulmonary insufficiency is significant. According to the Henderson-Hasselbach equation, this will result in a decrease in pH. If compensatory retention and increase in bicarbonate ion do not occur the pH may remain < 7.35. This is a condition of respiratory acidosis. The increased CO2 production is greatest when overfeeding occurs (2 x BEE). Lipogenesis, the synthesis of fat from glucose, produces 6 to 8 times more CO2 than the oxidative process (energy production).

Describe the inflammatory response following a traumatic injury.

The inflammation following a traumatic injury provokes a release of systemic catabolic hormones like epinephrine, glucagon and cortisol from the hypothalamus. These hormones are responsible for glycogenolysis, gluconeogenesis, proteolysis and free fatty acid release. The goal of the metabolic response by the patient is to maintain survival, homeostasis and promote recovery

When does the competitive interaction between zinc and copper occur?

The interaction between zinc and copper occurs when taken through the GI tract, not when infused intravenously

Where is the primary site of absorption of most nutrients (including water soluble vitamins)?

The jejunum

Why are patients with renal failure at increased risk for aluminum toxicity?

The kidneys are responsible for unbound aluminum excretion. The majority of aluminum in the blood stream is bound to protein, primarily transferrin and cannot be excreted

How do burns impact metabolism?

The metabolic stress that occurs in burn injury generates a hypercatabolic state that increases energy expenditure

Describe monosaccharides solubility.

The monosaccharides are water soluble and have low molecular weight

What should be done every time a nutrient is omitted or added to standard micronutrient recommendations?

The patient should be monitored for a potential deficiency or toxicity that could develop over time

How does the presence of glucose in the lumen of the small intestine impact sodium absorption?

The presence of glucose facilitates sodium absorption. Glucose is co-transported wit sodium in the small intestine enhancing both sodium and water uptake.

How does the prevalence of chronic cholestasis correlate with longer duration of PN usage?

The prevalence of chronic cholestasis in patients with intestinal failure has been observed to increase with longer duration of PN usage

In the event that an incompetent individual has an advance directive regarding artificial nutrition and hydration how should the decision be made using ethical principles?

The principle of autonomy ( based on respect and upholding the patient's right to self determination) should guide the health care team in making a decision regarding artificial nutrition and hydration. If an advance directive is not available, the principles of beneficence (health care providers actively seek the good of the patient) and nonmalfeasance (health care providers actively seeking to avoid harming the patient) are more central.

How are modular products prepared?

The products can be mixed with water according to package directions and administered via the feeding tube or they may be mixed with enteral formulas, supplements or food

What act of Medicare covers HPN?

The prosthetic device act

What should be included in the refeeding syndrome electrolyte replacement protocol?

The protocol should replete all electrolytes via the intravenous, oral or feeding tube route depending on the condition of the patient

What is necessary for infused nutrients prior to indirect calorimetry measurement?

The rate and composition of nutrients being infused on a continuous basis should be stable for at least 12 hours for an accurate study

What determines the rate of ketogenesis during starvation?

The rate of ketogenesis is determined by the supply of fatty acids and the regulation of fatty acid oxidation, which is promoted by low circulation of insulin concentration

How does the electromagnetic placement device show the NGT placement?

The receiver is placed on the patient at the xiphoid process therefore the magnet follows the tip placement relative to the lower esophageal sphincter (not the pylorus)

What are the current recommendations for vitamin D supplementation in infants? Why?

The recommendations to ensure adequate vitamin D status have been revised to include all infants, including those who are exclusively breastfed. It is now recommended that all infants have a minimum daily intake of 400 IU of vitamin D beginning soon after birth There are limited natural dietary sources of vitamin D and adequate sunshine exposure for the cutaneous synthesis of vitamin D is not easily determined for a given individual and may increase risk of skin cancer

What should be done with the result of nutrition screening?

The result of the nutrition screen shall be documented. Patients identified on initial screen as nutritionally-at-risk shall be referred to the provider for further orders regarding nutrition assessment and intervention. Patients identified as not nutritionally at risk shall be re-screened at regularly specified intervals or when their clinical or nutrition status changes

What is the limiting factor for amounts of calcium and phosphorus provided by PN solution?

