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1. Which of the following is the most common metabolic complication associated with PN? A. Hyperglycemia B. Essential fatty acid deficiency (EFAD) C. Azotemia D. Hyperammonemia

1. The correct answer is A. Hyperglycemia is the most common metabolic complication that occurs with PN. Hyperglycemia is associated with overfeeding but occurs frequently in appropriately fed patients. This is attributed to insulin suppression, resistance, and gluconeogenesis from stress and infection. Nondiabetic hospitalized patients receiving intravenous (IV) dextrose infusions at rates greater than 4 mg/kg/min have a 50% chance of developing hyperglycemia.1 EFAD is associated with fat-free PN and can be avoided by administering minimal amounts of IVFE. Azotemia may occur but is usually associated with renal or hepatic dysfunction or protein overfeeding. Hyperammonemia rarely occurs since the advent of crystalline amino acids.

1. Which of the following may increase the risk of phlebitis with peripherally administered parenteral nutrition (PPN)? A. Osmolarity ≤900 mOsm/L B. Potassium 100 mEq/L C. Intravenous fat emulsion (IVFE) piggybacked with PPN D. Addition of heparin to the PPN

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

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

1. The correct answer is B. Serum glucose levels must be strictly monitored during pregnancy to avoid the possible detrimental effects of neonatal hyperglycemia and hyperinsulinemia. The presence of glucose in a pregnant woman's urine is not abnormal and therefore does not necessarily indicate the presence of maternal diabetes.1 The presence of lactic acid in the urine is typically observed during strenuous exercise and has no value in terms of monitoring glycemic control

1. An alert and oriented patient is receiving a continuous infusion of a standard, fiber-containing enteral feeding formulation by small-bore nasogastric (NG) tube. Drugs administered by bolus administration through the side port of the tube are phenytoin suspension 400 mg daily and nizatidine 150 mg every 12 hours. The feeding tube becomes occluded and must be removed. Which of the following measures is most appropriate for preventing occlusion of the new tube? A. Replace the small-bore tube with a large-bore NG tube. B. Flush the feeding tube with 30 mL of water before and after administering each medication. C. Discontinue the fiber-containing enteral feeding formulation, and initiate feeding with a fiber-free enteral feeding formulation. D. Hold the feeding infusion for 2 hours before and after administering phenytoin.

1. The correct answer is B. The most likely cause of the feeding tube occlusion is improper flushing technique (Chapters 12 and 13). The tube should be flushed with a minimum of 10 to 20 mL of warm water before and after each medication, but 30 mL is commonly recommended and may be required to properly flush longer or larger tubes.1 Although the risk of occlusion is potentially greater with a small-bore tube than with a large-bore tube, the discomfort associated with a large-bore tube would make it a poor choice for enteral access in an alert patient, especially for more than a day or two. Switching from a fiber-containing to a fiberfree enteral feeding formulation would have little influence on risk of tube occlusion. The fiber used in enteral feeding formulations has been processed to a degree that makes its viscosity similar to that of polymeric fiber-free formulations.2 Holding the feeding infusion for 2 hours before and after phenytoin administration has been recommended as a method to enhance drug absorption; it would not be expected to influence tube occlusion.

1. Which one of the following claims for a dietary supplement would most likely cause the FDA to consider that the supplement should be regulated as a drug rather than as a dietary supplement? A. Supports strong bones and teeth B. Treats influenza C. Promotes urinary health D. Improves immune function

1. The correct answer is B. Under DSHEA, manufacturers of dietary supplements may make statements regarding product ability to affect structure or function of the body. Any claim regarding diagnosis, treatment, cure, or prevention of a disease is disallowed. Therefore, a claim to support strong bones and teeth would be allowed as a structure claim. The claims to promote urinary health and support the immune system would be function claims. The claim that a product treats influenza is an obvious claim regarding treatment of disease and would thus be disallowed

1. Which of the following is the most appropriate vascular access device for a patient requiring long-term parenteral nutrition (PN) therapy? A. Use of a midclavicular catheter as a cost-effective measure B. Placing a percutaneous nontunneled catheter to initiate PN and then replacement with an implanted port C. Placement of a single-lumen tunneled cuffed catheter D. Placement of a triple-lumen antibiotic-coated catheter to ensure adequate access for future needs

1. The correct answer is C. A single-lumen cuffed CVC would be the preferred device. The tunneled catheter was originally developed for patients with longterm PN.1 Tunneled catheters have been demonstrated to be safe and effective in long-term therapies ranging from months to years.2 A midclavicular catheter does not provide central access and, therefore, would not be an appropriate catheter choice. Percutaneous nontunneled catheters with additional features of multiple lumens and antibiotic/ antimicrobial coating provide PN access in the acute care setting for a shorter duration of time. It would be best to start with selection of the optimal device rather than a planned replacement. Ports are an alternative to external lumen catheters, and patients need to understand that repeated needle sticks will be required for daily therapy.

1. The correct answer is C. A single-lumen cuffed CVC would be the preferred device. The tunneled catheter was originally developed for patients with long-term PN.1 Tunneled catheters have been demonstrated to be safe and effective in long-term therapies ranging from months to years.2 A midclavicular catheter does not provide central access and, therefore, would not be an appropriate catheter choice. Percutaneous nontunneled catheters with additional features of multiple lumens and an antibiotic/antimicrobial coating provide PN access in the acute care setting for a shorter duration of time. It would be best to start with selection of the optimal device rather than a planned replacement. Ports are an alternative to external lumen catheters, and patients need to understand that repeated needle sticks will be required for daily therapy.

1. A 34-year-old pregnant woman complains of abdominal cramps and diarrhea. She asks if her recent consumption of blue cohosh could be causing her symptoms. Which of the following statements regarding blue cohosh is FALSE? A. Blue cohosh is a uterine stimulant used by some nurse midwives to induce labor. B. Blue cohosh contains caulosaponin and cardiac alkaloids. C. Blue cohosh produces no adverse reactions in infants whose mothers consumed the herbal product during pregnancy. D. Blue cohosh may be adulterated with other herbal products.

1. The correct answer is C. Adverse reactions in infants have been reported after their mothers consumed blue cohosh during pregnancy. For example, one infant developed myocardial infarction, congestive heart failure, and cardiovascular shock. Another infant developed seizures, renal damage, and respiratory failure

1. Which of the following physiological responses occurs as a result of severe injury? A. Positive nitrogen balance as soon as basal glucose requirements are provided B. Decreased epinephrine, glucagon, and growth hormone leading to increased lipogenesis and decreased glycerol and fatty acid release C. Negative nitrogen balance despite adequate caloric provision D. Increased gluconeogenesis and decreased insulin resistance

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

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

1. A 62-year-old patient with chronic kidney disease requires hemodialysis three times weekly. Her most recent laboratory work shows a blood urea nitrogen of 65 mg/dL, creatinine 3.2 mg/dL, potassium 3.9 mEq/L, and phosphorus 4.4mg/dL. Which of the following formulas would best meet her nutrient needs? A. A formula restricted in fluid, protein, and electrolytes. B. A formula not restricted in protein but restricted in fluid and electrolytes. C. A formula restricted in fluid but not restricted in protein or electrolytes. D. A formula not restricted in fluid or protein but restricted in electrolytes

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

1. What are the goals for protein support for adults with delayed healing of pressure ulcers? A. Provide adequate protein: 0.8 g protein/kg per day B. Provide adequate protein: 1.2 to 2.1 g protein/kg with recommended evening supplements (protein and energy) for depletion C. Ensure adequate protein: 1.25 to 1.5 g protein/kg per day D. All of the above

1. The correct answer is C. The goal for protein support for patients with pressure ulcers is to ensure 1.25 to 1.5 g/kg body weight per day.1-5

1. What is the optimal nutrition support for a moderately malnourished patient with an ileus expected to resolve in 7 to 8 days? A. Central parenteral nutrition B. Nasogastric enteral tube feedings C. Postpyloric enteral tube feedings D. Peripheral parenteral nutrition (PPN)

1. The correct answer is D. PPN may be used for short periods in patients who are not severely malnourished, have adequate peripheral venous access, and can tolerate large volumes of fluid. Although the most current American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines do not address appropriate PPN use, the previous A.S.P.E.N. guidelines indicated that PPN may be used in selected patients to provide partial or total nutrition support for up to 2 weeks in patients who cannot ingest or absorb oral or enteral tube-delivered nutrients, or when central-vein PN is not feasible.1,2 However, patients who are not severely malnourished may tolerate periods of no nutrition for varying periods (up to 7-10 days) without adversely affecting their outcome. Therefore, PPN is not the optimal choice for feeding patients with significant malnutrition, severe metabolic stress, large nutrient or electrolyte needs, fluid restriction, and/or the need for prolonged intravenous (IV) nutrition support.

