Free Nutrition Support Clinician Practice Test

1. A patient is taking the anti-HIV drug Zerit. This drug is likely to cause

a. lipodystrophy
b. AIDS wasting syndrome
c. malnutrition
d. metabolic syndrome

2. What is a reasonable level of protein for a patient with a 50% TBSA in the early post-burn period?

a. 1.0-1.2 grams per kg
b. 1.2-1.5 grams per kg
c. 1.5-2.0 grams per kg
d. 2.0-2.5 grams per kg

3. Which of the following is the LEAST likely cause of diarrhea in a hospitalized patient receiving enteral nutrition?

a. Soluble fiber
b. C. difficile
c. Elixir form of medications
d. Magnesium containing medications

4. In writing a nutrition support protocol related to peripheral parenteral nutrition (PPN), which of the following statements is NOT supported by evidence-based practice?

a. To reduce the risk for phlebitis, the peripheral cannula should be rotated approximately every 72 hours to a new location.
b. Solutions with an osmolarity between 900-1200 mOsm/L may be safely infused through a midline catheter.
c. PPN should only be selected for patients who require therapy for less than 2 weeks.
d. PPN solutions will generally require a lower dextrose concentration of 5-10% and a final amino acid concentration of 3%.

5. Which of the following is the LEAST appropriate source to use when applying evidence-based practice (EBP)?

a. Controlled trial without randomization
b. Meta-analysis
c. Cohort study
d. Case-control analysis studied

Answers & Explanations

1. A: Zerit (stavudine) is an anti-HIV drug that is likely to cause lipodystrophy. Protease inhibitors have also been known to cause lipodystrophy. Lipodystrophy is a change in the way the body produces, stores, and utilizes fat. Lipodystrophy can cause fat accumulation in certain areas of the body such as the back of the neck, the abdomen, and breasts in both men and women. This is measured by calculating the waist-to-hip ratio, as well as skin fold measurements and measurements of other areas affected. Lipodystrophy can also cause fat wasting in areas of the body such as the face (causing sunken cheeks and temporal wasting) and loss of fat in the extremities and buttocks. Lipodystrophy can also cause other metabolic abnormalities such as hyperlipidemia, hyperglycemia, and lactic acidosis. Older Caucasian men are more likely to develop lipodystrophy. Individuals who are obese and those that have had HIV for a period of time are also at higher risk for developing this disorder.

2. D: There are many equations to predict the amount of protein required for patients with burn injury. A major burn will increase the catabolic rate in the body. In the initial post-burn injury period, approximately 2.0-2.5 grams per kg are required, or approximately 2-25% of total calories. As the burn begins to heal additional protein may be required, especially with large total surface area burns. The provision of high amounts of protein will not prevent catabolism but will assist with achieving anabolism and begin to promote healing. Patient tolerance to an increased protein load should be monitored, watching for azotemia and level of wound healing. Nitrogen balance can be evaluated using the equation: grams of nitrogen - grams of urinary urea nitrogen + 4. Normal renal function and accurate intake and output records are required. An anabolic range of +5 to +10 is the goal during the acute recovery phase.

3. A: Diarrhea is a common occurrence for patients receiving enteral nutrition. A standard definition of diarrhea has not been adopted universally. A general definition is more than 500 mL of stool every 8 hours or more than 3 stools in a 24-hour period for 3 days in a row. Measurement of stool volume can be a difficult task. One method for incontinent hospitalized patients is to use a pad on the bed, which can be weighed before and after bowel movements. The assumption is 1 gram of weight is equivalent to 1 mL of stool. Diarrhea can be caused by many different factors. These include antibiotics, magnesium-containing medications, laxatives, and stool softeners. Medications in the elixir form may also be a cause due to sorbitol as an additive which causes an osmotic diarrhea. C. difficile is a very common occurrence in hospitalized patients and should be verified. One treatment for diarrhea can be the inclusion of soluble fiber either in the tube feeding or as a medication such as Metamucil.

4. B: Protocols for PPN should be written for the safety of patients receiving this type of nutrition support therapy. Generally, patients who are good candidates for PPN include those with good peripheral veins for placement of the peripheral catheter who will be able to tolerate a large amount of fluid. Therapy for PPN is limited to 2 weeks or less due to access issues and tolerance to PPN solutions. The osmolarity of PPN solutions should be less than 900 mOsm/L and are usually comprised of dextrose concentration of 5-10% and final amino acid concentration of 3%. Solutions with an osmolarity greater than 900 mOsm/L should be infused through a central vein. A midline catheter is a longer peripheral line that is placed in a larger vein but is still considered peripheral. Peripheral lines or cannulas should be rotated every 72 hours to reduce the risk for phlebitis. Research has shown that phlebitis is more likely on the fourth day of PPN.

5. B: Evidence-based practice utilizes up-to-date research to apply to current practice. It is imperative that the research used was a well-designed study. The gold standard for research is the randomized controlled trial (RCT). This type of research has the least amount of bias within the study design and can produce honest, straightforward results. If RCT is not available, the next type of research to use would be a non-randomized, well-designed controlled study. This would be followed by cohort or case-controlled analytic studies. The type of research that is least appropriate for use in EBP is meta-analysis, review articles, or consensus statements. It is difficult to stay abreast of current research but tools are available to help with this. Two examples of tools are clinical evidence and The Physician's Information and Education Resource from the American College of Physician's. Other tools include UpToDate and Harrison's Principles of Internal Medicine.

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Last Updated: 03/01/2017


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