1.

A 32-year-old, well-nourished man involved in a motor vehicle accident was admitted to the surgical intensive care unit with
multiple long bone fractures and abdominal injuries with no nutritional support for 4 days. Th is patient is most likely (A) suff
ering from moderate-to-severe kwashiorkor malnutrition. (B) at low risk for hospital-acquired infection and other complications.
(C) not suff ering from protein or calorie malnutrition. (D) suff ering from severe marasmus malnutrition. (E) not a candidate for
aggressive nutritional support.
2. A patient in the ICU on a ventilator was placed on a glucose system PN formulation providing 2040 kcal/day and 98 g
protein/day. A measured energy expenditure (MEE) of 2038 kcal and RQ of 1.1 were subsequently obtained. Which of the
following is correct based on this information? (A) Th e patient is receiving adequate glucose calories, and an adjustment in the
program is not necessary. (B) Th e daily protein intake has to be decreased to reduce the patient’s RQ. (C) Th e PN formulation
should be switched to a lipid system formulation to reduce the carbon dioxide load. (D) Th e patient is retaining oxygen from the
glucose calories in the PN formulation. (E) Lipid emulsion should be added to the current PN formulation to enhance
lipogenesis.
3. Total nutrient admixture (TNA) (A) is more complicated to administer for home parenteral nutrition patients. (B) should be fi
ltered with a 1.2- fi lter. (C) consists of glucose, amino acids, electrolytes, and trace minerals mixed in one container. (D) is the
method recommended by the FDA to administer lipid system PN. (E) can be visualized for particulate matter.
4.Th e calorie requirements of a moderately hypermetabolic hospitalized patient are best estimated by using the (A) nomogram
method. (B) nitrogen balance method. (C) (EEE) method. (D) PNI. (E) SGA method.
5. Lipid system PN (A) can be administered by peripheral vein if the glucose concentration is less than 15%. (B) requires daily
serum triglyceride monitoring. (C) is contraindicated in patients with elevated carbon dioxide levels. (D) requires daily lipid
administration to provide a portion of the patient’s nonprotein calorie requirements. (E) can be administered with a maximum
lipid dosage of 4.5 g/kg/day.
6. Commercial PN formulations for hypermetabolic critically ill patients (A) are enriched in branched-chain amino acids and
contain low concentrations of aromatic amino acids. (B) contain primarily essential amino acids. (C) have not demonstrated a
positive clinical outcome benefi t in this patient population. (D) are the preferred PN formulation used in this clinical setting. (E)
are enriched with arginine to enhance immune function.
7. Which of the following methods of parenteral nutritional support would be most appropriate in a severely protein calorie
malnourished patient with acute renal failure? (A) 2% amino acid/47% dextrose. (B) 4.25% amino acid/25% dextrose. (C) 4%
essential amino acid/47% dextrose. (D) 4.25% amino acid/25% dextrose with dialysis on a regular basis. (E) 2% amino
acid/47% dextrose/20% lipid emulsion
8. Which of the following statements regarding the monitoring of nutritional support is true? (A) Prealbumin is not the optimal
marker to follow for short-term nutritional progress. (B) Transferrin is falsely depressed in patients with iron defi ciency. (C)
Albumin is falsely elevated in renal failure. (D) A positive nitrogen balance of 3 to 6 g of nitrogen daily is optimal. (E) A weight
gain of 1.5 to 2.0 lb/day indicates optimal lean body weight gain.
9. Patients with end-stage liver disease (A) generally have increased levels of branched-chain amino acids and decreased
levels of aromatic amino acids. (B) should be placed on a low-branched chain, high-aromatic amino acid PN solution. (C)
should not have their protein restricted in the ICU as a clinical management strategy to reduce the risk of developing hepatic
encephalopathy. (D) require glutamine-enriched amino acid solutions. (E) can tolerate standard glucose system formulations
4.25% amino acid/25% dextrose with regular dialysis.
For questions 10–12: A 67-year-old white female presented to the attending physician with a 3-month history of progressive diffi
culty swallowing and a 10-kg weight loss. She is currently 160 cm tall and weighs 50 kg. She has just undergone a distal
esophagectomy and proximal gastrectomy for distal esophageal cancer. At the time of surgery, she had a feeding jejunostomy
tube inserted.