1. If an enteral access tube cannot be unclogged using warm water flushes, what is the next most reliable method for unclogging the tube before being replaced? A. Administer cola through the tube, and let it sit for a few hours. B. Administer Clog Zapper (CORPAK MedSystems, Wheeling, IL) and flush within 30 to 60 minutes. C. Wait a few hours to see if the clog dissolves spontaneously. D. Administer a mixture of pancreatic enzymes and bicarbonate solution, allow it to sit for 1 to 2 hours, and then flush with warm water. 206

1. The correct answer is D. The first suggestion is a common misconception: administering an acidic solution can actually make formula and many medication clogs much worse. Clog Zapper is a commercial mixture of papain, alpha amylase, and citric acid solution. It has a lower success rate when compared to pancreatic enzyme solutions. The correct answer is not C, as waiting longer will not help a tube become unclogged. Pancreatic enzyme solutions have been studied and in one report had a 90% success rate when the tube was allowed to sit for 2 hours. The mixture of one tablet of pancrelipase (6000 units, protease 19,000 units, amylase 30,000 units) and sodium bicarbonate 325 mg (half of a 650-mg tablet) is crushed and mixed with 5 mL of warm water and instilled into the feeding tube for 30 minutes to 2 hours. This can be tried an additional time if the shorter waiting period is ineffective.

1. Vitamin C (ascorbic acid) is necessary for all of the following EXCEPT: A. Collagen synthesis B. Hydroxylation of proline and lysine C. Immune function D. Synthesis of DNA and RNA

1. The correct answer is D. Vitamin C is an essential water-soluble nutrient known to enhance normal wound healing. Vitamin C functions as a cofactor in the hydroxylation of proline and lysine in collagen formation; it is also required for angiogenesis and fibroblast formation. In addition, vitamin C has an effect on immune function, specifically neutrophil activity, which aids in preventing wound infections.1-4 Vitamin C deficiency has been associated with delayed wound healing. Scurvy causes increased wound capillary fragility, diminished angiogenesis, delayed wound healing and increased risk for wound infections and dehiscence.5 Zinc, on the other hand, is a component of enzymes involved in the synthesis of DNA and RNA.

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

2. The correct answer is A. Catheter occlusions are commonly secondary to a thrombotic etiology. Thrombotic causes include an intraluminal thrombus, an extraluminal fibrin sleeve, and vessel thrombosis.3 The successful use of thrombolytics to treat catheters occluded with a thrombus is well documented. Historically, streptokinase and urokinase have been used. These agents lyse thrombus by activating and converting plasminogen to plasmin. Plasmin degrades fibrin clots. More recently, tissue plasminogen activator (TPA) has also been used. Nonthrombogenic catheter occlusion includes intraluminal drug and lipid precipitates. Pharmacological agents that change the pH within the lumen increase the solubility of the precipitate

2. After periods of prolonged starvation, which of the following metabolic and physiological changes occur as a patient begins PN therapy? A. Anabolism begins almost immediately. B. Basal metabolic rate (BMR) decreases to conserve energy. C. Insulin levels decrease. D. Liver gluconeogenesis decreases.

2. The correct answer is A. During starvation, the body adapts by decreasing gluconeogenesis and increasing use of ketones and fatty acids that do not require phosphate to produce energy.2 When refeeding occurs, there is a sudden shift to glucose as the primary fuel.3 BMR increases when nutrition support is initiated after starvation. Anabolism begins almost immediately. There is a rapid alteration in hormone levels, primarily insulin as glucose becomes the dominant fuel. A rapid alteration in calories, fluid, and particularly sodium intake may cause fluid shifts and intravascular volume overload, which may increase risk for developing congestive heart failure.4 Management and prevention of refeeding syndrome includes identifying patients at risk, serum electrolyte monitoring, restoring circulatory volume, and increasing calories slowly

2. Which of the following statements is true regarding the nutrition management of pregnant women receiving nutrition support? A. Hyperlipidemia is a normal occurrence of pregnancy. B. Women with hyperemesis gravidarum (HG) should not be fed via feeding tube. C. Placement of percutaneous endoscopic gastrostomy (PEG) tubes is contraindicated in pregnancy. D. Administration of parenteral lipid emulsions is associated with preterm labor in humans.

2. The correct answer is A. Hyperlipidemia is a common occurrence during pregnancy. Serum triglyceride and cholesterol may rise to 150% and to 125% to 150%, respectively, ofnonpregnant levels. This is the result of enhanced adipose tissue lipolysis, increased triglyceride synthesis, increased chylomicron production from dietary lipids, and reduced lipoprotein lipase activity in extrahepatic tissues.2,3 Women with HG may be successfully fed via an enteral feeding tube.4,5 There are no reports of aspiration of enteral feeding. PEG feeding in conscious pregnant women has been reported,6 and PEG feedings may be a possible feeding alternative. At this time, parenteral lipids in reasonable amounts are considered safe for pregnant women.7

2. Which one of the following practices has been shown to prevent catheter-related infections? A. The use of maximal barrier precautions during CVC insertion B. Routine replacement of CVCs C. Prophylactic use of antibiotics before catheter placement D. The use of 10% povidone-iodine as a skin antiseptic

2. The correct answer is A. The key to reducing catheterrelated infections is prevention. The Centers for Disease Control and Prevention (CDC) has revised previously published guidelines addressing the prevention of intravascular catheter-related infections.3 A working group of 13 professional organizations convened to review and provide to practitioners evidence-based guidelines. The strongest emphasis was given to five areas of recommended practice: education and training of health care providers, the use of maximal barrier precautions during CVC insertion, skin antisepsis using 2% chlorhexidine, the avoidance of routine replacement of CVCs and the indication for antiseptic/antibiotic bonded types of catheters in high-risk patient populations. A 2% chlorhexidine solution is shown to be a superior superior skin antiseptic.4 No studies have demonstrated that antibiotic or antifungal drugs as prophylaxis reduce the incidence of catheter-related infections in adults.

2. Zinc is necessary for which of the following processes? A. Cell replication and growth B. Muscle contraction C. Red cell formation D. All of the above

2. The correct answer is A. Zinc is an essential trace mineral necessary for cell replication and growth. Zinc supplementation is recommended only for patients with zinc deficiencies. For patients with normal levels of zinc, supplementation offers no benefit and may result in zinc toxicity.6,

2. A 55-year-old critically ill patient has been tolerating a standard 1 cal/mL feeding formula well over the past week. She begins having frequent bouts of loose stools. What should be the clinician's next suggestion? A. Change to a peptide-based formula B. Determine the cause of diarrhea C. Add pre- and probiotics D. Change to a fiber-supplemented formula

2. The correct answer is B. Determining the cause of acute diarrhea is the correct answer. The feeding formula that she had been tolerating fine over the past week is the least likely cause of the diarrhea. Assessing for newly ordered medications that can cause diarrhea or ruling out infections such as Clostridium difficile may help to determine the cause of diarrhea. If no obvious cause of diarrhea can be found, then a different feeding formula may be trialed

2. For routine colon surgery, which of the following components of enhanced recovery after surgery (ERAS) contributes to the improved outcomes? A. Keep the patient nothing by mouth after midnight to avoid aspiration on induction of general anesthesia. B. Provide a glucose-rich supplementation 6 and 2 hours prior to surgery. C. Utilize a bowel prep to prevent wound infections. D. Limit mobility of the patient to prevent wound dehiscence.

2. The correct answer is B. The principles of a perioperative plan to improve outcomes in elective colon surgery have included avoiding starvation, limiting intravenous fluids, and increasing mobility. Providing a carbohydrateenhanced drink preoperatively as part of a complex perioperative plan has improved outcomes. Patients consuming 800 mL of a carbohydrate-rich liquid (100 g of carbohydrate) at midnight and 400 mL 2 hours prior to surgical intervention demonstrate a faster recovery, fewer infectious complications, and no increased aspirations. By providing this fluid and nutritional supplementation without a preoperative bowel prep, patients received less intravenous fluids, which improved recovery. In addition, a decrease in insulin resistance has been observed that has been shown to be associated with decreased complications and mortality.

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

2. The correct answer is B. Whenever a patient with a lowprofile feeding tube gains or loses a significant amount of weight, there is a chance his or her tube is no longer sized correctly. This is the most problematic with weight gain, as this can cause abnormal internal pressure from the bolster or balloon, which can erode the gastric mucosa. If this process continues, buried bumper syndrome may develop. It results from growth of the gastric mucosa partially or completely over the internal bumper, usually because of excessive tension between the internal and external bumpers. Poor wound healing and significant weight gain without adjusting the external bumper or changing to a longer low-profile feeding tube can contribute as well. Patients are often unaware of this until the tube site becomes extremely painful. As the skin becomes irritated and swells, it magnifies the problem. This patient needs to be evaluated soon and have the feeding tube exchanged for either a longer low-profile tube or a standard tube. If the process has progressed too far, more intensive treatment with antibiotics and tube removal may be required.

2. The EN formulation for a home patient receiving EN through a percutaneous gastrostomy (PEG) was recently changed from a high-protein, fibercontaining, 1 kcal/mL formulation to the only 1.5 kcal/mL formulation available in the local store. The new product is marketed for use in patients with compromised pulmonary function and contains low amounts of carbohydrate, 55% of calories from fat, about 15% less protein per day than the 1 kcal/mL formulation, and no fiber. What component of the new formulation is most likely to contribute to interactions resulting from slow gastric emptying? A. Lower fiber content B. Lower protein content C. Higher fat content D. Higher caloric density

2. The correct answer is C. High fat intake slows gastric emptying. High protein intake and high caloric density can also slow gastric emptying but have less effect than high fat. In addition, protein intake will be lower with the new formulation. Low fiber intake has been associated with slow colonic transit and constipation rather than altered gastric emptying.

