Module 2B: Complications of Parenteral Nutrition

Question: 5 Hyperglycemia in a patient receiving PN is associated primarily with what type of sodium/fluid imbalance? 1: Hypertonic hyponatremia 2: Hypotonic hyponatremia 3: Isotonic hypernatremia 4: Hypertonic hypernatremia

1: Hypertonic hyponatremia

Question: 51 A 75-year-old female with moderate malnutrition is status-post radical cystectomy with ileal conduit. She is initiated on a peripheral parenteral nutrition (PPN) solution at 125mL/h. This formula contains 210 grams of dextrose, 75 grams of amino acids, and 45 grams of fat. In the patient case above, what is the osmolarity of the daily PPN formula? 1: 600mOsm/L 2: 1200 mOsm/L 3: 1800 mOsm/L 4: 2400 mOsm/L

1: 600mOsm/L

Question: 1 Which one of the following factors is most likely to contribute to metabolic bone disease in PN-dependent patients? 1: Aluminum toxicity 2: Calcium supplementation 3: Moderate amino acid intake in PN 4: Balanced acetate load in PN

1: Aluminum toxicity

Question: 19 A 75-year-old female with moderate malnutrition is status-post radical cystectomy with ileal conduit. She weighs 50kg, and she has a 20-gauge IV access in the left cephalic vein. She is initiated on a PPN solution at 125mL/h. This formula contains 210 grams of dextrose, 75 grams of amino acids, and 45 grams of fat. Which of the following complications is she at greatest risk for developing? 1: Fluid overload 2: Hypertriglyceridemia 3: Azotemia 4: Hyperglycemia

1: Fluid overload

Question: 3 A 70-kg adult patient receiving PN providing 3000 kcal/day presents with mild to moderate elevations of serum aminotransferases and mild elevations of bilirubin and serum alkaline phosphatase. This patient is most likely exhibiting what type of PN-associated liver disease (PNALD)? 1: Hepatic steatosis 2: Cholestasis 3: Gallbladder sludging 4: Fulminant hepatic failure

1: Hepatic steatosis

Question: 21 What feature of a Groshong® Central Venous Catheter reduces the risk of catheter occlusion? 1: Pressure sensitive three-way valve 2: Large lumen(s) size 3: Heparin coated tip 4: Soft grade medical silicon tubing

1: Pressure sensitive three-way valve

Question: 2 Which of the following is a risk factor for the development of PN-associated liver complications in PN-dependent patients? 1: Prolonged use of soybean-based lipid injectable emulsion (ILE) 2: Cyclic infusion of PN 3: Supplemental trophic enteral feeding 4: Medication therapy with ursodiol

1: Prolonged use of soybean-based lipid injectable emulsion (ILE)

Question: 33 The most accurate method of diagnosing PN-associated metabolic bone disease is to measure 1: bone mineral density. 2: urinary calcium concentrations. 3: serum vitamin D concentration. 4: serum parathyroid hormone concentrations

1: bone mineral density.

Question: 13 The use of 0.1N hydrochloric acid is most effective for clearing catheter occlusions due to precipitation of 1: calcium-phosphate. 2: tobramycin. 3: phenytoin. 4: lipid residue.

1: calcium-phosphate.

Question: 38 Your patient develops sudden chest pain and shortness of breath following placement of a central line for parenteral nutrition support. A pneumothorax is suspected and radiographically confirmed. This situation should be viewed as a 1: sentinel event. 2: process measure. 3: clinical measure event. 4: accountability measure.

1: sentinel event.

Question: 11 The preferred site for placement of a central venous acces device (CVAD) for adult patients to reduce the risk of infection is 1: subclavian. 2: internal jugular. 3: femoral. 4: external jugular.

1: subclavian.