The risk of calcium-phosphate precipitation

Why are patients with ileostomy at risk for hyponatremia?

The sodium content of ileostomy output can be as high as 120 mEq/liter. Hyponatremia can result when fluid replacement does not contain adequate sodium to correct for ileostomy losses.

Why can gastric feedings be delivered by bolus and intermittent methods?

The stomach serves as a reservoir thus delaying the rapid emptying of formula into the small bowel

Describe the "teach back" process.

The teach back process is an active process in which the learner can demonstrate health care skills and verbalize home care instructions. This process allows the educator to verify understanding, to correct inaccurate information, and to reinforce new home care skills

Why is it important to replace a jejunostomy tube immediately?

The tract for the jejunostomy tube can close quickly

Why does the dislodged jejunostomy tube need to be replaced immediately?

The tract for the jejunostomy tube closes quickly

When does the adaptive phase occur after burns?

The transition from acute to adaptive phase of the flow response is gradual

What is the evidence for the use of fiber to treat constipation?

The use of fiber to treat constipation although theoretically sensible has not consistently been shown to improve bowel function

What impacts the viscosity of an enteral formula?

The viscosity of a formula depends on the concentration and characteristics of the macronutrients and fiber

What is the theory behind use of BCAA enriched formulas in refractory encephalopathy?

Theoretically, there is believed to be an increased ratio of aromatic amino acids (AAA) and branched-chain amino acids (BCAA) in patients experiencing hepatic encephalopathy. The decrease in BCAA is suspected to be due to an increased breakdown in BCAA from skeletal muscles and utilization. The increased levels of AAA generate false neurotransmitters, resulting in hepatic encephalopathy symptoms. Enteral formulas with higher amounts of BCAA and less AAA are available.

What is the purpose of therapeutic intervention during the inflammatory response following a traumatic injury?

Therapeutic intervention is geared toward blunting the inflammatory response without making the patient susceptible to immunosuppression

What is the evidence for discontinuing enteral feeds when 66% of nutrient needs are met PO?

There are no clinically proven points at which tube feeding should be discontinued with adequacy of oral intake, a general guideline is that oral intake should meet at least 66% of nutrient intake

What are the guidelines for when treatment of diarrhea should begin?

There are no definite guidelines on when treatment for diarrhea should begin . However, stool output greater than 500 mL/day for 2 consecutive days should be evaluated with intervention started to reduce the risk of volume depletion and electrolyte deficiencies

What are the indicators of chromium deficiency?

There are no known reliable indicators of chromium status

What is the current evidence on hypermagnesemia in PN patients?

There are several published reports of hypermanganesemia, some symptomatic, and some not, in patients on long-term PN

Although the preferred treatment for hyperemesis is enteral feeds what is the disadvantage?

There is a risk for aspiration if the patient cannot tolerate the feeds and continues to vomit

What are the current recommendations for probiotics and prebiotics in IBD?

There is currently a growing interest in the role of prebiotics and probiotics in the management of patients with IBD. However, there are no evidence-based recommendations for using prebiotics and probiotics as standard therapy with diarrhea

What is the current evidence for soluble fiber lowering the risk of colon cancer?

There is currently no clear evidence to support that soluble fiber lowers the risk of developing colon cancer or reducing risk of developing colon cancer or reducing recurrence of adenomas

What is the major advantage of ethanol as a lock solution?

There is no known microbial resistance to ethanol

What is the role of oxalic acid in metabolic bone disease?

There is no known role

What is the role of soy protein-based formulas in preventing allergy or in management of non-specific gastrointestinal symptoms (infantile colic and regurgitation)?

There is no role for soy protein formula in non-specific gastrointestinal symptoms

Why is hyperlipidemia a consequence of vitamin D deficiency?

There is potential for hyperlipidemia given the need for vitamin D in lipid cell membranes formation

Why is timing of fiber and medications important?