2. The smallest pore size filter that is recommended for TNA is A. 0.22 micron B. 0.5 micron C. 1.2 microns D. 5 microns

2. The correct answer is C. The 1.2-micron filter is not a sterilizing filter, but it will remove large microorganisms such as Candida albicans and large particles that might otherwise lodge in pulmonary capillaries if allowed to pass through. A 0.22-micron filter is used for the 2-in-1 dextrose and amino acid type of PN, and does qualify as a sterilizing filter. Because the size of fat particles is generally between 0.1 micron and 1 micron, IVFE could occlude 0.22-micron and 0.5-micron filters, or the emulsion could be destabilized if used with these filters. The 5-micron filter removes particulate matter, but would allow many types of microbial contaminants to pass through.

2. Many consumers believe that because dietary supplements are "natural," they must be safe. Which of the following statements regarding the safety of dietary supplements is TRUE? A. The safety of dietary supplements is assured under the Dietary Supplement Health and Education Act (DSHEA). B. Various quality assessment programs exist that verify the quality of dietary supplements, as well as their safety and efficacy. C. There are multiple instances of adulteration of dietary supplements, whether intentional or unintentional, resulting in harm and potential death. D. Dietary supplements do not have the potential for interacting with prescription or over-thecounter medications.

2. The correct answer is C. Under DSHEA, the burden of proof of harm lies with the Food and Drug Administration (FDA) meaning if the FDA has a safety concern about a dietary supplement, the FDA must prove that the product will be harmful before requiring that product be removed from the shelves. Although quality assessment programs exist to verify the quality of individual product lots, they do not verify efficacy or safety. A multitude of case reports exist documenting adulteration of dietary supplements and the subsequent development of adverse effects. For example, a Chinese herbal weight loss product was adulterated with Aristolochia species, resulting in irreversible renal failure and urothelial cancer

2. Which of the following statements regarding the use of the gastrointestinal (GI) tract in trauma patients is TRUE? A. EN should be provided to achieve estimated energy requirements within 24 hours of injury to achieve the immune benefits. B. EN cannot be given until at least 96 hours after injury because of small bowel ileus. C. Jejunal feeding is safe even during low-flow states because the GI tract can increase its oxygen extraction 10-fold. D. A trauma patient may not require nutrition support if he or she eats within 3 to 5 days of injury.

2. The correct answer is D. Even though metabolic response to injury increases the metabolic rate, initiating intravenous or tube feeding for fewer than 3 to 5 days or for a relatively minor injury is unlikely to benefit the patient. If, however, the patient is unable to consume adequate nutrients within 3 to 5 days of injury, then an alternative nutrition plan should be implemented.

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

2. The correct answer is D. Surveys have shown varying percentages of the U.S. population using dietary supplements. Data from a large nationwide survey published in 2011 indicated that about 53% of adults use them. Many persons using dietary supplements do not report this use to their allopathic health providers. This lack of disclosure could be due to the patient's not thinking of these supplements as medications or their believing that the health provider will be judgmental about their use. Although most patients think that their health care provider should be knowledgeable regarding dietary supplements, only about half of patients in a recent survey felt that these providers actually were knowledgeable. Many patients using dietary supplements also use prescription medications; this concomitant use could result in supplement interactions with medication or increased incidence of adverse events

3. Which of the following is the preferred method of administering a hospitalized patient's antihypertensive medication when tube feeding is administered? A. By the oral route B. As an oral liquid via the feeding tube C. As a crushed tablet via the feeding tube D. By the intravenous (IV) route

3. The correct answer is A. The oral route is preferred whenever possible because this is the route oral medications were designed to be administered. If the patient is allowed to take adequate water to swallow the medication, the oral route should be considered. For medications to be taken with food, the patient should have either food from oral ingestion or enteral formulation in the stomach before medication administration by mouth. Medications that are not administered via the feeding tube will not cause tube occlusion, making this a very effective method of preventing tube occlusion caused by medications.

3. Which of the following statements regarding nutrition requirements of the trauma patient is true? A. Trauma patients typically require 35 to 45 kcal/ kg/d from nutrition support because of their hypermetabolism and negative nitrogen balance. B. Trauma patients typically require 25 to 30 kcal/ kg/d from nutrition support because of their hypermetabolism and negative nitrogen balance. C. The optimal protein requirement for trauma patients is 2.5 to 3.0 g/kg/d. D. Carbohydrate should be provided at a rate of 8 mg/kg/min with insulin administration as needed to maintain optimal serum glucose concentrations.

3. The correct answer is B. Despite hypermetabolism and increased nitrogen losses, trauma patients typically require 25 to 30 kcal/kg/d. Amounts greater than this may cause metabolic complications and feeding intolerance. The optimal protein requirement for trauma patients is 1.5 to 2.0 g/kg/d. Excessive protein administration has not been shown to be beneficial and, in fact, may cause azotemia.1 Carbohydrate administration should not exceed the maximum rate of glucose oxidation, which is 4 to 7 mg/kg/min.

3. Dietary supplement use in the United States continues to grow in popularity. Which of the following recommendations is suggested for advising patients regarding dietary supplements? A. Discourage patients from disclosing their use of dietary supplements to their health care providers. B. Do not recommend these products in infants, children, elderly patients, or those with multiple chronic diseases taking several medications on a daily basis. C. Reassure patients that misinformation in advertising pertaining to dietary supplements is minimal because it is regulated by the Federal Trade Commission (FTC). D. Recommend continuing therapy indefinitely if a given dietary supplement seems to be working

3. The correct answer is B. Dietary supplements have not been adequately evaluated for safety in infants, children, and elderly patients, and they have the potential for interacting with medications and/or disease states in those with serious medical conditions. Patients should be encouraged to talk about their dietary supplement use; otherwise, adverse effects and/or interactions may arise that could have been prevented if the health care provider knew the patient was taking these products. Misinformation pertaining to these products abounds, particularly in health food stores and on the Internet. Although the FTC is responsible for dietary supplement advertising, there remain numerous instances of misleading and false advertising claims. Dietary supplements should only be taken as recommended by the manufacturer; just because a supplement is safe and efficacious in the short term does not indicate it will be safe and efficacious long term.

3. Which of the following nutrients has been shown to be toxic during pregnancy when ingested at high levels? A. Calcium B. Vitamin A C. Folic acid D. Choline

3. The correct answer is B. Maternal intake of high doses of vitamin A have been associated with adverse fetal outcome.8-11 On the other hand, supplementation of calcium (> 2000 mg/d) or folic acid (as much as 4 mg/d), which is significantly above the dietary reference intakes (DRIs), is not considered to be harmful and is sometimes prescribed for pregnant women.12,13 For example, extra folic acid is provided as prophylactic treatment for women with a history of fetal neural tube defect. Extra calcium may be supplemented as an attempt to prevent pregnancy-induced hypertension, although this therapy has not been proved to be beneficial.

3. All of the following are recommended to prevent formula contamination except: A. Use aseptic technique when preparing formula B. Use formula decanted from a flip top container C. Change administration sets every 24 hours D. Allow sterile decanted formula to hang for no longer than 8 hours

3. The correct answer is B. Using formula decanted from a screw cap container instead of a flip top container has resulted in less contamination. Aseptic technique for formula preparation, changing administration sets daily, and allowing sterile formula to hang for 8 hours or less are all recommended to prevent formula contamination

3. Which of the following criteria is used to define a catheter-related bloodstream infection? A. Erythema and purulence at the catheter site B. Growth of ≥ 15 colony-forming units from the proximal catheter segment C. Isolation of the same organism from a semiquantitative culture of the catheter segment and blood D. Induration extending beyond 2 cm of the catheter exit site and fever

3. The correct answer is C. All answers describe signs or symptoms of catheter-related infection. Systemic catheter-related infections are now more accurately identified as catheter-related bloodstream infections (CR-BSI).3,5,6 To define CR-BSI more clearly, standardized criteria have been accepted. These criteria span a variety of culturing techniques based on laboratory testing methods and if the catheter is removed or left indwelling. Criteria for defining a CR-BSI include systemic symptoms in a patient with no other source of infection and either: isolation of the same organism (≥15 colony-forming units [CFUs]) from a semiquantitative or quantitative culture of the catheter segment and from a peripherally drawn blood culture; simultaneous quantitative cultures of blood with a ratio of ≥5:1 CVC versus peripheral; or differential time to positivity at least 2 hours earlier from the CVC as compared to the peripheral culture. A colonized catheter is defined as a growth of >15 colony-forming units from the proximal catheter segment in the absence of clinical symptoms of infection. Erythema and purulence usually define an exit site infection. When the induration extends beyond 2 cm it is classified as a tunnel infection.

