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module3
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  1. Question: 1
    Which one of the following factors is most likely to contribute to metabolic bone disease in PN-dependent patients?

    1: Aluminum toxicity
    2: Calcium supplementation
    3: Low amino acid intake in PN
    4: Balanced acetate load in PN
    1: Aluminum toxicity
  2. Question: 2
    Which of the following is a risk factor for the development of PN-associated liver complications in PN-dependent patients?

    1: Short bowel syndrome
    2: Cyclic infusion of PN
    3: Supplemental trophic enteral feeding
    4: Medication therapy with ursodiol


    1: Short bowel syndrome
  3. Question: 3
    A 70-kg adult patient receiving PN providing 3000 kcal/day presents with mild to moderate elevations of serum aminotransferases and small elevations of bilirubin and serum alkaline phosphatase. This patient is most likely exhibiting what type of PN-associated liver disease (PNALD)?

    1: Hepatic steatosis
    2: Cholestasis
    3: Gallbladder sludging
    4: Fulminant hepatic failure
    1: Hepatic steatosis
  4. Question: 4
    Patients at risk for refeeding syndrome often require supplementation of

    1: vitamin A.
    2: vitamin K.
    3: thiamine.
    4: vitamin C.


    3: thiamine.
  5. Question: 5
    Hyperglycemia is associated primarily with what type of sodium/fluid imbalance?

    1: Hypertonic hyponatremia
    2: Hypotonic hyponatremia
    3: Isotonic hypernatremia
    4: Hypertonic hypernatremia
    1: Hypertonic hyponatremia
  6. Question: 6
    A long-term PN patient presents with involuntary movements, tremor, and rigidity. Which of the following etiologies may explain these symptoms?

    1: Manganese deficiency
    2: Manganese toxicity
    3: Selenium deficiency
    4: Selenium toxicity


    2: Manganese toxicity
  7. Question: 7
    In order to prevent rebound hypoglycemia upon discontinuation of PN, the infusion rate of PN should be reduced by

    1: 25% for the last 1 hour of infusion.
    2: 25% for the last 2 hours of infusion.
    3: 50% for the last 1 hour of infusion.
    4: 50% for the last 2 hours of infusion.
    4: 50% for the last 2 hours of infusion.
  8. Question: 8
    Which of the following would be the most likely complication of hypertriglyceridemia?

    1: Azotemia
    2: Pancreatitis
    3: Polyuria
    4: Peripheral neuropathy
    2: Pancreatitis
  9. Question: 9
    All of the following are risk factors for the development of hyperglycemia in a patient receiving PN EXCEPT

    1: cirrhosis.
    2: obesity.
    3: pancreatitis.
    4: hypothyroidism.
    4: hypothyroidism.
  10. Question: 10
    All of the following are risk factors for the development of rebound hypoglycemia in a patient receiving PN EXCEPT

    1: chronic starvation.
    2: liver failure.
    3: hypertension.
    4: hypothyroidism.


    3: hypertension.
  11. Question: 11
    To reduce the risk of infection, the preferred site for catheter insertion is

    1: subclavian.
    2: internal jugular.
    3: femoral.
    4: umbilical artery.
    1: subclavian.
  12. Question: 12
    Fibrin that builds up on the wall of blood vessels may also adhere to the catheter creating a

    1: fibrin sheath.
    2: fibrin tail.
    3: intraluminal thrombus.
    4: mural thrombus.
    4: mural thrombus.
  13. Question: 13
    The use of 0.1N hydrochloric acid is most effective for clearing catheter occlusions due to precipation of

    1: calcium-phosphate.
    2: tobramycin.
    3: phenytoin.
    4: lipid residue.


    1: calcium-phosphate.
  14. Question: 14
    A 40-year-old male receiving chronic PN therapy (initiated 15 years ago) secondary to massive bowel resection develops metabolic bone disease. His current 12-hour cyclic PN formula provides 5 g/kg/day dextrose, 2 g/kg/day protein and 1 g/kg/day of fat. What is the most appropriate intervention to reduce hypercalciuria?