There may be an association between the intake of dietary fiber and decreased effectiveness of some medications, administration should be spaced apart

How does the Waterlow criteria determine the degree of malnutrition in children?

These categorization systems compare actual weight and length with expected standards (for example the 50% on the CDC growth chart). Degree of undernutrition is divided into 4 levels: normal, mild, moderate and severe. The Waterlow criteria take into account both weight and length. Weight for length is evaluated as an index of wasting due to acute malnutrition. Length/age is evaluated as an index of stunting due to chronic malnutrition.

What are the Waterlow criteria?

These categorization systems compare actual weight and length with expected standards. Degree of undernutrition is divided into 4 levels: normal, mild, moderate and severe. The Waterlow criteria take into account both weight and length. Weight for length is evaluated as an index of wasting due to acute malnutrition. Length/age is evaluated as an index of stunting due to chronic malnutrition.

Why do open system enteral feedings have a shorter hang time?

They are more likely to be exposed to contaminants

What do the PINI, NRI and PNI have in common?

They are prognostic indices that include objective measures of nutrition status

What is the purpose of modular products?

They increase the protein, calorie or fiber content of the feeding regimen

What vitamin deficiency can cause neuropathy but not anemia?

Thiamin deficiency

How does thiamin deficiency present in heart failure? What is the treatment?

Thiamin deficiency in the form of wet beriberi is characterized by an enlarged heart, nonspecific electrolyte alterations, profound vasodilation and peripheral neuritis. Symptoms of heart failure secondary to wet beriberi have been shown to improve fairly rapidly in response to thiamin supplementation in tablet or injection form

Why would a thiamin deficiency result in a lactic acidosis?

Thiamine is necessary for the metabolism of glucose, specifically, the conversion of pyruvate to acetyl CoA. In the absence of thiamine, pyruvate is converted to lactic acid

Why don't many third party payers cover the cost of enteral formula?

Third party payers equate the costs of enteral formulas to "groceries" and do not cover this expense, while they will cover the costs of an enteral pump and supplies

Why is the preferred approach for subcutaneous insulin administration is basal-bolus insulin therapy?

This approach allows for basal insulin administered for hepatic glucose output combined with scheduled bolus insulin administered for meal times. There are three components to basal-bolus insulin therapy: basal insulin, nutritional component prior to meals and a correctional insulin

Why are PN ingredients ordered in amounts per day for adults and amounts per kilogram per day for pediatric and neonatal patients?

This limits the confusion of conversion from amounts per liter, percent concentration or volume. Amount per day refers to macronutrients in grams per day and micronutrients in mEq, mmol, mcg or mg per day.

Name another group of patients (besides head and neck pathology or patients going to OR) who should not have blindly placed NGT?

Those s/p gastric bypass surgery

Is growth the goal of post-operative neonatal nutrition?

Though growth is often the primary goal in neonatal nutrition, growth cannot occur until recovery from the stress response has begun

What is thought to be the purpose of sequestering of iron into storage form following injury and infection?

Thought to have several protective measures for the host. It reduces the availability of iron for microorganism proliferation and also reduces free radical production and oxidative damage to membranes and DNA

What is the focus of metabolic support during the catabolic phase of the metabolic response to critical illness?

Tight glucose control and ongoing metabolic support

What is top priority for intervention following a traumatic injury?

Timely resuscitation, including restoration of perfusion, oxygenation and hemodynamic stability

Why must vascular access devices (VADs) for home parenteral nutrition be placed in the central venous system?

To accommodate the hyperosmolar HPN solutions

What is the purpose of the recertification process for parenteral nutrition by Medicare?

To document the patients continued need for therapy

What is the only way to treat galactosemia?

To eliminate galactose from the diet. Soy based infant formulas are used as substitutes for milk in galactosemia. The galactose content (approximately 20 mg/L) of lactose-free cows milk infant formula is considerably higher than soy and hypoallergenic formulas

Why is it vital for the patient and health care providers to understand the benefits provided by the patient's insurance coverage?

To ensure compliance with reimbursement and to contain the cost of treatment.

Why is the education, training and evaluation of patient/caregiver competency an important part of a quality teaching program?