10. Th e dieticians who are adept at using the HarrisBenedict equation have gone home for the day, and the surgeon calls you
for your best guess at what the hourly goal rate for this patient should be using isotonic enteral formula, which provides 0.85
nonprotein calories (NPCs)/mL. Your answer should be (A) 65 mL/hr. (B) 75 mL/hr. (C) 85 mL/hr. (D) 95 mL/hr. (E) 50 mL/hr.
11. The enteral formulation the surgeon has selected is enriched with fi sh oils. He is hoping this additive will (A) prevent
diarrhea. (B) prevent dermatitis. (C) prevent hyperglycemia. (D) improve immune function. (E) improve neurological function.
12. On the 5th postoperative day, the feeding jejunostomy tube becomes clogged and unusable. Th e patient will be NPO an
additional 5 days to ensure the integrity of her surgical anastomosis. Th e most appropriate course at this time is (A) start the
patient on a lipid-based peripheral PN program. (B) keep the patient NPO and without PN support. (C) have a central venous
catheter inserted, and initiate a lipid-based PN program. (D) start the patient on a glucose-based peripheral PN program. (E)
have a central venous catheter inserted, and start the patient on a high branched-chain amino acid parenteral program. For
questions
13–14: RJ is a 28-year-old pregnant woman. She is in the 9th week of her pregnancy and is diagnosed with hyperemesis
gravidarum. Her pregravid weight was 57 kg, and her height is 5 ft ., 5 in. She has lost 7 kg (12.3%) during her pregnancy. She
was placed on a central glucose PN program.
13. Which one of the following represents the best estimate of her daily caloric requirements? (A) 1675 kcal (B) 1790 kcal (C)
2261 kcal (D) 2062 kcal (E) 1925 kcal
14. MVI-12 is used as the parenteral vitamin preparation in the PN formulation. Which of the following vitamin(s) need to be
supplemented in the daily PN formulation to meet the daily requirements during pregnancy? (A) Vitamin K (B) Th iamine (B1)
(C) Folic acid (D) A and C (E) Pyridoxine (B6)
For questions 15–17: A 55-year-old male with multiple traumatic injuries and type II diabetes was admitted to the surgical ICU.
He was placed on mechanical ventilation and initiated on glucose system PN. Aft er 3 days of PN therapy his blood glucose
levels have ranged from 250 to 285 mg/dL over the past 24 hrs with 80 U of insulin/L in his PN formulation. He is on no other
insulin supplementation at this time. 15. Th e nutritional support service recommends an insulin drip with the goal of achieving a
blood glucose level of (A) 180 to 225 mg/dL. (B) 200 to 215 mg/dL. (C) 140 to 200 mg/dL. (D) 65 to 100 mg/dL. (E) 70 to 105
mg/Dl

16.What parenteral trace mineral therapy may be an eff ective adjunct if the insulin drip fails to achieve the glucose level goal?
(A) 20 to 40 mg zinc/day (B) 150 to 200 g chromium/day (C) 0.5 to 1.5 mg copper/day (D) 150 to 400 mcg manganese/day (E)
40 to 60 g selenium/day
17. Th e recommended ACP guideline for management of glucose levels in this patient population has shown that: (A) Th e
range of optimal glucose level is defi nitive. (B) Hyperglycemia results in decreased duration of PN therapy. (C) Most patients
receiving intensive insulin therapy have no reduction in mortality but have a signifi cantly increased risk for severe
hypoglycemia. (D) Length of time on the ventilator is decreased. (E) A & C.
For questions 18–19: A 35-year-old female with severe morbid obesity (BMI 51 kg/m2 ) of more than 12 years duration and
refractory to conventional obesity treatment was entered into a bariatric surgery program. Th e patient underwent a Roux-en-Y
procedure without any major postoperative complications.
18. Th e patient was readmitted to the hospital 3 months aft er discharge with intolerance to solid and liquid foods and
persistent hyperemesis. She also presented with generalized paresthesia, ataxis, and mental confusion. Which of the following
nutrients is most likely defi cient in this patient? (A) Selenium (B) Vitamin D (C) Calcium (D) Th iamine (E) Vitamin E
19. Th is patient should be placed on which of the following nutrient supplementations to prevent potential cardiomyopathy? (A)
Folate (1 mg/day) (B) Vitamin B12 (350 to 1000 mcg/day) (C) Selenium (40 to 80 mcg/day) (D) Vitamin A (10,000 IU/day) (E)
Vitamin K (300 mcg/day)
For questions 20–22: A pharmacist managing the PN department of an IV home infusion company decided to review all
technical aspects of PN preparation with the pharmacy staff in an effort to update procedures and educate pharmacy staff on
current standards of PN admixtures.