    1: Increase calcium gluconate
    2: Decrease phosphorus supplementation
    3: Shorten PN infusion time to 10 hours
    4: Decrease amino acid content of PN solution
    4: Decrease amino acid content of PN solution
  15. Question: 15
    The best approach to prevent PN-induced cholelithiasis is administration of

    1: choline.
    2: CCK-octapeptide (CCK-OP).
    3: ursodiol.
    4: oral or enteral feeding.


    4: oral or enteral feeding.
  16. Question: 16
    All of the following may be short-term complications of home parenteral nutrition EXCEPT

    1: dehydration.
    2: metabolic bone disease.
    3: refeeding syndrome.
    4: catheter malposition.


    2: metabolic bone disease.
  17. Question: 17
    Which of the following is most likely responsible for elevated serum bicarbonate levels in a home parenteral (PN) patient?

    1: Excess chloride salts in the PN
    2: Diarrhea
    3: Excess acetate salts in the PN
    4: ARF


    3: Excess acetate salts in the PN
  18. Question: 18
    The clinical presentation of refeeding syndrome includes all of the following EXCEPT

    1: pulmonary edema.
    2: seizures.
    3: cardiac decompensation.
    4: dehydration.


    4: dehydration.
  19. Question: 19
    A 75-year-old female status-post ileoconduit with poor intravenous access weighing 50 kg is initiated on 3L of peripheral parenteral nutrition (PPN) daily. The PPN formula is written as 7% dextrose, 3.5% amino acids and 1.5% IVFE. Which of the following complications is she at greatest risk for developing?

    1: Fluid overload
    2: Hypertriglyceridemia
    3: Azotemia
    4: Hyperglycemia


    1: Fluid overload
  20. Question: 20
    A critically ill 68-year-old female receiving PN has the following arterial blood gas (ABG) results: pH=7.31, PaCO
    2=36 mm Hg, and serum bicarbonate=20 mEq/L. What is the most appropriate PN intervention?

    1: Do nothing
    2: Increase PN chloride concentration
    3: Increase PN acetate concentration
    4: Decrease calorie content of PN
    3: Increase PN acetate concentration
  21. Question: 21
    What feature of a Groshong PICC reduces the risk of catheter occlusion?

    1: Pressure sensitive three-way valve
    2: Large lumen(s) size
    3: Heparin coated tip
    4: Soft grade medical silicon tubing
    1: Pressure sensitive three-way valve
  22. Question: 22
    A 45-kg patient receiving chronic PN therapy develops an intraluminal clot in their central venous access device. What is the most appropriate pharmacological intervention to clear this access device?

    1: Heparin 100 units/mL
    2: Alteplase 2mg/2mL
    3: Argatroban 350 mcg/kg bolus over 3-5 minutes
    4: Reteplase 10 units


    2: Alteplase 2mg/2mL
  23. Question: 23
    A patient receiving PN is afebrile, has negative blood cultures, but presents with redness and purulence at the catheter exit site. How is this infection best managed?

    1: Remove CVC
    2: Exchange catheter over a guidewire
    3: Initiate empiric antimicrobial therapy with vancomycin
    4: Apply topical antibiotic ointment
    3: Initiate empiric antimicrobial therapy with vancomycin
  24. Question: 24
    A PN-dependent pt with an average daily ostomy output of 3L presents with elevated BUN/SCr ratio and mild hyponatremia. What is the most appropriate PN intervention for this patient?

    1: Increase sodium, restrict protein
    2: Increase sodium, increase fluid
    3: Increase fluid, restrict protein
    4: Increase sodium, restrict fluid


    2: Increase sodium, increase fluid
  25. Question: 25
    The use of 70% ethyl alcohol is most effective for clearing catheter occlusions due to precipitation of

    1: calcium-phosphate.
    2: lipid residue.
    3: phenytoin.
    4: tobramycin.


    2: lipid residue.
  26. Question: 26
    The most common route of infection for a tunneled central venous catheter (CVC) is

    1: extraluminal colonization of the catheter.
    2: contamination of the catheter hub.
    3: infusate contamination.
    4: hematogenous seeding from another focus of infection.
    2: contamination of the catheter hub.
  27. Question: 27
    A patient arrives in your clinic complaining of intermittent catheter malfunction. You identify that the catheter malfunction is relieved by raising the patient’s arm where the catheter is located. Which condition should be suspected?