To facilitate patient and provider independence

What is the role of pancreatic enzymes?

To increase nutrient absorption and decrease the presence of steatorrhea

Why is jejunal feeding usually delivered by a continuous pump?

To minimize diarrhea and abdominal bloating

Why is jejunal feeding delivered by continuous pump? Why is this necessary?

To minimize diarrhea and abdominal bloating. Gastric feeding can be given by the bolus or intermittent gravity methods. The stomach serves as a reservoir thus delaying the rapid emptying of formula into the small bowel

What is the purpose of published safe enteral nutrition guidelines?

To minimize the risk of enteral nutrition formula contamination during the production, preparation, storage and administration processes

Why should holding of feedings be minimized?

To optimize meeting calorie and protein needs

Why is the rate-limiting enzyme phophofructokinase necessary?

To prevent further breakdown of glucose and allow the cell to divert glucose to be stored as glycogen for later use

Why is calcium supplementation recommended in SBS?

To reduce the risk of calcium-oxalate nephrolithiasis by competing with fatty acids in the lumen to bind oxalate

Are transitional infant formulas sufficient in iron for premature babies?

Transitional infant formulas are fortified with sufficient iron to meet the needs of infants with a history of prematurity

Describe the transitional infant formula as a source of iron.

Transitional infant formulas are fortified with sufficient iron to meet the needs of infants with a history of prematurity

How are glucose and galactose transported into the enterocyte?

Transported from the intestinal lumen into the enterocyte via the sodium-glucose transporter 1 (SGLT-1) an ATP dependent active transporter

What is the best way to determine if the patient is chromium deficient?

Treating hyperglycemic patients with chromium supplementation and observing for resolution of symptoms empirically is the best way to determine fi the patient was chromium deficient

In what situations is tricep skinfold thickness not reliable?

Tricep skinfold may be falsely elevated with edema, and may not be reliable in obese patients

What is an abnormal tricep skinfold thickness?

Tricep skinfold thickness below the 5th percentile is abnormal in hospitalized patients

What is a side effect of Trimethoprim use?

Trimethoprim induces hyperkalemia by impairing renal potassium excretion. The use of trimethoprim in a patient with renal insufficiency may likely cause hyperkalemia.

Describe tube feeding syndrome.

Tube feeding syndrome is related to se of high protein tube feedings with inadequate fluid provision. Inadequate fluid delivery results in an inability to sufficiently excrete the solute load which can lead to the development of azotemia, hypernatremia and dehydration. Prevention and treatment requires the provision of adequate fluid (30-40 mL/kg/d meets fluid requirements for the average adult)

Define tube feeding syndrome.

Tube feeding syndrome is related to the use of high-protein tube feedings with inadequate fluid provision. Inadequate fluid delivery results in an inability to sufficiently excrete the solute load which can lead to the development of azotemia, hypernatremia and dehydration.

What is tubefeeding syndrome?

Tube feeding syndrome is the development of azotemia, hypernatremia and dehydration related to the use of high protein tube feedings and inadequate fluid provisions

What is tumor lysis syndrome (TLS)?

Tumor lysis syndrome (TLS) is caused by massive tumor cell lysis with release of large amounts of potassium (hyperkalemia), phosphate (hyperphosphatemia) and nucleic acids into the systemic circulation. Catablism of the nucleic acids to uric acid leads to hyper uricemia. TLS most often occurs after the initiation of cytotoxic therapy.

How does tumor lysis syndrome impact serum phosphate?

Tumor lysis syndrome can result in high serum phosphorus levels

What is the influence of dietary fiber on total oral to anal transit time dependent on?

Type and source of fiber

When is the usual onset for infantile anorexia?

Typically occurs between 6 months to 3 years of age and often occurs during the transition to spoon- and self-feeding

Who should perform the first replacement of a gastrostomy or PEG tube? What about subsequent replacements?

Typically performed by the physician who inserted the tube, after that it is appropriate for trained nurses to replace these tubes

What is the etiology of gastric ulceration with PEG tube placement?