20. There is some confusion among the staff as to where to obtain the most current document on medication standards for
pharmacy prepared sterile products that provides evidence-based instructions for pharmacy design, quality assurance,
washing, garbing, and personnel training and evaluation to improve compounding practice for PN admixtures. The most
appropriate source to obtain this information is the (A) ASHP 2015 Initiative. (B) ASPEN Practice Guidelines. (C) USP Chapter
797 Monograph. (D) National IV Th erapy Association. (E) FDA Intravenous Compounding Guidelines.
21. In reviewing their procedures for storage of prepared PN admixtures, they found a beyond-use date of 14 days under
refrigeration until PN is initiated in the home setting. Based upon the most current standards for pharmacy prepared sterile
products, which one of the following is the correct beyond-use date for storage of PN admixtures prepared for home use? (A)
30 hrs under refrigeration (B) 3 days under refrigeration (C) 14 days under refrigeration (D) 24 hrs at room temperature (E) 9
days under refrigeration
22. In compounding PN for home patients, there are several patients with SBS for whom physicians are prescribing the addition
of the amino acid glutamine to the PN formulation. The pharmacists must use nonsterile glutamine powder to compound these
PN formulations. In updating their procedure manual, what would be the risk-level for compounding these specialty PN
formulations based on the most current document on medication standards for pharmacy prepared sterile products? (A)
Intermediate-risk level (B) High-risk level (C) Low-risk level (D) Medium-risk level (E) Minimum-risk level
For questions 23–24: A 28-year-old white male involved in a motor vehicle accident was admitted to the SICU with severe
abdominal and head injuries. The patient is fluid restricted because of his head injury and was subsequently placed on a
concentrated glucose system PN. His calcium and phosphate serum levels are quite low and because of his fluid restriction,
they want to add as much calcium and phosphate to the PN formulation to correct these electrolyte deficiencies.
23. Which of the following strategies would allow for the best calcium and phosphate solubility? (A) Use a brand of amino acids
that has the lowest pH. (B) Calcium should be added and diluted in the PN prior to the addition of phosphate. (C) Th e amino
acid concentration should be kept as low as possible. (D) Th e temperature of the PN solution should be kept as high as
tolerable. (E) Th e pH of the PN solution should be increased by the addition of 0.1N sodium hydroxide.
24. Th e form of calcium phosphate that is most soluble in PN solutions is (A) dibasic. (B) divalent. (C) monobasic. (D)
trivalent. (E) tribasic.

1.The answer is A [see I.B.3]. A hypermetabolic state (e.g., trauma, infection) combined with protein deprivation can rapidly
develop into a severe kwashiorkor malnutrition characterized by hypoalbuminemia, edema, and impaired cellular immune
function.
2. Th e answer is C [see V.D.1]. Even in the presence of appropriate amounts of NPCs administered as carbohydrate, the
normal carbon dioxide load generated by glycolysis may be excessive for the patient with underlying pulmonary dysfunction.
PN lipid system formulations, in which the lipid component constitutes 40% to 50% of the total NPCs, may be benefi cial in
reducing the ventilatory demands in respiratory failure patients because lipolysis generates less carbon dioxide than glycolysis.
3. The answer is B [see III.A.6.b.(2).(b).(iii)]. A particle fi lter (i.e., 1.2 ) should be used with TNA administration.
4. The answer is C [see II.B.1]. Energy requirements are determined as nonprotein calories by indirect calorimetry, estimated
energy expenditure, and the simple nomogram method. Th e nomogram method is the least accurate method of estimating
caloric requirements.
5. Th e answer is D [see III.A.6.b.(1)]. Th e lipid system PN is a formulation in which lipid is administered daily to provide a
substantial portion of the NPCs.