3. What factors differentiate patients experiencing a chronic wound from an acute wound? A. No differences in baseline demands for protein and energy metabolism B. Endogenous arginine stores meet the needs of both groups C. Adequate protein and energy has been shown to enhance healing in both groups D. None of the above

3. The correct answer is C. Although there are distinct differences from acute wounds that should be taken into account when considering the nutritional requirements in an individual with a chronic wound, adequate protein and energy has been shown to enhance healing in both groups. These differences may be due to a number of factors including chronic stress state, greater than baseline demands for protein metabolism, protein calorie malnutrition, hypercatabolism, comorbidities, and/or dehydration. Chronic wounds are characterized by a disruption in the sequence of expected healing events or prolonged inflammatory metabolism.8-13 There are also distinct differences at the molecular level of chronic wounds; increased levels of inflammatory cytokines such as tumor necrosis factor alpha, interleukin-1 and -6, and proteases such as matrix metalloproteinases, particularly matrix metalloproteinase-2 and matrix metalloproteinase-9, are evident in chronic wound fluid. This results in an inhibition of fibroblast and endothelial cell proliferation and function, as well as decreased levels of tissue inhibitors of metalloproteinases. Increased bacterial burden (tissue bacterial levels exceed 100,000 colony forming units per gram of tissue) and altered keratinocyte function as well as extracellular matrix degradation have also been implicated in chronic wounds.8-13 Endogenous sources of arginine stores are compromised and may not adequately meet the needs for adequate wound healing of complex acute and chronic wounds healing.1-5 Individuals who experience involuntary weight loss and protein calorie malnutrition (PCM) are at risk for delayed wound healing. Although PCM is implicated as a factor in impaired wound healing, it is also related to susceptibility to infection and increased risk of developing chronic wounds including pressure ulcers, diabetic ulcers, venous ulcers, and dehisced surgical wounds.4,5 Nutrition regimens for preventing skin breakdown and enhancing wound healing are controversial because of a lack of randomized clinical trials and outcomes data to support treatment. This demonstrates the need for further research and emphasizes the importance of individualized nutrition care plans for high-risk patients. This chapter presents an overview of literature on the role of nutrition support in the healing of wounds to help guide clinical practice and identify implications for further research. There is also a section on monitoring wound healing. Finally, the chapter concludes with practice scenarios that illustrate common practice problems associated with wound healing and nutrition support.

3. Which of the following measures would be considered most beneficial in a patient receiving longterm PN who develops cholestasis? A. Stop all oral or enteral intake. B. Switch from a cyclic to continuous method of PN administration. C. Decrease intravenous fat emulsion (IVFE) dose from 2 g/kg/d to less than 1 g/kg/d. D. Increase protein dose from 1 to 2 g/kg/d

3. The correct answer is C. Cholestasis has been associated with IVFE doses greater than 1 g/kg/d in adult patients receiving long-term PN,6 and a trial of lowering the IVFE dose may, therefore, be beneficial. Cyclic infusion has been shown to reduce serum liver enzyme and conjugated bilirubin concentrations when compared to continuous infusion. 7 Enteral feeding should be attempted to promote enterohepatic circulation of bile acids.

3. Which of the following statements about maternal energy needs in pregnancy is accurate? A. Five hundred kcals/d to support pregnancy should be added to calculated energy needs derived from traditional energy predictive formulas used in potentially hypermetabolic conditions. B. Providing 36 to 40 kcals/kg of pregravid weight is acceptable to support pregnancy in most women. C. Estimated daily energy requirement in pregnancy increases above nonpregnant values by about 180 to 340 kcals/d. D. An extra 5 kcals/kg of pregravid weight should be added to daily energy calculations during the first trimester of pregnancy.

3. The correct answer is C. The Food and Nutrition Board has determined that the daily estimated energy requirement in pregnancy should be increased by 8 kcals per each second or third trimester week plus 180 kcals/d energy deposition.8 Formulas used to calculate energy needs in potentially hypermetabolic conditions should be adjusted by 200 to 300 kcals/d to support pregnancy. While 36 to 40 kcals/kg is recommended for women whose pregravid weight was less than desirable, lower energy provisions are recommended for other pregnant women.9 No increase in energy needs are indicated during the first trimester

3. Which of the following practices has been shown to reduce the risk of central line-associated infections? A. Systemic use of antimicrobial prophylaxis at the time of insertion or access B. Routine replacement of central venous devices C. Use of the central line bundle for insertion and maintenance D. Selection of an internal jugular site as opposed to subclavian site

3. The correct answer is C. The central line bundle for insertion and maintenance includes: maximal barrier precautions; wearing a cap, masks, gown, and gloves; and skin antisepsis with chlorhexidine gluconate (CHG). The use of this bundle has been documented to decrease the incidence of catheter-associated infections. The systemic use of antimicrobial prophylaxis at the time of insertion or access is not recommended and may actually promote the resistance of microbial populations associated with catheter infections. The routine replacement of CVADs is not recommended, and catheters should only be removed when clinically indicated. Studies have shown a lower rate of catheter-associated infections in line placements via the subclavian site.4

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

3. The correct answer is C. The higher the concentration of amino acids in the formulation, the less likely precipitation is to occur. Amino acids can form soluble complexes with calcium, which reduce the effective concentrations of free calcium available to form insoluble precipitates with phosphorus ions. Calcium chloride is more dissociated than calcium gluconate making the risk of precipitation with phosphate higher. The salt form of phosphate does not affect calcium solubility if the phosphate amount remains constant; that is, one mmol of phosphate as the sodium salt has the same potential to precipitate with calcium as one mmol of phosphate as the potassium salt. However, there is more phosphate per mEq of sodium as phosphate (4 mEq of sodium to 3 mmol of phosphorus) than per mEq of potassium as phosphate (4.4 mEq of potassium to 3 mmol of phosphate). Precipitation is more likely to occur at warmer temperatures because increased dissociation of calcium salts occurs as the temperature rises, promoting the availability of ions to form insoluble complexes with phosphate.6

3. Which of the following antioxidants have not been shown to benefit trauma patients? A. Vitamin C B. Vitamin E C. Selenium D. Zinc

3. The correct answer is D. Numerous studies have evaluated antioxidants in the critically ill; however, few have focused on trauma patients. Vitamins C and E combined have demonstrated some improvement in a prospective trial with trauma patients. In a large but retrospective study of strictly trauma patients, lower mortality was associated with the use of vitamins C and E, and selenium in combination. Zinc administration has not demonstrated improved outcomes in trauma patients.

3. Even if current Good Manufacturing Practices (cGMPs) promulgated by the DSHEA are being properly implemented, which of the following would still be likely to occur? A. A dietary supplement product adulterated with a prescription drug such as sibutramine is being marketed and sold. B. A dietary supplement product is analyzed and found to have much less of the active ingredient than what is indicated on the label. C. A dietary supplement product is analyzed and found to have much more of the active ingredient than what is indicated on the label. D. A dietary supplement product is marketed and sold, but there are no studies to confirm its efficacy for any condition.

3. The correct answer is D. The DSHEA mandated that cGMPs be set up for the dietary supplement industry. Under these cGMPs, which were supposed to be fully implemented by 2010, process controls are to be in place at each step of manufacturing. Thus, the dietary supplements arriving on the shelf should contain the correct ingredients in the correct amounts and should be free of adulterants. There should be consistency between lots in terms of content. Unfortunately, the FDA does not have the manpower to do extensive inspection of manufacturing plants and final products. The cGMPs do not address whether there are any data supporting the efficacy of dietary supplements.

4. The National Healthcare Safety Network criteria for central line-associated bloodstream infection (CLABSI) includes all of the following except: A. The catheter must be in place for a minimum of 24 hours. B. The patient must have a recognized pathogen cultured from one or more blood cultures, which is not associated with any other site of infection. C. The patient exhibits one of the following: fever (38°C), chills, or hypotension. D. If the patient is 1 year of age and has at least one of the following signs or symptoms: fever, (38°C), hypothermia (36°C core), apnea or bradycardia, and a positive laboratory culture not related to another infected site.

4. The correct answer is A. CLABSI represents a new nomenclature that is slightly different from the previously used terminology, catheter-related bloodstream infection (CR-BSI).4 CLABSI is primarily used for surveillance, whereas CR-BSI is designated as a clinical definition for practice and research. CR-BSI requires clear laboratory findings associating the catheter with infection, including a pathogen cultured with either a quantitative blood culture or a differential time to positivity laboratory testing and no other source of infection. CLABSI requires one of the following four criteria: the patient must have a recognized pathogen cultured from one or more blood cultures that is not associated with any other site of possible infection; symptoms of a fever; hypotension, or in the case of a patient 1 year of age, symptoms of fever, hypothermia, apnea, or bradycardia; and the catheter must have been in place for 48 hours.