Question: 7 In order to prevent rebound hypoglycemia upon discontinuation of parenteral nutrition (PN), it is recommended the PN infusion rate be reduced over what time span? 1: 0 hours 2: 1-2 hours 3: 2-3 hours 4: 3-4 hours

2: 1-2 hours

Question: 22 A patient receiving chronic PN therapy develops an intraluminal clot in his (or her) central venous access device. What is the most appropriate pharmacological intervention to clear this access device? 1: Heparin 100 units/mL 2: Alteplase 2mg/2mL 3: Argatroban 350 mcg/kg 4: Streptokinase 10,000 units

2: Alteplase 2mg/2mL

Question: 31 Manganese toxicity is a concern for long-term parenteral nutrition (PN) patients due to its presence in trace element mixtures and as a contaminant from other PN solution components. Symptoms of manganese toxicity are associated most commonly with accumulation of the mineral in which organ? 1: Kidney 2: Brain 3: Muscle 4: Heart

2: Brain

Question: 50 A home PN dependent patient with a peripherally inserted central catheter (PICC) presents with arm, shoulder and neck swelling. Which of the following is the most likely cause? 1: Pinch off syndrome 2: Catheter related central venous thrombosis 3: Fibrin sheath occlusion 4: Parenteral nutrition associated infection

2: Catheter related central venous thrombosis

Question: 49 A critically ill 42 year old male status post small bowel resection for Crohn's disease is receiving PN for severe post-operative ileus with NG tube output of 2.5-3 liters per day. He has the following arterial blood gas (ABG) results: pH=7.49, PCO2= 45 mm Hg, and serum bicarbonate=34 mEq/L. What is the most appropriate PN intervention? 1: Maintain current chloride:acetate ratio 2: Increase chloride:acetate ratio 3: Decrease chloride:acetate ratio 4: Decrease calorie content of PN

2: Increase chloride:acetate ratio

Question: 24 A PN-dependent patient with an average daily ileostomy output of 3L presents with BUN/serum creatinine ratio of 30:1 and mild hyponatremia. What is the most appropriate PN intervention for this patient? 1: Increase sodium, restrict protein 2: Increase sodium, increase fluid 3: Increase fluid, restrict protein 4: Decrease sodium, increase fluid

2: Increase sodium, increase fluid

Question: 6 A long-term PN patient presents with involuntary movements, tremor, and rigidity. Which of the following etiologies may explain these symptoms? 1: Manganese deficiency 2: Manganese toxicity 3: Selenium deficiency 4: Selenium toxicit

2: Manganese toxicity

Question: 8 Which of the following would be the most serious complication of hypertriglyceridemia in a patient receiving parenteral nutrition (PN)? 1: Azotemia 2: Pancreatitis 3: Polyuria 4: Peripheral neuropathy

2: Pancreatitis

Question: 27 A patient arrives in your clinic complaining of intermittent catheter malfunction. You identify that the catheter malfunction is relieved by raising the patient's arm where the catheter is located. Which condition should be suspected? 1: Fibrin sheath 2: Pinch-off syndrome 3: Superior vena cava syndrome 4: Catheter migration

2: Pinch-off syndrome

Question: 26 The most common route of infection for a tunneled central venous access device (CVAD) is 1: extraluminal colonization of the catheter. 2: contamination of the catheter hub. 3: contamination of the infusate. 4: hematogenous seeding from another focus of infection.

2: contamination of the catheter hub.

Question: 48 Patients with diabetes who are receiving PN 1: should have blood glucose checked every 8-10 hours. 2: have an increased risk for catheter related infections. 3: have a maximum carbohydrate infusion rate of 7mg/kg/min of dextrose. 4: should have initial insulin amount of 1.0 unit of regular insulin/gm dextrose infused.

2: have an increased risk for catheter related infections.

Question: 47 Excess carbohydrate administration in PN has been associated with 1: hypercalcemia. 2: hepatic steatosis. 3: decreased CO2 production. 4: metabolic bone disease.

2: hepatic steatosis.

Question: 25 The use of 70% ethyl alcohol is most effective for clearing catheter occlusions due to precipitation of 1: calcium-phosphate. 2: lipid residue. 3: phenytoin. 4: tobramycin.

2: lipid residue.

Question: 16 All of the following are considered as short-term complications of home parenteral nutrition EXCEPT 1: dehydration. 2: metabolic bone disease. 3: refeeding syndrome. 4: catheter malposition.

2: metabolic bone disease.