Ulceration of the gastric mucosa is caused by excessive tension between the external and internal bolster which leads to erosion and bleeding

How should celiac disease be diagnosed once symptoms are identified? What is required for a formal diagnosis?

Upon symptom identification gluten need to remain in the diet until after serology testing and biopsy are completed. Intestinal biopsy is needed for formal diagnosis

What should be done upon symptom identification of celiac disease?

Upon symptom identification gluten needs to remain in the diet until after serology testing and biopsy are completed. Intestinal biopsy is needed for formal diagnosis

When determining nitrogen balance using urinary urea what assumption is this approximation based on? Why is this an assumption? What is a more reliable measure?

Urea accounting for about 80% of total urinary nitrogen losses Urinary urea nitrogen concentration is affected by stress and increased urinary excretion of non-urea nitrogen Nitrogen balance determined with total urinary nitrogen is consistently more reliable

How is a urinary urea nitrogen calculated?

Urine is collected for a 24 hour period in order to quantify the amount of urinary urea nitrogen

What marker is used primarily to monitor protein intake during nutrition support?

Urine urea nitrogen

What are current recommendations for checking gastric residual volumes?

Use a large-bore feeding tube and a 60 mL syringe to check GRVs the first two days of feeding

Once enteral nutrition administration is stable what type of insulin regimen should be used?

Use of a basal/bolus insulin regimen is recommended to achieve safe, effective glucose control

Why is a concentrated enteral formula recommended for nutritional management of chronic lung disease?

Use of a concentrated formula allows for provision of adequate nutrition while restricting fluid intake. Fluid restriction is indicated due to fluid build up around the heart and lungs?

What type of formula is recommended in infants with chronic lung disease? Why?

Use of a concentrated formula allows for provision of adequate nutrition while restricting fluid intake. The use of low carbohydrate formulas, hydrolyzed protein formulas, or MCT oil predominant formulas are not indicated for use in treatment of chronic lung disease fluid restriction is indicated due to fluid build up around the heart and lungs

Are acidic liquid medications recommended enterally? Why?

Use of acidic liquid medications is not recommended, may result in protein denaturation

What can result from the administration of enteral acidic liquid medications?

Use of acidic liquid medications may result in protein denaturation and are therefore not recommended

When should octreotide be used? Why?

Use of octreotide should be reserved for patients with large volume stool losses in whom fluid and electrolyte management is problematic and should be avoided in the early adaptation stage due to an increased risk for cholelithiasis, expense and the potential for octreotide to inhibit bowel adaptation. Its effects are often short lasting and have not been shown to improve absorption or lead to the elimination of the need for parenteral nutrition

How often should closed enteral systems be changed?

Use the manufacturer recommendations. Closed system EN can be safely used for 24-48 hours after opening, depending on manufacturer's guidelines.

What is the recertification process for after the initial certification of parenteral nutrition by Medicare for?

Used to document the patient's continued need for therapy, additional re-certifications may be requested on an individual bases

What is the use of loperamide?

Used to slow intestinal transit

Where are vascular access devices placed? Why?

VADs must be placed in the central venous system to accommodate the hyperosmolar HPN solution

What value of selenium erythrocyte concentration is indicative of a deficiency

Values < 10.5 U/mL

What is the most likely cause of diarrhea leading to mild dehydration in an infant?

Vital gastroenteritis that will resolve in 72-96 hours

Why is vitamin A important in wound healing?

Vitamin A has multiple functions in wound healing including cellular differentiation, enhancement of epithelialization and collagen synthesis

What vitamin deficiency can cause anemia and peripheral neuropathy?

Vitamin B12

What is is required for B12 absorption?

Vitamin B12 requires intrinsic factor for absorption. Intrinsic factor binds to B12 and is taken up by receptors in the distal ileum. Vitamin B12 is released from proteins by HCl and pepsin, binds with intrinsic factor, and is taken up by receptors in the distal ileum.

What vitamin deficiency is associated with hypocalcemia, osteomalacia and osteoporosis?

Vitamin D

What vitamin deficiency is considered a worldwide epidemic?