4. Thrombotic occlusions are most commonly treated with which of the following: A. Thrombolytics B. Anticoagulants C. 0.1 N HCl D. Sodium bicarbonate

4. The correct answer is A. Catheter occlusions are commonly secondary to a thrombotic etiology.7 Thrombotic causes include intraluminal thrombus, extraluminal fibrin sleeve, and vessel thrombosis.8 The successful use of thrombolytics to treat catheters occluded with thrombus are well documented. Traditionally, streptokinase and urokinase have been used. These agents lyse thrombus by activating and converting plasminogen to plasmin. Plasmin degrades fibrin clots.9 More recently, tissue plasminogen activator (TPA) has also been used. Nonthrombogenic catheter occlusion includes intraluminal drug and lipid precipitates.10 Pharmacological agents that change the pH within the lumen increase the solubility of the precipitate

4. A medication that is ordered as a liquid to be administered via the feeding tube is available in the pharmacy in the IV form, as a capsule (powdered drug in a hard gelatin capsule), and as a film-coated tablet. What is the most appropriate and cost-effective choice for administration of this medication? A. Administer the IV form via the IV route. B. Administer the IV form via the feeding tube. C. Make a slurry of the capsule powder and administer via the feeding tube. D. Crush the tablet to a fine powder and administer via the feeding tube.

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

4. Serum prealbumin concentration is not recommended in the nutrition assessment of septic, critically ill patients because: A. The half-life of prealbumin is approximately 2 days. B. Serum concentrations decrease with exogenous albumin administration. C. Sepsis and inflammation down-regulate the production of prealbumin. D. Anthropometric measures are more cost-effective.

4. The correct answer is C. Serum prealbumin has a rapid turnover and small total body pool, which makes it an attractive indicator of nutritional status. It is not affected by exogenous albumin infusions, which are sometimes administered in the intensive care unit (ICU) patient. However, prealbumin is affected by inflammation and hepatic reprioritization (Chapters 9 and 23). For this reason, it is not recommended as an evaluative tool during sepsis.

4. Which of the following PN modifications is recommended for the prevention and/or treatment of osteoporosis in a long-term PN patient? A. Maintain protein intake at least 2 g/kg/d. B. Provide calcium gluconate greater than 20 mEq/d. C. Supplement the multivitamin preparation with additional vitamin D. D. Provide phosphorus 20-40 mmol/d.

4. The correct answer is D. An inadequate phosphorus dose may increase urinary calcium excretion, therefore doses of 20 to 40 mmol/d added to the PN formulation have been recommended.8 Although patients receiving PN are vulnerable to a negative calcium balance, calcium supplementation in the PN formulation is limited by physical compatibility with phosphorus and higher doses are offset by higher urinary losses. The recommended dose of calcium gluconate to be added to the PN formulation is 10 to 15 mEq/d.8 High protein doses (2 g/ kg/d compared with 1 g/kg/d) in PN formulations have been associated with increased urinary calcium excretion in adult patients. Excessive vitamin D doses can be detrimental to the bone because it can suppress parathyroid hormone and promote bone resorption

4. According to recommendations by the National Advisory Group on Standards and Practice Guidelines for Parenteral Nutrition Formulations, the amount of dextrose used in preparation of a PN formulation is required to appear on the label as the: A. percentage of original concentration and volume (dextrose 50% water, 500 mL). B. percentage of final concentration after admixture (dextrose 25%). C. grams per liter of PN admixed (dextrose 250 g/L). D. grams per day (dextrose 250 g/d).

4. The correct answer is D. Grams of dextrose per day is most consistent with that of a nutrient label, supports the use of the 24-hour nutrient infusion system, and requires the least number of calculations to determine the calories per day. Using the quantity per liter is an option that may appear on the label by adding a second column reflecting quantities per liter in parentheses.

5. A patient requires approximately 70 g of protein and 1700 total kcal/d. Which of the following regimens would most closely supply this patient's needs? A. Manually compounded mix of equal volumes of dextrose 30% water and amino acids 8.5% (initial concentrations used in compounding) to infuse at 70 mL/h with IVFE 10%, 500 mL/d, piggybacked into the PN line B. Manually compounded mix of equal volumes of dextrose 50% water and amino acids 10% (initial concentrations used in compounding) to infuse at 60 mL/h with IVFE 20%, 300 mL/d, piggybacked into the PN line C. TNA containing amino acids 10%, 700 mL, dextrose 50% water, 650 mL, and IVFE 20%, 300 mL, per daily bag D. TNA containing amino acids 8.5%, 850 mL, dextrose 30% water, 600 mL, and IVFE 10%, 500 mL, per daily bag

5. The correct answer is A. At 70 mL/h × 24 h/d, a total of 1680 mL of dextrose/amino acids formulation will be infused each day, or dextrose 30% water, 840 mL, plus amino acids 8.5%, 840 mL. Dextrose 30% water, 840 mL, provides 30 g/100 mL = X g/840 mL; solving for X yields dextrose 252 g. This represents 252 g × 3.4 kcal/g = 857 dextrose kcal. Amino acids 8.5%, 840 mL, provides 8.5 g/ 100 mL = X g/840 mL; solving for X yields amino acids 71 g, which supplies 284 kcal. IVFE 10%, 500 mL, supplies 500 mL × 1.1 kcal/mL or 550 kcal. Thus, the total kcal from this regimen is 857 + 284 + 550 = 1691 kcal. Answer B supplies 2112 kcal and amino acids 72 g. Answer C supplies 1985 kcal and amino acids 70 g. Answer D supplies 1451 kcal and amino acids 72 g.

One of the best validated screening indicators for malnutrition risk is what? A. Patient reports a nonvolitional weight loss of 10% of usual body weight. B. Patient reports following a low-carbohydrate weight loss diet. C. Patient is 2 days status post laparoscopic cholecystectomy. D Patient reports a recent flu-like febrile illness.

The correct answer A. The only well-validated indicator of the options provided to screen for malnutrition risk is a nonvolitional weight loss of 10% of usual body weight. The other options might all be noted in screening and assessment but do not in and of themselves confer validated measures of malnutrition risk.

The National Healthcare Safety Network criteria for central line-associated bloodstream infection (CLABSI) includes all of the following except: A. The catheter must be in place for a minimum of 24 hours. B. The patient must have a recognized pathogen cultured from one or more blood cultures, which is not associated with any other site of infection. C. The patient exhibits one of the following: fever (38°C), chills, or hypotension. D. If the patient is 1 year of age and has at least one of the following signs or symptoms: fever, (38°C), hypothermia (36°C core), apnea or bradycardia, and a positive laboratory culture not related to another infected site

The correct answer is A. CLABSI represents a new nomenclature that is slightly different from the previously used terminology, catheter-related bloodstream infection (CR-BSI).4 CLABSI is primarily used for surveillance, whereas CR-BSI is designated as a clinical definition for practice and research. CR-BSI requires clear laboratory findings associating the catheter with infection, including a pathogen cultured with either a quantitative blood culture or a differential time to positivity laboratory testing and no other source of infection. CLABSI requires one of the following four criteria: the patient must have a recognized pathogen cultured from one or more blood cultures that is not associated with any other site of possible infection; symptoms of a fever; hypotension, or in the case of a patient 1 year of age, symptoms of fever, hypothermia, apnea, or bradycardia; and the catheter must have been in place for 48 hours.

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

The correct answer is A. Catheter occlusions are commonly secondary to a thrombotic etiology. Thrombotic causes include an intraluminal thrombus, an extraluminal fibrin sleeve, and vessel thrombosis.3 The successful use of thrombolytics to treat catheters occluded with a thrombus is well documented. Historically, streptokinase and urokinase have been used. These agents lyse thrombus by activating and converting plasminogen to plasmin. Plasmin degrades fibrin clots. More recently, tissue plasminogen activator (TPA) has also been used. Nonthrombogenic catheter occlusion includes intraluminal drug and lipid precipitates. Pharmacological agents that change the pH within the lumen increase the solubility of the precipitate.3

initial action for the management of tube feedingassociated diarrhea? A. Change to an enteral formulation with fiber. B. Discontinue tube feeding and begin parenteral nutrition (PN). C. Change to a peptide-based enteral formulation. D. Add an antimotility agent

The correct answer is A. If clinically significant diarrhea develops during EN, the most appropriate initial action is to add fiber either by changing to a formulation that contains fiber or by adding fiber. Other reasonable approaches include changing to continuous duodenal feeding or decreasing the rate of infusion. Enteric pathogens and disease or inflammatory processes must also be ruled out as contributing factors. Adding an antimotility agent or changing to a peptide-based formula should be considered if diarrhea continues despite these initial approaches. PN should be initiated only if all treatment modalities fail (see Figure 13-1)

Which of the following nutrition regimens is most appropriate for a patient with respiratory failure and difficulty weaning from a ventilator? A. 25 kcal/kg standard intact formulation B. 35 kcal/kg standard intact formulation C. 25 kcal/kg low-carbohydrate, high-fat pulmonary formulation D. 35 kcal/kg low-carbohydrate, high-fat pulmonary formulation

The correct answer is A. Patients with respiratory failure should be fed approximately 25 kcal/kg/d. Overfeeding total kilocalories may lead to hypercapnia, making it difficult to wean the patient from the ventilator. As long as patients are not overfed total kilocalories, a low-carbohydrate, high-fat pulmonary formulation has no additional benefit

Which one of the following practices has been shown to prevent catheter-related infections? A. The use of maximal barrier precautions during CVC insertion B. Routine replacement of CVCs C. Prophylactic use of antibiotics before catheter placement D. The use of 10% povidone-iodine as a skin antisepticjo ]