    1: Fibrin sheath
    2: Pinch-off syndrome
    3: Superior vena cava syndrome
    4: Catheter migration
    • 2: Pinch-off syndrome
  28. Question: 28
    All of the following conditions predispose a patient to the refeeding syndrome EXCEPT

    1: chronic starvation and chronic alcoholism.
    2: anorexia or malabsorption.
    3: morbid obesity with weight loss.
    4: bulimia nervosa.
    4: bulimia nervosa.
  29. Question: 29
    Which of the following are the most common electrolyte imbalances observed in patients with refeeding syndrome?

    1: Hypokalemia, hyperphosphatemia, hypoglycemia
    2: Hyperkalemia, hyperphosphatemia, hypoglycemia
    3: Hypokalemia, hypophosphatemia, hypermagnesemia
    4: Hypokalemia, hypophosphatemia, and hypomagnesemia
    4: Hypokalemia, hypophosphatemia, and hypomagnesemia
  30. Question: 30
    Hyperkalemia is most likely to be associated with

    1: pregnancy.
    2: hyperinsulinemia.
    3: respiratory failure.
    4: metabolic acidosis.
    4: metabolic acidosis.
  31. Question: 31
    A patient with hypokalemia should be assessed for what electrolyte disorder?

    1: Hyperglycemia
    2: Hyponatremia
    3: Hyperphosphatemia
    4: Hypomagnesemia
    4: Hypomagnesemia
  32. Question: 32
    Failure to remove manganese from PN in a patient with hepatobiliary disease results in accumulation of manganese in the

    1: brain.
    2: liver.
    3: kidney.
    4: red blood cells.
    1: brain.
  33. Question: 33
    A critically ill 75-year-old male receiving PN has the following arterial blood gas (ABG) results: pH=7.32, PaCO
    2=49 mm Hg, and serum bicarbonate=29 mEq/L. What is the most appropriate PN intervention?

    1: Do nothing
    2: Decrease calorie content of PN
    3: Decrease acetate concentration
    4: Decrease chloride concentration


    2: Decrease calorie content of PN
  34. Question: 34
    Acetate is added to PN formulas when a patient experiences

    1: metabolic acidosis.
    2: metabolic alkalosis.
    3: respiratory acidosis.
    4: respiratory alkalosis.
    1: metabolic acidosis.
  35. Question: 35
    Use of nutrition support teams with patients receiving PN has been shown to DECREASE

    1: morbidity due to hyperglycemia.
    2: morbidity due to hypophosphatemia.
    3: mortality due to metabolic complications.
    4: length of stay in the intensive care unit
    3: mortality due to metabolic complications
  36. Question: 36
    The most accurate method of diagnosing PN-associated metabolic bone disease is to measure

    1: bone density.
    2: serum calcium concentrations.
    3: serum phosphate concentrations.
    4: serum parathyroid hormone concentrations.


    1: bone density.
  37. Question: 37
    Which one of the following co-morbidities is NOT a risk factor for the development of metabolic bone disease?

    1: Crohn's disease
    2: Malignancy
    3: Short bowel syndrome
    4: Hypothyroidism
    4: Hypothyroidism
  38. Question: 38
    A rise in which of the following laboratory values would most likely indicate cholestasis?

    1: Prothrombin time
    2: Asparate aminotransferase/Alanine aminotransferase ratio
    3: Cholesterol and gamma glutamyltransferase
    4: Alkaline phosphatase and total bilirubin


    4: Alkaline phosphatase and total bilirubin
  39. Question: 39
    During long-term PN administration, hepatobiliary complications can best be prevented by

    1: adding carnitine to the PN formula.
    2: discontinuing IV fat emulsion (IVFE).
    3: converting to cyclic administration.
    4: administering IVFE twice weekly.