Vitamin D deficiency

Why should vitamin K be closely monitored in patients on 3-in-1 PN and warfarin therapy?

Vitamin K is in adult multivitamin formulations. Vitamin K is also found in lipid emulsions. Vitamin K can partially reverse the effects of Warfarin. The INR should be monitored closely with transitioning on or off PN in patients on Warfarin

What is the other nutrition concern when supplementing oral consumption products vs. enteral products?

Vitamins, although an important part of enteral products, are generally a very small percentage of the total formula

Are vitamins, minerals and water considered modular products?

Vitamins, minerals and water are required nutrients but are not considered modular products

What does weight for length in the Waterlow criteria represent?

Wasting due to acute malnutrition

What is the preferred flush solution to maintain feeding tube patency?

Water

What is the preferred way to prevent feeding tube occlusion?

Water is the flush of choice, 2 reports have demonstrated superiority of prophylactic use of pancreatic enzymes to prevent tube occlusion compared to standard water flushes

What outputs are considered in insensible losses? How can they be estimated?

Water output from the feces, skin and lungs is considered insensible loss Estimated at approximately 10 mL/kg/day

Which has been shown to better irrigate feeding tubes and maintain patency, cranberry juice or water?

Water was found to be superior to cranberry juice as an irrigant to maintain feeding tube patency in several clinical trials

What is used as an index of wasting due to acute malnutrition in children?

Weight for Length

What is the impact of Wheat Bran (insoluble fiber) on IBS?

Wheat Bran (insoluble fiber) actually seems to increase symptoms of abdominal pain and bloating in IBS

Under what conditions is phophofructokinase inhibited?

When ATP is plentiful

According to safe enteral nutrition guidelines where should enteral formulas be prepared?

When possible enteral formulas should be mixed, reconstituted or diluted in a centralized location, such as an enteral formulary room or pharmacy to minimize the risk of contamination

At what calcium-phosphorus product does metastatic and vascular calcification of non-skeletal tissue occur?

When the calcium-phosphorus product exceeds 55 mg2/dL2

How do colocutaneous fistulas occur with PEG placement? What is the prevalence?

When the colon is inadvertently punctured during placement, occurs in only 0-0.27% of cases

Why is B12 deficiency a concern after gastrectomy?

When the stomach is resected there is no longer adequate intrinsic factor to bind with B12 (parietal cells in the stomach are responsible for producing intrinsic factor, which under normal circumstances binds with B12 and aids in the absorption of B12 n the small bowel)

Which of the following tube feeding orders best reflects the use of an intermittent schedule? 1. 240 mL administered over 45 minutes, 5xs per day 2. 50 mL/hour over 24 hours 3. 100 mL/hour over 12 hours 4. 120 mL administered over 15 minutes one time per day

1. 240 mL administered over 45 minutes, 5xs per day

Which of the following is true regarding infectious complications associated with enteral feedings? 1. Bacterial contamination may originate from the patient's throat, lung and stomach 2. Exceeding manufacture hang-time guidelines is not a risk for bacterial contamination 3. Open systems have less exogenous bacterial contamination 4. The enteral tube site should be routinely cultured

1. Bacterial contamination may originate from the patient's throat, lung and stomach

List 3 ways to treat/prevent hypergranulation.

1. Cauterized with silver nitrate sticks or other cauterizind devices (if excessive) 2. Preventative education stressing the need for keeping the area dry and the tube stabilized 3. Occlusive dressing may promote the retention of moisture at the exit site and should not be used to manage hypergraunlation

Leakage around the gastrostomy site is a common complication, List 3 ways to reduce gastrostomy exit site leakage

1. Exit site care 2. Proper outer bumper placement 3. Prevention of tension on the tube

Name the 2 routes of bacterial contamination of enteral feeds.