Question: 20 A 68-year-old female with normal liver function and a lactate of 1 mmol/L is in acute kidney injury status-post colon resection and is receiving PN. She has the following arterial blood gas (ABG) results: pH=7.31, PCO2=36 mm Hg, and serum bicarbonate=20 mEq/L. What is the most appropriate PN intervention? 1: Maintain current chloride:acetate ratio 2: Increase chloride:acetate ratio 3: Decrease chloride:acetate ratio 4: Decrease calorie content of PN

3: Decrease chloride:acetate ratio

Question: 43 A critically ill patient has been receiving parenteral nutrition providing 45 kcals/kg. The consequences of providing excessive calories to a critically ill patient include all of the following EXCEPT 1: Fatty infiltration of the liver. 2: Ventilator weaning failure. 3: Elevated phosphate. 4: Elevated blood sugar.

3: Elevated phosphate.

Question: 17 Which of the following is most likely responsible for elevated serum bicarbonate levels in a home parenteral nutrition (PN) patient? 1: Excess chloride salts in the PN 2: Diarrhea 3: Excess acetate salts in the PN 4: Acute renal failure

3: Excess acetate salts in the PN

Question: 45 A 60-year-old female (height 152 cm, weight 45 kg) is receiving PN for a rectovaginal fistula. The PN formula consists of the following components: 70 grams protein, 400 grams dextrose, and 25 grams fat in a total volume of 1.5 liters, including all electrolytes and additives, which is infused continuously over 24 hours daily. Which one of the following complications is she at greatest risk for developing? 1: Hypertriglyceridemia 2: Azotemia 3: Hyperglycemia 4: Pulmonary edema

3: Hyperglycemia

Question: 23 A patient is receiving PN through a tunneled catheter in the IJ. He has a low grade fever 38.1 and is mildly tachycardic (HR 110), but blood cultures are negative. There is some mild redness and tenderness but no purulence at the catheter exit site. How is this exit site infection best managed? 1: Remove central venous access device (CVAD) 2: Exchange catheter over a guidewire 3: Initiate systemic antimicrobial therapy 4: Apply topical antibiotic ointment

3: Initiate systemic antimicrobial therapy

Question: 37 A patient has been receiving PN through a central venous catheter (CVC) for the past week while in the hospital. They now present with shortness of breath, cough, and cyanosis of the face, neck, shoulder, and arms. What type of device complication is characterized by this patient's symptoms? 1: Tunnel infection 2: Pinch-off syndrome 3: Superior vena cava syndrome 4: Thrombosis

3: Superior vena cava syndrome

Question: 4 A 55-year-old male is admitted with an undesired weight loss of 20 pounds during the past month secondary to an ongoing Crohn's flare up. The patient is found to be at high risk for refeeding syndrome. Which micronutrient should be supplemented? 1: Vitamin A 2: Vitamin K 3: Thiamin 4: Ascorbic acid

3: Thiamin

Question: 36 During long-term PN administration, hepatobiliary complications can best be prevented by 1: adding carnitine to the PN formula. 2: discontinuing lipid injectable emulsion (ILE). 3: converting to cyclic administration. 4: reducing magnesium.

3: converting to cyclic administration.

Question: 10 All of the following are risk factors for the development of rebound hypoglycemia after cessation of PN EXCEPT 1: malnutrition. 2: hepatic dysfunction. 3: hypertension. 4: renal insufficiency.

3: hypertension.

Question: 44 A patient presents to clinic with a suspected catheter occlusion. All of the following are appropriate initial actions EXCEPT to 1: determine if the occlusion is relieved with postural changes. 2: remove the dressing and check for kinks in the tubing. 3: replace the catheter over a guidewire. 4: review recent flushing techniques with the patient.

3: replace the catheter over a guidewire.

Question: 42 A patient receiving PN that has chills, fever, positive blood cultures, but no redness or purulence at the catheter exit site probably has which of the following types of catheter infection? 1: Tunnel infection 2: Exit site infection 3: Catheter-related phlebitis 4: Catheter-related bloodstream infection

4: Catheter-related bloodstream infection

Question: 35 A rise in which of the following laboratory values would most likely indicate cholestasis? 1: Prothrombin time 2: Asparate aminotransferase/Alanine aminotransferase ratio 3: Cholesterol 4: Conjugated (direct) bilirubin

4: Conjugated (direct) bilirubin

Question: 14 A 40-year-old male receiving chronic PN therapy (initiated 15 years ago) secondary to massive bowel resection develops metabolic bone disease. His current 12-hour cyclic PN formula provides 5 g/kg/day dextrose, 2 g/kg/day protein and 1 g/kg/day of fat. What is the most appropriate intervention to reduce hypercalciuria? 1: Increase calcium gluconate 2: Decrease phosphorus supplementation 3: Shorten PN infusion time to 10 hours 4: Decrease amino acid content of PN solution

