CNSC EXAM 2023 (100%Solved).

CNSC EXAM 2023 (100%Solved). NGT size - Answer 8 - 16 french 36 inches Nasoenteric tube size - Answer 8 - 12 french Duodenal: 43 inches Jejunal: 60 inches Gastrostomy tube size - Answer 12 - 28 french G-J tube size - Answer 6 - 12 french Most common complication s/p enterostomy tube placement - Answer peristomal infection Buried bumper syndrome - Answer results from growth of gastric mucosa over the internal bumper risk factors: excessive tension between internal/external bumpers, poor wound healing, significant weight gain Decreasing risk of aspiration PNA - Answer recent data suggests jejunal feeding may be associated with decreased risk of asp PNA Diarrhea - Answer >500mL stool/24hr (weigh stool = 1gm/1mL) or >3 stools for at least 2 consecutive days Drug-induced diarrhea - Answer magnesium, sorbital, PPI, prokinetics, ABX Hang time for reconstituted formula - Answer 4hr Hang time for prepared formulas - Answer depends on manufacturer; generally 4- 12hr Dehydration - Answer dry mouth, dry tongue, thirst, light-headedness, HA, fatigue, loss of appetite, flushed skin , dark urine, orthostatic hypotension, elevated HR, poor skin turgor, sunken eyes, muscle cramps, delirium, elevated BUN (BUN:Cr ratio >20:1)(note: protein intake, renal function, muscle mass can affect this ratio), elevated plasma osmolality Normal urine output - Answer Minimum output ~700mL/d Typical range 0.5 - 2 mL/kg/hr Hepatic steatosis - Answer Hepatic steatosis generally occurs in adults and presents with mild elevations in aminotransferases, serum alkaline phosphatase, and bilirubin concentrations. This particular type of hepatobiliary disorder is most often a complication of overfeeding. Cholestasis - Answer Cholestasis, occurring primarily in children, is characterized by impaired biliary secretion. Elevated conjugated bilirubin levels are the most common laboratory manifestation in this population. CNSC EXAM 2023 (100%Solved). CNSC EXAM 2023 Elevations of alkaline phosphatase, gamma glutamyltransferase and conjugated (direct) bilirubin most likely represent cholestasis or biliary obstruction. Elevated serum conjugated bilirubin, typically defined as >2 mg/dL, is considered a prime indicator of cholestasis Gallbladder sludge - Answer Gallbladder sludging or stones is thought to result from the lack of enteral stimulation in the GI tract and occurs with long-term PN use. Preferred site of CVC placement in adults - Answer subclavian Mural thrombus - Answer develops when fibrin builds up inside the vein which may cause the vascular access device to adhere to the vessel wall Fibrin sheath - Answer The aggregation of fibrin resulting from the presence of a venous access device in the vein often develops as a fibrin layer (fibrin sheath) that forms around the outside of the catheter Fibrin tail - Answer In some cases, the fibrin sheath can grow over the tip of the catheter, or may accumulate exclusively at the distal tip of the catheter creating a "fibrin tail."Cannot aspirate Intraluminal thrombus - Answer An intraluminal thrombus occurs as fibrin or blood products build up inside the catheter lumen, creating a partial or total occlusion. Cannot infuse or aspirate Effective solvent for dissolving calcium phosphate - Answer The use of 0.1N hydrochloric acid has been reported effective in clearing catheters with crystalline occlusions because its acidic pH is favorable for calcium and phosphate solubility. Clinicians should be aware, however, that direct infusion of hydrochloric acid into the venous system can be associated with fever, phlebitis, and sepsis. Effective solvent for dissolving lipid residue - Answer 70 percent ethanol is the most effective solvent to dissolve lipid residue Decreasing the risk of metabolic bone disease - Answer The most important contributor to metabolic bone disease is a negative calcium balance. Hypocalcemia occurs as a result of decreased calcium intake and/or increased calcium urinary excretion. Factors that cause hypercalciuria include: excessive calcium and inadequate phosphorus supplementation, excessive protein in PN solutions, cyclic PN infusions, and chronic metabolic acidosis. Causes of metabolic alkalosis with PN - Answer An elevated serum bicarbonate level is one of the markers of metabolic alkalosis. Metabolic alkalosis may be caused by nasogastric suctioning, volume depletion and diuretic use. In a PN patient, excess use of acetate, which is metabolized to bicarbonate, may precipitate a metabolic alkalosis. Causes of metabolic acidosis with PN - Answer Excess chloride, diarrhea and acute renal failure (ARF) are common causes of metabolic acidosis. CNSC EXAM 2023 Normal pH - Answer 7.35 - 7.45` Normal PaCO2 - Answer 35 - 45mmHg Normal serum bicarbonate - Answer 23 - 30mEq/L Goshung PICC - Answer A Groshong