1. Exogenously through the feeding equipment 2. Endogenously through retrograde contamination of the feeding apparatus from the patient's own infected secretions

Which of the following individuals would best benefit from cyclic tube feedings? 1. Status post CVA who has initiated oral foods during the day 2. Critically ill motorcycle accident victim in the ICU 3. Critically ill patients with diabetes and hyperglycemia 4. Postoperative bowel surgery patient who has an ileus

1. Status post CVA who has initiated oral foods during the day

The initiation of enteral tube feeding should be delayed when the patient is 1. hemodynamically unstable 2. at a decreased level of consciousness 3. without bowel sounds 4. scheduled for discharge

1. hemodynamically unstable

Name 6 possible causes of constipation with enteral nutrition.

1. lack of adequate hydration 2. long term fiber-free feedings 3. prolonged bedrest 4. Impaction 5. Obstruction 6. Narcotics

In the patient with a newly placed gastrostomy or jejunostomy tube, observation of which of the following conditions at the tube exit site would signal concern for infection? 1. Serosanguineous drainage 2. Foul-smelling drainage 3. Coffee-ground drainage 4. Vile-colored drainage

2. Foul smelling drainage

Which of the following medications would be appropriate to crush and deliver via an enteral feeding tube? 1. Nifedipine XL 2. Metoprolol immediate release 3. Enteric coated aspirin 4. Diltiazem CD

2. Metoprolol immediate release

One method of minimizing the complications associated with refeeding syndrome is to initiate an electrolyte replacement protocol before nutrition therapy begins. Which of the following is true regarding such a plan? 1. Potassium, magnesium and calcium are the most important electrolytes to closely monitor 2. Patients considered not-at-risk should also be included in the protocol 3. The protocol should replete all electrolytes ONLY via the feeding tube 4. Feeding should be delayed until the risk of electrolyte imbalance is eliminated

2. Patients considered not-at-risk should also be included in the protocol

Early initiation of enteral feeding has been suggested to benefit ICU patients by reducing infectious complications, length of hospital stay and even possibly reducing mortality. Which group of patients might be at significant risk from early enteral feeding? 1. Cancer patients who underwent surgery of the GIT 2. Patients with increasing vasopressor support 3. TBI patients with intracranial pressure controlled by hypertonic saline 4. Patients admitted to the hospital with acute on chronic pancreatitis

2. Patients with increasing vasopressor support

A patient with oral cancer who has gained 10 lbs. since starting home bolus enteral feedings via gastrostomy tube complains of pain and pressure on the "inside of his stomach" but no redness or drainage at the exterior gastrostomy site. Which of the following is the most appropriate response for the clinician? 1. Tell the patient to take over the counter pain medication and rotate the G tube 180 degrees each day 2. refer the patient to the gastroenterologist or enterostomal nurse 3. Decrease the infusion volume of the formula in half to avoid excessive distention of the stomach 4. change to a slower tube feed infusion by using a gravity bag for feedings

2. Refer the patient to the gastroenterologist or enterostomal nurse

When initiating and advancing enteral feedings in the hospitalized patient, which of the following is most appropriate? 1. 1/2 strength formula at 25 mL/hr, advance to goal rate and strength over 5-7 days 2. 240 mL bolus feeds of full strength hypertonic formulas every 4 hours 3. full strength formula at 10-40 mL/hour and advance by 10-20 mL/hour every 8-12 hours to goal rate 4. 1/4 strength formula at goal rate. Advance to full strength over 3-5 days

3 Full strength formula at 10-40 mL/hour and advance by 10-20 mL/hour every 8-12 hours to goal rate

Which is considered inappropriate management of hypergranulation around the PEG site? 1. Keeping the area dry 2. Using a tube stabilizing device 3. Applying an occlusive dressing 4. Cauterization with silver nitrate

3. Applying an occlusive dressing

In patients with severe acute pancreatitis enteral nutrition has been documented to provide the following benefits over parenteral nutrition EXCEPT: 1. decreased infection rate 2. decreased hospital LOS 3. decreased pain 4. decreased mortality

3. Decreased pain

Which of the following describes an optimal method of preparing and administering medications via an enteral feeding tube? 1. Crush tablets and add them directly in the EN formula 2. Administer liquid formulations undiluted to minimize fluid overload 3. Flush the tube with water before and after each medication administered 4. Add crushed tablets to liquid medication sand administer the mixture all together