6. Th e answer is C [see V.C.1]. PN formulations enriched in branched-chain amino acids have been made available with the
rationale that, being the preferred fuel source in this patient population, it would enhance protein synthesis, decrease protein
catabolism, and improve the patient’s clinical outcome. However, these more expensive branched-chain amino acid
formulations have not been shown to favorably infl uence clinical outcomes in critically ill patients.
7. Th e answer is D [see V.B.3]. Standard glucose system formulations (4.25% amino acid/25% dextrose) can generally be
used in renal failure patients who are being dialyzed on a regular basis. Th is formulation is particularly useful in severely
malnourished patients because it can provide adequate protein to attain positive nitrogen balance, which is not possible with
renal failure PN.
8. Th e answer is D [see II.B.2.a.(4)]. A positive nitrogen balance of 3 to 6 g is the goal.
9. Th e answer is C [see V.C.3]. Protein requirements in ICU patients should not be restricted as a clinical management
strategy to reduce the risk of developing hepatic encephalopathy.
10. Th e answer is B [see II.B.1.c]. Use the nomogram of 30 kcal/kg to determine the NPCs/ day, and divide that by the
NPCs/mL of the enteral formula to determine the volume of formula per day, which is divided by 24 hrs to yield the hourly goal
rate.
11. Th e answer is D [see V.A.5]. Omega-3 polyunsaturated fatty acids are derived from fish oils and are currently found in
some enteral formulations. These fatty acids have been shown experimentally to enhance immune response.
12.The answer is A [see III.A.3.b]. With the use of new catheter technology and new techniques for infusion, it is now feasible
to administer peripheral PN in selected patients for short-term therapy (7 to 10 days) with a low incidence of peripheral vein
thrombophlebitis. Th is method of PN administration avoids the potential of more serious complications associated with central
venous route administration.
13. Th e answer is A [see V.I]. Th e estimated basal energy expenditure is calculated using the pregravid weight in the Harris-
Benedict equation. An additional 300 kcal/day is added to the basal energy expenditure to provide the required calories per day
during pregnancy.
14. Th e answer is A [see V.I.3]. An additional 65 g of vitamin K needs to be added to the daily PN formulation when MVI-12 is
used as the parenteral vitamin preparation to meet the daily requirements during pregnancy.
15. Th e answer is C [see V.H.2]. ACP recommends a target blood glucose level of 140 to 200 mg/dL if insulin therapy is used
in SICU/MICU patients
16. Th e answer is B [see II.B.5.g]. Suggested IV requirements of chromium for defi ciency and severe glucose intolerance are
150 to 200 g/day.
 17. Th e answer is C [see V.H.3.c]. A few studies show that IIT improves mortality, whereas most have shown that patients
who receive IIT have no reduction in mortality and have a signifi cantly increased risk for severe hypoglycemia.
18. Th e answer is D [see V.L.4]. Th iamine defi ciency is not common aft er bariatric surgery but is seen in patients with
postoperative hyperemesis syndromes.
19. Th e answer is C [see V.L.6]. Selenium defi ciency and a life-threatening cardiomyopathy have been reported in patients aft
er malabsorptive surgery. Supplementation of selenium at 40 to 80 mcg/ day is recommended in patients undergoing
malabsorptive surgery.
20. Th e answer is C [see VI.A]. Th e USP Chapter 797 provides evidence-based instructions for pharmacy design, washing,
garbing, quality assurance, and personnel training and evaluation to improve compounding practices for sterile products,
including PN.
21. Th e answer is E [see VI.A]. In the home care setting, the beyond-use date can be extended to 9 days, but the PN
admixture must be stored under refrigeration at 36° to 46° F until use.
22. Th e answer is B [see VI.A]. When PN is compounded using powdered amino acids, it is classifi ed as a “high-level” CSP
because its preparation involves the use of nonsterile ingredients and carries the highest risk for contamination by microbial,
chemical, or physical matter.
23. Th e answer is A [see VI.B]. Th e pH of the PN solutions is determined primarily by the concentration and type (brand) of
amino acids. PN solutions containing higher concentrations of amino acids have a lower pH that allows for greater solubility of
calcium and phosphate. Th e type (brand) of amino acid solutions commercially available diff er in their pH.
24. Th e answer is C [see VI.B]. Dibasic calcium phosphate is very insoluble, whereas monobasic calcium phosphate is
relatively soluble.