    3: converting to cyclic administration.
  40. Question: 40
    Inability to aspirate blood through a central vascular catheter when there is no obstruction to the infusion of fluid suggests

    1: pinch-off syndrome.
    2: intraluminal thrombus.
    3: calcium precipitate occlusion.
    4: fibrin sleeve formation at the catheter tip.
    4: fibrin sleeve formation at the catheter tip.
  41. Question: 41
    After placement of a central line, discovery of a pneumothorax during PN administration should be viewed as a

    1: sentinel event.
    2: process indicator.
    3: resource indicator.
    4: structural indicator.
    1: sentinel event.
  42. Question: 42
    All of the following are examples of nonthrombotic catheter occlusions EXCEPT

    1: catheter migration during use.
    2: lipid deposits.
    3: calcium-phosphate precipitate.
    4: fibrin sheath.
    4: fibrin sheath.
  43. Question: 43
    What are the major symptoms of acute thrombosis due to central venous catheterization?

    1: Pain and difficulty breathing
    2: Pain and swelling in the arm and neck
    3: Fever and inability to aspirate blood from the catheter
    4: Pain while attempting to infuse fluids through the catheter


    2: Pain and swelling in the arm and neck
  44. Question: 44
    The most effective strategy to DECREASE the risk of catheter-associated sepsis is use of

    1: povidone-iodine as a skin preparation.
    2: antibiotic ointment at catheter exit site.
    3: antibiotic prophylaxis during catheter insertion.
    4: full-barrier precautions during catheter insertion.
    4: full-barrier precautions during catheter insertion
  45. Question: 45
    Which of the following is an evidence-based intervention for reducing the risk of central venous catheter-related infections?

    1: Administering antibiotics prior to catheter insertion
    2: Using minimal barrier technique during catheter insertion
    3: Cleansing insertion sites with 2% alcohol preparation
    4: Training nurses who maintain central venous catheters
    4: Training nurses who maintain central venous catheters
  46. Question: 46
    A patient receiving PN that has chills, fever, positive blood cultures, and no redness or purulence at the catheter exit site probably has which of the following types of catheter infection?

    1: Tunnel
    2: Exit site
    3: Catheter-related phlebitis
    4: Catheter-related bloodstream
    4: Catheter-related bloodstream
  47. Question: 47
    If a ventilated patient with a history of chronic renal insufficiency is receiving PN that provides 40 kcal/kg, 2 g/kg protein, 5 mg/kg/min of dextrose, and 1.5 g/kg fat, which of the following is most likely to occur?

    1: Negative nitrogen balance along with a decline in prealbumin levels
    2: Increased urine output, decreased specific gravity, and change in urine pH
    3: Improvement in hepatic protein stores, weight gain, and improved immune function
    4: Hypercapnia, elevated liver function studies, and alterations in BUN/creatinine values


    4: Hypercapnia, elevated liver function studies, and alterations in BUN/creatinine values
  48. Question: 48
    A patient presents to clinic with a suspected catheter occlusion. All of the following are appropriate initial actions EXCEPT to

    1: determine if the occlusion is relieved with postural changes.
    2: remove the dressing and check for kinks in the tubing.
    3: replace the catheter over a guidewire.
    4: review recent flushing techniques with the patient.


    3: replace the catheter over a guidewire.
  49. Question: 49
    A 60-year-old female (45 kg) is receiving PN for a rectovaginal fistula. The PN formula consists of the following components: 700 mL Dextrose 70%, 600 mL Aminosyn II® 15%, and 125 mL of 20% IV Fat Emulsion. Which one of the following complications is she at greatest risk for developing? (24-hour continuous PN infusion; Total PN Volume with electrolytes and additives is 1.5 L)

    1: Hypertriglyceridemia
    2: Azotemia
    3: Hyperglycemia
    4: Pulmonary edema
    3: Hyperglycemia
  50. Question: 50
    Discontinuation of IVFE is recommended treatment of catheter-related bloodstream infection due to

    1: coagulase-negative staphylocci.
    2: staphylococcus aureus.
    3: pseudomonas aeruginosa.
    4: malassezia furfur.


    4: malassezia furfur.

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