3. Flush the tube with water before and after each medication administered

Enteral nutrition may be contraindicated in the early post-transplant period in adult patients with hematopoietic cell transplants because of: 1. increased incidence of sinusitis with enteral feedings 2. lack of benefit from enteral feedings in allogeneic patients 3. gastrointestinal toxicities related to the conditioning regimen 4. improved survival seen in autologous patients receiving PN

3. Gastrointestinal toxicities related to the conditioning regimen

Modular products are used to enhance the nutrient profile of a feeding regimen. Which of the following combinations represents modular products? 1. Safflower oil, protein, glucose and selenium 2. Glucose, glutamine, water and MCT oil 3. Protein, cholecalciferol, fiber and safflower oil 4. MCT oil, glucose, fiber and protein

4. MCT oil, glucose, fiber and protein

A patient with acute respiratory distress syndrome (ARDS) may benefit from a feeding formula containing supplemental 1. arginine 2. glutamine 3. nucleic acids 4. omega-3 fatty acids

4. omega-3 fatty acids

Up to 26% of enterally fed patients report nausea and/or vomiting. If delayed gastric emptying is suspected as the causative factor, which of the following is LEAST likely to improve the patient's symptoms? 1. reduce or discontinue narcotic medications 2. switch to a low fat enteral formula 3. reduce the rate of enteral nutrition infusion 4. use a more concentrated enteral formula

4. use a more concentrated enteral formula

What is the general length for cyclic feedings?

8-20 hours per day

Define ARDS.

Acute respiratory distress syndrome - inflammatory response leading to diffuse alveolar damage and lung capillary endothelial injury.

What should be considered in the enterally fed patient with abdominal distention?

Aggressive bowel regimens need to be considered in these patients to reduce distention and prevent impaction

Why would concentrated enteral solutions not be recommended for nausea/vomiting?

Concentrated enteral solutions generally contain more fat and can contribute to enteral intolerance by presenting a higher osmotic load to the GI tract. They also slow gastric emptying.

What enteral feeding schedule can facilitate more steady and predictable blood glucose concentrations in critically ill patients?

Continuous

Should IV hydration be performed in the terminal patient? Why?

IV hydration in the terminal patient can raise the risk of patient discomfort and respiratory distress

What may happen with excessive tightening of the external bolster on a feeding tube? What is the incidence of this complication?

May lead to ischemic necrosis of the gastric wall and migration of the internal bolster either into the gastric wall, abdominal wall or event he subcutaneous tissue and skin Incidence ranges from 0.3% to 2.4% of patients

Why are modified release dosage forms of drugs inappropriate to crush and give via EN feeding tubes?

Modified release dosage forms (often designated with abbreviations such as XL, XR, SR, CD etc.) are inappropriate to crush and give via EN feeding tube because crushing these dosage forms destroys their modified releasing properties. This may lead to an excessive dose of the drug being released at one time (instead of slowly over a longer period of time), which can lead to adverse effects and has even been reported as a cause of death

Protein powders, carbohydrate powders, fat emulsion, MCT oil, fiber and specific amino acids are examples of what?

Modular products

What does weight gain after feeding tube placement increase the risk of?

Pressure necrosis and ulceration at the tube site because of increase in abdominal girth

What is the evidence for BCAA enriched amino acid enteral formulas?

Published randomized trials have shown mixed results in patients with hepatic failure receiving these specialized formulas. Due to the lack of evidence supporting their use and the increased cost of such products it has been suggested that the use of these hepatic fomulas be limited to patients with encephalopathy refractory to standard medical therapy (lactulose, non-absorbed antibiotics)

What is the theory behind use of BCAAs in hepatic encephalopathy?

There is believed to be an increased ratio of aromatic amino acids to BCAAs in patients experiencing hepatic encephalopathy. The decrease in BCAA is suspected to be due to an increased breakdown in BCAA from skeletal muscles and utilization. The increased levels of AAA generate false neurotransmitters, resulting in hepatic encephalopathy symptoms.