4: Decrease amino acid content of PN solution

Question: 32 A critically ill 75-year-old male with pneumonia and sepsis who weighs 63 kg is receiving PN containing 2800 kcal and 100 g amino acids per day. He has the following arterial blood gas (ABG) results: pH=7.32, PCO2=49 mm Hg, and serum bicarbonate=25 mEq/L. What is the most appropriate PN intervention? 1: Increase calorie content of PN 2: Increase chloride:acetate ratio 3: Decrease chloride:acetate ratio 4: Decrease calorie content of PN

4: Decrease calorie content of PN

Question: 29 Which of the following illustrates the most common electrolyte imbalances observed in patients with refeeding syndrome? 1: Hypokalemia, hyperphosphatemia, hypocalcemia 2: Hyperkalemia, hyperphosphatemia, hypocalcemia 3: Hypokalemia, hypophosphatemia, hypermagnesemia 4: Hypokalemia, hypophosphatemia, and hypomagnesemia

4: Hypokalemia, hypophosphatemia, and hypomagnesemia

Question: 30 A patient with refractory hypokalemia should be assessed for what related electrolyte disorder? 1: Hypernatremia 2: Hyponatremia 3: Hyperphosphatemia 4: Hypomagnesemia

4: Hypomagnesemia

Question: 34 Which one of the following co-morbidities is NOT a risk factor for the development of metabolic bone disease for a patient on long-term parenteral nutrition? 1: Crohn's disease 2: Ovarian cancer 3: Short bowel syndrome 4: Hypothyroidism

4: Hypothyroidism

Question: 46 Discontinuation of lipid injectable emulsion (ILE) is recommended treatment for catheter-related bloodstream infection due to 1: Escherichia coli. 2: Staphylococcus aureus. 3: Pseudomonas aeruginosa. 4: Malassezia furfur.

4: Malassezia furfur.

Question: 41 A patient in an acute care hospital has undergone placement of a central venous access device (CVAD) for PN infusion. Which evidence-based intervention should be implemented to reduce the risk of CVAD-related infection? 1: Administration of antibiotics prior to CVAD insertion 2: Use standard contact barrier precautions during CVAD insertion 3: Cleansing of CVAD insertion site with 2% alcohol preparation 4: Training of nursing staff to maintain CVAD

4: Training of nursing staff to maintain CVAD

Question: 18 The clinical presentation of refeeding syndrome includes all of the following EXCEPT 1: respiratory failure. 2: seizures. 3: cardiac arrythmias. 4: dehydration.

4: dehydration.

Question: 39 Which of the following is an etiology of a thrombotic catheter occlusion? 1: catheter migration during use. 2: formation of lipid deposits. 3: calcium-phosphate precipitate. 4: fibrin sheath formation.

4: fibrin sheath formation.

Question: 40 The most effective strategy to decrease the risk of catheter-associated sepsis is use of 1: povidone-iodine as a skin preparation. 2: antibiotic ointment at catheter exit site. 3: antibiotic prophylaxis during catheter insertion. 4: full-barrier precautions during catheter insertion.

4: full-barrier precautions during catheter insertion.

Question: 12 Catheter related thrombosis caused by fibrin build up within blood vessels adhering to a central venous catheter is called 1: fibrin sheath. 2: fibrin tail. 3: intraluminal thrombus. 4: mural thrombus.

4: mural thrombus.

Question: 15 The best approach to prevent PN-induced cholelithiasis is administration of 1: choline. 2: cholecystokinin-octapeptide (CCK-OP). 3: ursodiol. 4: oral or enteral feeding.

4: oral or enteral feeding.

Question: 28 All of the following conditions predispose a patient to the refeeding syndrome EXCEPT 1: chronic alcoholism. 2: malabsorptive syndromes. 3: weight loss after bariatric surgery. 4: poor oral intake for 3 days.

4: poor oral intake for 3 days.

Question: 9 All of the following are potential causes of hyperglycemia in a patient receiving PN EXCEPT 1: carbohydrate administration > 5 mg/kg/min. 2: obesity. 3: sepsis. 4: renal failure.

4: renal failure.