The correct answer is A. The key to reducing catheterrelated infections is prevention. The Centers for Disease Control and Prevention (CDC) has revised previously published guidelines addressing the prevention of intravascular catheter-related infections.3 A working group of 13 professional organizations convened to review and provide to practitioners evidence-based guidelines. The strongest emphasis was given to five areas of recommended practice: education and training of health care providers, the use of maximal barrier precautions during CVC insertion, skin antisepsis using 2% chlorhexidine, the avoidance of routine replacement of CVCs and the indication for antiseptic/antibiotic bonded types of catheters in high-risk patient populations. A 2% chlorhexidine solution is shown to be a superior

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

The correct answer is A. The nutrient that is added to rehydration liquids to promote Na+ and water absorption in patients with diarrhea is glucose. The presence of glucose in the lumen of the small intestines facilitates the absorption of Na+. When more Na+ is absorbed, the osmotic load of the intestine contents is decreased. If the osmotic load of the intestinal contents is decreased, the osmotic influx of water is decreased, and diarrhea decreases. For this reason, oral rehydration fluids used to treat Na+ and water losses from diarrhea include NaCl and glucose.6

3. PN is contraindicated in which of the following conditions? A. Do Not Resuscitate (DNR) status B. Peritonitis C. Intestinal hemorrhage D. High-output fistulas

The correct answer is A. Trujillo and colleagues abstracted indications for PN from the 1993 A.S.P.E.N. guidelines as peritonitis, intestinal hemorrhage, intestinal obstruction, intractable vomiting, paralytic ileus, severe pancreatitis, stool output greater than 1 L/d, high-output fistulas, short bowel syndrome, and bone marrow recipients.5 Therapy was considered to be contraindicated if the patients were classified as well nourished and had inadequate enteral nutrition (EN) for less than 7 days; had a DNR status, and were deemed to warrant comfort measures only or terminally ill; or those receiving adequate EN.

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

The correct answer is A. Trujillo and colleagues5 abstracted indications for PN from the 1993 A.S.P.E.N. guidelines as peritonitis, intestinal hemorrhage, intestinal obstruction, intractable vomiting, paralytic ileus, severe pancreatitis, stool output greater than 1 L/d, high-output fistulas, short bowel syndrome, and bone marrow recipients. Therapy was considered to be contraindicated if the patients were classified as well nourished and had inadequate enteral nutrition (EN) for less than 7 days; had a DNR status, and were deemed to warrant comfort measures only or terminally ill; or those receiving adequate EN.

All of the following are characteristic of enteral product formulations EXCEPT: A. Rigorous clinical trials of efficacy and safety exist similar to those pertaining to medication approval. B. Formula content is based on general nutrition principles and concepts of the Dietary Reference Intakes (DRI). C. Products are categorized as "medical foods" by the Food and Drug Administration (FDA). D. Water is a significant ingredient

The correct answer is A. Unlike FDA-approved medications, enteral product formulations do not undergo rigorous clinical trials for efficacy and safety. The products are consistent with the principles,concepts, and criteria of general nutrition references such as the Institute of Medicine's Dietary Reference Intakes. The FDA categorizes enteral product formulations as "medical foods." Most products comprise 70% to 85% water.

You are asked to see a patient admitted from a nursing home with aspiration pneumonia and skin excoriation from leakage of gastric contents at the gastrostomy site. You notice that the patient has a foley catheter type gastrostomy, the peristomal area is denuded from leakage of gastric contents, and that the tube has migrated into the stomach. What is your initial assessment of this situation? A. Tube migration has caused the inflated balloon to obstruct the pylorus. The catheter will need to be replaced with a tube designed for gastric feeding. B. Immediately pull the foley catheter out and call the wound care nurse. C. Recommend a tube study and keep the patient NPO. D. Start parenteral nutrition.

The correct answer is A. Use of a foley catheter as an enteral access device should be avoided. These catheters do not have an external retention device and are prone to migrate and obstruct the pylorus risking vomiting and aspiration of stomach contents. The foley catheter has the potential to migrate into and obstruct the small bowel due to the inflated balloon inflated with up to 20 mL of fluid. Removal of this catheter without a replacement tube will result in closure of the stoma. If the tube had migrated into the small bowel, removal of the tube without deflating the balloon can result in intestinal intussusception and small bowel necrosis. Once an appropriate feeding tube is in place, enteral feedings can begin and parenteral nutrition avoided

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

The correct answer is B. A review of PN literature has reported improved outcomes in patients with upper GI tract malignancies when PN is initiated 7 days before surgery.3 An early report of a decrease in length of stay and infectious complications in allogeneic bone marrow transplant patients receiving PN has not been confirmed.4 A review of published data on the use of PN in cancer chemotherapy, perioperative period, and critical illness reports no positive effect of PN on clinical outcome and a significant increase in infectious complications in patients randomized to PN therapy as compared to those receiving no nutrition support.

The correct answer is B. A review of PN literature has reported improved outcomes in patients with upper GI tract malignancies when PN is initiated 7 days before surgery. 3 An early report of a decrease in length of stay and infectious complications in allogeneic bone marrow transplant patients receiving PN has not been confirmed.4 A review of published data on the use of PN in cancer chemotherapy, in the perioperative period, and during critical illness reports no positive effect of PN on the clinical outcome and a significant increase in infectious complications in patients randomized to PN therapy as compared to those receiving no nutritional support.3

The entire enteral feeding system, from the feeding tubes to the bags and sets, has been reviewed and is being redesigned in an effort to avoid any potentially dangerous complications associated with medical misconnections. Medical misconnections are primarily associated with _________ connectors. A. Syringe B. Luer C. Y-port D. Dialysis catheter

The correct answer is B. At the center of the catheter/tubing misconnections in health care are the Luer connector systems. These Luer connectors are called Luer-Lok, Luer-Slip, Luer tip, or small-bore connectors.7 As a part of the new 2013 enteral standards developed by the International Organization for Standardization, female Luer connectors will no longer be found on feeding tubes. This will force the use of a compatible oral/enteral syringe to give oral medications via a feeding tube

Which of the following practices is most likely to succeed in improving oral nutrient intake in patients with a prolonged history of weight loss due to poor intake, nausea, and depressed appetite? A. Provide a high calorie oral liquid supplement three times daily. B. Offer six small, low-fat meals daily. C. Order fiber supplemented snacks three times daily. D. Plan primarily solid meals; limit fluids.

The correct answer is B. Because their stomach size often shrinks, patients with prolonged negative energy balance may not be able to consume their goal nutrient targets in three meals.1 Six small meals may be more realistic. To address nausea, measures should be taken to prevent slowing of gastric emptying, which could potentiate nausea. These measures may include limiting high-fat foods.2,3 Providing high-calorie or high-fiber supplements may not initially be the best recommendation because, like fat, caloric density and fiber content can slow gastric emptying.2-4 Answer D is not a good choice because providing fluids, not limiting them, facilitates gastric emptying.2

A 55-year-old critically ill patient has been tolerating a standard 1 cal/mL feeding formula well over the past week. She begins having frequent bouts of loose stools. What should be the clinician's next suggestion? A. Change to a peptide-based formula B. Determine the cause of diarrhea C. Add pre- and probiotics D. Change to a fiber-supplemented formula

The correct answer is B. Determining the cause of acute diarrhea is the correct answer. The feeding formula that she had been tolerating fine over the past week is the least likely cause of the diarrhea. Assessing for newly ordered medications that can cause diarrhea or ruling out infections such as Clostridium difficile may help to determine the cause of diarrhea. If no obvious cause of diarrhea can be found, then a different feeding formula may be trialed

Which of the following actions is most appropriate for enhancing gastric emptying during EN? A. Keep the bed in Trendelenburg position. B. Decrease the volume of each bolus feeding. C. Switch to an enteral formulation with a higher fat content. D. Switch to an enteral formulation with a higher protein content

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

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

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

The correct answer is B. If clinically significant diarrhea develops during EN, the most appropriate initial action is to evaluate whether hyperosmolar medications are being administered that could result in liquid stooling. If none are in use, assessing for the presence of Clostridium difficile- induced diarrhea is suggested; if negative, the addition of fiber either by changing to a formulation that contains fiber or by providing supplemental fiber may be beneficial. Adding an antimotility agent or changing to a peptide-based formula should be considered if diarrhea continues despite these initial approaches. Parenteral nutrition (PN) should be initiated only if all treatment modalities fail (Figure 13-1)

Which method is recommended to maintain the patency of an enteral access device? A. Flush daily with a mixture of cranberry juice and club soda B. Routine flushing with water C. Administer all medications together in one syringe to avoid repeated entry into the access device D. Weekly exchange of the feeding tube to avoid clogging from medications and formula residue

The correct answer is B. Routine flushing with water is the method of choice for maintaining patency of enteral access devices (Chapter 13). The use of sodas and juices can interact with medications and formula to actually potentiate clogging of the feeding tube. Several methods are available to assist in the event that a tube becomes clogged. These methods include the use of pancreatic enzymes mixed with bicarbonate, a mixture of digestive enzymes in a prefilled syringe, or a declogger that mechanically breaks down the obstruction. Unless performed under fluoroscopic guidance, the insertion of a stylet or guidewire to clear the blockage is not advised because of the risk of piercing the catheter and perforating the gastrointestinal tract

All of the following are recommended to prevent formula contamination except: A. Use aseptic technique when preparing formula B. Use formula decanted from a flip top container C. Change administration sets every 24 hours D. Allow sterile decanted formula to hang for no longer than 8 hours

The correct answer is B. Using formula decanted from a screw cap container instead of a flip top container has resulted in less contamination. Aseptic technique for formula preparation, changing administration sets daily, and allowing sterile formula to hang for 8 hours or less are all recommended to prevent formula contamination.

