CRNI Parenteral Nutrition Administration Questions and Answers 1 — Questions and Answers
Question 1: A patient has been receiving continuous parenteral nutrition for three weeks. The central venous catheter becomes occluded, and the infusion is abruptly stopped. Which of the following is the nurse's priority assessment?
- Signs of hypervolemia, such as crackles and edema
- Signs of hypoglycemia, such as diaphoresis and shakiness (Correct answer)
- Signs of catheter-related infection, such as fever and chills
- Signs of essential fatty acid deficiency, such as scaly dermatitis
Correct answer: Signs of hypoglycemia, such as diaphoresis and shakiness
When a high-dextrose parenteral nutrition solution is stopped abruptly, the pancreas may continue to secrete high levels of insulin, leading to a rapid drop in blood glucose. This condition, known as rebound hypoglycemia, is the most immediate metabolic complication. The nurse must prioritize assessing for and managing signs of hypoglycemia.
Question 2: A CRNI is preparing to administer a 3-in-1 total nutrient admixture (TNA) containing dextrose, amino acids, and a lipid emulsion. Which in-line filter is required for the safe administration of this solution?
- A 5-micron filter
- A 0.22-micron filter
- No filter is necessary if a dedicated lumen is used
- A 1.2-micron filter (Correct answer)
Correct answer: A 1.2-micron filter
A 1.2-micron filter is required for administering total nutrient admixtures (TNAs) or any lipid-containing parenteral nutrition. The lipid particles are too large to pass through a smaller 0.22-micron filter, which would cause an occlusion. The 1.2-micron filter allows the large lipid molecules to pass through while still filtering out particulate matter, larger microorganisms like Candida albicans, and precipitates.
Question 3: To minimize the risk of refeeding syndrome in a severely malnourished patient starting on parenteral nutrition, which of the following is the most important nursing intervention?
- Initiate the PN infusion at a slow rate and advance gradually over several days. (Correct answer)
- Administer a rapid fluid bolus of 5% Dextrose prior to starting the PN.
- Ensure the initial PN formulation has a high concentration of dextrose.
- Restrict all oral fluid intake for the first 24 hours of PN therapy.
Correct answer: Initiate the PN infusion at a slow rate and advance gradually over several days.
The cornerstone of preventing refeeding syndrome is to reintroduce nutrition cautiously. Initiating parenteral nutrition at a slow rate (e.g., starting with 10-20 kcal/kg/day or 100-150g of dextrose) and advancing the goal rate over 4 to 7 days allows the body to adapt metabolically. This prevents the sudden, massive intracellular shift of electrolytes (phosphate, potassium, magnesium) that characterizes this potentially fatal syndrome.
Question 4: A patient is receiving cyclic parenteral nutrition infused over 12 hours nightly. The nurse observes the solution and notes a separated, oily layer on the surface of the admixture. This observation is best described as:
- Precipitation
- Caramelization
- Cracking (Correct answer)
- Sedimentation
Correct answer: Cracking
"Cracking" is the term used to describe the irreversible breakdown of a lipid emulsion in a total nutrient admixture (TNA). It appears as a visible oily layer or fat globules on the surface of the solution. A cracked TNA is unstable and must not be infused, as it can lead to fat embolism.
Question 5: A patient is scheduled to receive cyclic parenteral nutrition from 2000 to 0800. At 0600, the nurse discovers that 500 mL of the solution is remaining when only 200 mL should be left. What is the most appropriate action for the nurse to take?
- Increase the infusion rate to ensure the full volume is delivered by 0800.
- Continue the infusion at the prescribed rate and document the remaining volume. (Correct answer)
- Stop the infusion at 0800 as scheduled, regardless of the volume remaining.
- Administer an intravenous bolus of 50% dextrose at 0800 to prevent hypoglycemia.
Correct answer: Continue the infusion at the prescribed rate and document the remaining volume.
The nurse should never increase the rate of a parenteral nutrition infusion to "catch up." Doing so can cause severe hyperglycemia, fluid overload, and electrolyte imbalances. The safest action is to continue the infusion at the prescribed rate, document the discrepancy, and notify the provider and pharmacist. The plan for the subsequent infusion cycle may need to be adjusted.
Question 6: Which of the following laboratory values is most critical for the CRNI to monitor in a patient at high risk for refeeding syndrome during the first 72 hours of initiating parenteral nutrition?
- Serum creatinine
- Hemoglobin and hematocrit
- Blood urea nitrogen (BUN)
- Serum phosphate (Correct answer)
Correct answer: Serum phosphate
Hypophosphatemia is the hallmark biochemical feature of refeeding syndrome. When a malnourished patient begins to receive carbohydrates, insulin is released, causing a rapid shift of phosphate, potassium, and magnesium from the bloodstream into the cells for metabolism (e.g., ATP synthesis). This can lead to dangerously low serum phosphate levels, resulting in cardiac and respiratory failure. Therefore, monitoring phosphate is a top priority.
CRNI Parenteral Nutrition Administration Questions and Answers 1
A patient has been receiving continuous parenteral nutrition for three weeks.
The central venous catheter becomes occluded, and the infusion is abruptly stopped.
Which of the following is the nurse's priority assessment?