Which of the following is the most appropriate vascular access device for a patient requiring long-term parenteral nutrition (PN) therapy? A. Use of a midclavicular catheter as a cost-effective measure B. Placing a percutaneous nontunneled catheter to initiate PN and then replacement with an implanted port C. Placement of a single-lumen tunneled cuffed catheter D. Placement of a triple-lumen antibiotic-coated catheter to ensure adequate access for future needs

The correct answer is C. A single-lumen cuffed CVC would be the preferred device. The tunneled catheter was originally developed for patients with long-term PN.1 Tunneled catheters have been demonstrated to be safe and effective in long-term therapies ranging from months to years.2 A midclavicular catheter does not provide central access and, therefore, would not be an appropriate catheter choice. Percutaneous nontunneled catheters with additional features of multiple lumens and an antibiotic/antimicrobial coating provide PN access in the acute care setting for a shorter duration of time. It would be best to start with selection of the optimal device rather than a planned replacement. Ports are an alternative to external lumen catheters, and patients need to understand that repeated needle sticks will be required for daily therapy.

Which of the following criteria is used to define a catheter-related bloodstream infection? A. Erythema and purulence at the catheter site B. Growth of ≥ 15 colony-forming units from the proximal catheter segment C. Isolation of the same organism from a semiquantitative culture of the catheter segment and blood D. Induration extending beyond 2 cm of the catheter exit site and fever

The correct answer is C. All answers describe signs or symptoms of catheter-related infection. Systemic catheter-related infections are now more accurately identified as catheter-related bloodstream infections (CR-BSI).3,5,6 To define CR-BSI more clearly, standardized criteria have been accepted. These criteria span a variety of culturing techniques based on laboratory testing methods and if the catheter is removed or left indwelling. Criteria for defining a CR-BSI include systemic symptoms in a patient with no other source of infection and either: isolation of the same organism (≥15 colony-forming units [CFUs]) from a semiquantitative or quantitative culture of the catheter segment and from a peripherally drawn blood culture; simultaneous quantitative cultures of blood with a ratio of ≥5:1 CVC versus peripheral; or differential time to positivity at least 2 hours earlier from the CVC as compared to the peripheral culture. A colonized catheter is defined as a growth of >15 colony-forming units from the proximal catheter segment in the absence of clinical symptoms of infection. Erythema and purulence usually define an exit site infection. When the induration extends beyond 2 cm it is classified as a tunnel infection.

All of the following are attributes of closed enteral nutrition systems EXCEPT: A. Lower rates of contamination B. Ready to hang C. Easily adjusted/customized to meet patient needs D. Less nursing time involved

The correct answer is C. Because the closed system containers are premixed and ready to hang, the addition of other additives is restricted. However, there is less manipulation, labor involvement (nursing time), and opportunity for contamination associated with closed systems

Which of the following methods is not recommended when attempting to unclog a feeding tube? A. Flush with warm water and gentle pressure. B. Instill a mixture of bicarbonate and pancreatic enzyme solution into the feeding tube. C. Flush the feeding tube with cranberry juice. D. Utilize a guide wire with caution

The correct answer is C. Flushing a feeding tube with cranberry juice has been shown to increase the likelihood of a tube clog (Chapter 12). Cranberry juice has an acidic pH, which denatures or "curdles" the protein in the enteral formula, leading to a formula clog. Flushing the tube with warm water using gentle pressure is the method most often used to clear a feeding tube clog. Instilling a mixture of pancreatic enzymes and bicarbonate as well as using a guide wire, with caution, can be utilized as subsequent measures. Guide wire insertion must be done with extreme care, preferably with fluoroscopic guidance, as bowel perforations have occurred when the wire pops through the clog

minimize contamination of the enteral feeding formula? A. Preparation of enteral formulas following handwashing and with the use of sterile gloves. B. Immediate use of a newly opened enteral feeding formula container. C. Infusing reconstituted powered formulas or formulas with added modular components for more than 4 hours. D. Changing an "open" feeding container every 24 hours

The correct answer is C. Infusing a formula prepared from reconstituted powder or one in which modular components have been added should be infused for no more than 4 hours. Infusion times greater than this are associated with formula contamination. Other actions involved with the preparation and administration of enteral feedings including the use of good handwashing and sterile gloves along with immediately using a newly opened formula container will minimize contamination. In addition, changing an "open" feeding container every 24 hours will minimize the bacterial growth than can result in formula contamination.

Monitoring for enteral tube feeding should include all of the following except: A. Monitoring to detect signs of refeeding syndrome B. Assessing for signs of inadequate fluid intake C. Stopping tube feeding for a residual of 100 mL D. Assessing adequacy of nutritional intake

The correct answer is C. Monitoring for enteral feeding should include checking for signs of refeeding syndrome. These may include a precipitous drop in phosphorus, magnesium, and/or potassium levels in addition to fluid retention and other issues.7 Inadequate fluid intake could have very deleterious effects, and monitoring should include watching for signs of this serious consequence of administering enteral feeding without adequate water.8 Critical thinking skills regarding when to administer additional fluid should be encouraged for patients who will be responsible for their own feeding after discharge. As with all nutritional support, periodic assessment is important to ensure that the nutritional regimen is adequately meeting needs. Gastric residual volumes have been found to be poorly correlated with aspiration and are not necessarily an accurate indicator of feeding tolerance, so it is not recommended to stop enteral feeding for an isolated high residual volume.9 The NSP should watch the residual trend and characteristics of the residual, watch for abdominal firmness and distention, and observe the patient's general comfort level

A 62-year-old patient with chronic kidney disease requires hemodialysis three times weekly. Her most recent laboratory work shows a blood urea nitrogen of 65 mg/dL, creatinine 3.2 mg/dL, potassium 3.9 mEq/L, and phosphorus 4.4mg/dL. Which of the following formulas would best meet her nutrient needs? A. A formula restricted in fluid, protein, and electrolytes. B. A formula not restricted in protein but restricted in fluid and electrolytes. C. A formula restricted in fluid but not restricted in protein or electrolytes. D. A formula not restricted in fluid or protein but restricted in electrolytes.

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

Which of the following techniques should be the last one employed in a nutrition-focused physical examination of the abdomen? A. Inspection B. Auscultation C. Palpation D. Percussion

The correct answer is C. Palpation may disturb or distort bowel sounds and is performed last. Although inspection is generally the first tool used in a nutrition-focused physical examination, it is employed throughout the examination, to observe color, shape, texture, and size. Percussion, or tapping to assess the "sounds" of the body, helps to determine the borders, shape, and position of organs. Auscultation, or listening with the ear and/or a stethoscope, allows the examiner to hear sounds in the abdomen and intestines

Which of the following is a contraindication to initiation of enteral nutrition? A. Severe acute pancreatitis B. Inability to eat for 15 days C. Complete mechanical bowel obstruction D. Absence of bowel sounds

The correct answer is C. Studies have not shown enteral nutrition to be contraindicated for patients with severe acute pancreatitis, history of hypotension, or an absence of bowel sounds. In these instances, early feedings should be advanced slowly and, with close monitoring, feedings can generally be advanced as tolerated in these patient populations. 4-6 However, in patients where the bowel is completely obstructed, the initiation of early enteral nutrition is contraindicated.3-5

Which of the following practices has been shown to reduce the risk of central line-associated infections? A. Systemic use of antimicrobial prophylaxis at the time of insertion or access B. Routine replacement of central venous devices C. Use of the central line bundle for insertion and maintenance D. Selection of an internal jugular site as opposed to subclavian site

The correct answer is C. The central line bundle for insertion and maintenance includes: maximal barrier precautions; wearing a cap, masks, gown, and gloves; and skin antisepsis with chlorhexidine gluconate (CHG). The use of this bundle has been documented to decrease the incidence of catheter-associated infections. The systemic use of antimicrobial prophylaxis at the time of insertion or access is not recommended and may actually promote the resistance of microbial populations associated with catheter infections. The routine replacement of CVADs is not recommended, and catheters should only be removed when clinically indicated. Studies have shown a lower rate of catheter-associated infections in line placements via the subclavian site.

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

The correct answer is C. The goal of PN therapy is to maintain the nutritional status of the patient until some form of EN is tolerated. The exception is the critically ill patient in whom therapy is withdrawn during the terminal stages of their disease process. In most other situations, GI function returns, or appropriate enteral access is obtained, and PN is tapered as the amount of reliable enteral intake increases. PN support may be discontinued when the patient is able to tolerate solid food by mouth unless they are elderly, debilitated, or there is a malignancy or ethnic food issues present. Then, a detailed transitional feeding plan should be established

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

The correct answer is C. The goal of PN therapy is to maintain the nutritional status of the patient until some form of EN is tolerated. The exception is the critically ill patient in whom therapy is withdrawn during the terminal stages of their disease process. In most other situations, GI function returns, or appropriate enteral access is obtained, and PN is tapered as the amount of reliable enteral intake increases. PN support may be discontinued when the patient is able to tolerate solid food by mouth unless they are elderly, debilitated, or there is a malignancy or ethnic food issue present. Then, a detailed transitional feeding plan should be established

The two screening criteria that best predict the Subjective Global Assessment Score in hospitalized adult patients are: A. Reduced appetite and swallowing difficulty B. Metabolic stress and gastrointestinal symptoms C. Weight loss and reduced appetite D. Weight loss and bedridden status

The correct answer is C. Unintended weight loss and reduced appetite are the best criteria for predicting nutritional status using a Subjective Global Assessment Score. Metabolic stress is somewhat less predictive followed by bedridden status.

A small-bore nasogastric feeding tube has just been inserted. Which method should be used to determine it has been correctly placed in the stomach? A. Auscultation while insufflating air B. pH testing of gastric contents C. X-ray confirmation D. Aspirating stomach contents

The correct answer is C. X-ray confirmation remains the gold standard for confirming nasogastric and nasointestinal tube placement. Other methods such as auscultation while insufflating air into a nasal tube, pH monitoring, and aspiration of stomach contents should not be used to confirm the initial placement of small-bore nasal tubes, and should be reserved for the monitoring of ongoing placement

The job responsibilities of the nutrition support professional (NSP) in the management of specialized enteral nutrition support include all of the following EXCEPT: A. Utilizing professional standards and guidelines to guide practice B. Instituting measures to promote safety in the clinical setting C. Working to ensure a smooth transition from hospital to home for patients that need EN indefinitely D. Monitoring comments on list serves for ideas to change practice or maintain practice as is because "this is the way we always do it"

The correct answer is D. A, B, and C are all important responsibilities of the NSP. The NSP must carefully evaluate opinions and suggestions for their merit and applicability before making practice changes. Research must be evaluated based on the soundness of the research methodology and ability to be applied in other settings. "We do this because this is the way we always do it" does not necessarily mean that it is in the patient's best interest. The NSP should stay abreast of current research and recommendations for practice and use good judgment in determining if practice in his or her domain, such as in the area of enteral feeding, should be changed.

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

The correct answer is D. Although more confirming evidence is needed, the addition of fermentable fibers to enteral formulas likely has multiple beneficial effects, both in the healthy gut and in the malfunctioning gut. Fermentable fibers (eg, pectin, gums, fructooligosaccharides) are metabolized by colonic bacteria to produce SCFAs. SCFAs have multiple benefits for the intestinal mucosa. These include providing a significant source of energy for and exerting trophic effects on the intestinal lining.

Which of the following measurements is the most reliable indicator of nutritional recovery? A. Nutritional Risk Index B. Nitrogen balance C. Serum albumin D. Anthropometrics

The correct answer is D. Anthropometric measurements provide the best evidence of recovery from uncomplicated malnutrition (as well as evidence of recovery from illness), particularly serial measurements. Serum albumin concentration reflects inflammatory metabolism and even in severe cases of uncomplicated malnutrition such as with anorexia nervosa, serum concentration can be normal. The Nutritional Risk Index is affected by inflammation because it uses serum albumin as well as body weight. Nitrogen balance requires precise quantification of exogenous nitrogen intake and 24-hour urine aliquots, making nitrogen balance calculations difficult.

Which enteral access device is most appropriate for the patient with a complete esophageal obstruction from previous head and neck cancer treated with chemotherapy, radiation, and surgery? A. Nasogastric tube B. Percutaneous endoscopic gastrostomy C. Laparoscopic jejunostomy D. Open gastrostomy

The correct answer is D. Both a nasogastric tube and a percutaneous endoscopic gastrostomy require a patent esophagus. Inserting a feeding tube into the stomach through an open gastrostomy bypasses the oral cavity and the esophageal stricture, making this the access device of choice. This patient does not require a jejunostomy because of a functional stomach.

What is the optimal nutritional support for a moderately malnourished patient with an ileus expected to resolve in 7 to 8 days? A. Central parenteral nutrition (CPN) B. Nasogastric enteral tube feedings C. Postpyloric enteral tube feedings D. Peripheral parenteral nutrition (PPN)

The correct answer is D. PPN may be used for short periods in patients who are not severely malnourished, have adequate peripheral venous access, and can tolerate large volumes of fluid. Although the most current American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines do not address appropriate PPN use, the previous A.S.P.E.N. guidelines indicated that PPN may be used in select patients to provide partial or total nutrition support for up to 2 weeks in patients who cannot ingest or absorb oral or enteral tube-delivered nutrients, or when centralvein PN is not feasible.1 However, patients who are not severely malnourished may tolerate periods of no nutrition for varying periods (up to 7 to 10 days) without adversely affecting their outcome. Therefore, PPN is not the optimal choice for feeding patients with significant malnutrition, severe metabolic stress, large nutrient or electrolyte needs, fluid restriction, and/or the need for prolonged intravenous (IV) nutrition support.2

Early enteral nutrition support in critically ill patients results in positive clinical outcomes through all of the following proposed mechanisms except: A. Preservation of gut barrier function B. Preservation of gastrointestinal mucosal integrity C. Preservation of mucosal immunological functions D. Exacerbation of the hypermetabolic response

The correct answer is D. Preservation of gut barrier function, gastrointestinal mucosal integrity, and mucosal immunological functions are reported benefits associated with the initiation of early enteral nutrition support that promotes such positive clinical outcomes as reduced infectious complications and reduced length of both ICU and hospital length of stay.1-3 Early enteral nutrition reportedly also attenuates the hypermetabolic response in some ICU populations.2,3

An example of a patient condition that would be anticipated to manifest severe systemic inflammatory response would be which of the following? A. Anorexia nervosa with body mass index (BMI) of 15 kg/m2 B. Major depression with compromised dietary intake and 5% loss of body weight C. Homebound elder with restricted access to food and 10% loss of body weight D. Thermal burn injury of second and third degrees covering 15% body surface area

The correct answer is D. The burn injury is significant and will be associated with severe systemic inflammatory response. The diagnosis, clinical signs/physical examination, and laboratory indicators of such a patient will all support this conclusion. The other patient conditions are all states of starvation that are not likely to be associated with severe systemic inflammatory response.

Utilizing the normal route of digestion and absorption of the gastrointestinal (GI) tract supports maintenance of the: A. Functional integrity of the gut B. Gut barrier functions C. Gut-associated and mucosa-associated lymphoid tissues D. All the above

The correct answer is D. The presence of nutrients in the small intestine maintains normal gallbladder function by stimulating the release of cholecystokinin, reducing the risk of cholecystitis that may occur with parenteral nutrition. Besides the benefit of maintaining normal digestive and absorptive capabilities, luminal nutrients provide structural support and also aid to maintain the gut-associated and mucosa-associated lymphoid tissues vital to gut-associated immune function. Immunoglobulin A (IgA), secreted within the GI tract, can prevent bacterial adherence and translocation. IgA production is reduced when intraluminal nutrients are not present.1

A physician tells you a patient has reduced serum albumin of 2.8 g/dL and prealbumin of 14 mg/dL and asks whether these laboratory findings mean the patient is malnourished. Appropriate response or responses would be? A. The patient's protein intake must be inadequate, and the patient should receive prompt nutrition support. B. Additional evidence suggesting loss of body cell mass or compromised dietary intake is warranted in order to appropriately diagnose a malnutrition syndrome. C. Evaluation of clinical and laboratory signs of inflammatory response would be helpful in interpreting these laboratory findings. D. Review of the medical history and clinical diagnosis may help to discern whether inflammatory response and/or malnutrition are likely to be present.

The correct answers are B, C, and D. By themselves, these proteins should be interpreted with caution because they lack specificity and sensitivity as indicators of nutritional status. Both albumin and prealbumin may be reduced by the systemic response to injury, disease, or inflammation. Patients with low albumin or prealbumin may or may not be malnourished. Responses B, C, and D will all help to clarify whether inflammation is present and whether the patient is malnourished.

In critically ill patients, EN should be initiated early within _____ of admission to the intensive care unit (ICU). A. 24 to 48 hours B. 3 to 5 days C. 12 hours D. First hour

be initiated early within 24 to 48 hours of admission to the ICU.2-5 McClave and Heyland propose that there is a "window of opportunity" in which the benefits of early EN (EEN) can be obtained.6 It has been noted that the early delivery of EN affects the functional and structural integrity of the GI tract. They looked at 14 prospective, randomized controlled clinical trials comparing the provision of early enteral nutrition (initiated 48 hours after admission) to delayed enteral nutrition. There was a reported significant 24% reduction in infectious complications and a 32% reduction in mortality.4,6

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