PICC has a pressure sensitive three-way valve at the IV tip of the catheter that prevents reflux of blood into the catheter which should decrease the risk of occlusion. Since blood cannot reflux into the catheter, the Groshong catheter need only be flushed with saline. Flushing with heparin is not necessary to maintain patency. Although additional features of Groshong catheters include soft medical grade tubing, presence of antimicrobial cuff and large lumen size, none of these contribute to a decreased incidence of catheter occlusion. Groshong catheters are not coated with heparin. Treatment for CVAD occlusion - Answer Alteplase is the only FDA-approved thrombolytic agent for CVAD occlusions. Management of catheter exit site infection - Answer Management of catheter exit site infection includes culture of any drainage from the catheter exit site in addition to blood cultures.Topical antimicrobial agent can be used if there is no purulence from the catheter exit site and no clinical signs of sepsis. Systemic antimicrobial treatment is used in the presence of purulent drainage from the catheter exit site or if topical treatment is unsuccessful. The catheter should be removed if systemic antimicrobial treatment fails or if the patient has clinical signs of sepsis. Nonthrombotic catheter occlusion - Answer Nonthrombotic catheter occlusions can result from mechanical obstructions, drug or mineral precipitates, or lipid deposits. Mechanical obstruction may reflect catheter migration or malposition that occurs during insertion or use. Precipitates that form due to drug crystallization, drug-drug incompatibilities, or drug-solution incompatibilities can produce catheter occlusion. Thrombotic catheter occlusion - Answer A fibrin sheath, or fibrin sleeve, is a thrombotic catheter occlusion and develops when fibrin adheres to the external surfaces of the catheter. Interventions for reducing CVC-related infections - Answer (1) using maximal barrier technique during catheter insertion, (2) cleansing insertion sites with 2% chlorhexidine preparation, and (3) education and training of health care personnel. Administering antibiotics prior to inserting central venous catheters has not been shown to be effective in reducing the rates of central venous catheter-related infections. Microorganism causing CVC-related blood-stream infections - Answer Malassezia furfur is classically associated with superficial infections of the skin and associated structures. This yeast has been reported as a cause of catheter-related blood stream infections. This occurs most commonly in premature infants and patients receiving PN containing IVFE. The IVFE presumably provides growth factors required for replication of the organism. Appropriate treatment of patients requires administration CNSC EXAM 2023 of antifungal therapy, discontinuation of IVFE, and removal of the intravascular catheter, especially with nontunneled catheter infections. s/s of catheter-related central venous thrombosis - Answer Central venous catheters cause endothelial trauma and inflammation which can lead to venous thrombosis. Inflammation of the vessel wall can cause pain and tenderness along the course of the vein. Obstruction of blood flow may cause collateral vein congestion and edema on the affected side. Arm, shoulder, or neck swelling, limb, jaw, or ear pain, and dilated collateral veins over the arm, neck or chest are hallmark symptoms of catheter related central venous thrombosis . Thiamine repletion - Answer Thiamine is a water-soluble vitamin and body stores can be easily depleted by malnutrition, weight loss and chronic alcoholism. Dextrose infusion places additional demand on thiamine as it is an essential coenzyme in carbohydrate metabolism. Thiamine requirements are increased in patients with malnutrition, weight loss and chronic alcoholism, and additional supplementation (50- 100 mg/day IV or at least 100 mg/day PO for 5-7 days) is suggested for patients at risk for deficiency. Supplementation with a multi-vitamin and additional folic acid at 1 mg/day, may be indicated. Treatment of hypertonic hyponatremia 2/2 hyperglycemia - Answer correct glucose levels/underlying issue Catheter-related infection types - Answer Exit site: erythema,tenderness or purulence within 2 cm - warm compress, oral ABX Tunnel: erythema, tenderness, or purulence >2cm of site - catheter removal Pocket: erythema and necrosis over post reserviour or purulent exudate in subcutaneous pocket - catheter removal Bloodstream: same isolate on catheter culture and blood - ABX Most common non-infectious complication of CVC - Answer occlusion (specifically thrombotic) Thrombotic vs nonthrombotic occlusions - Answer Thrombotic: intraluminal occlusion, fibrin sleeve, vessel thrombosis, pericatheter thrombosis, mechanical occlusion Nonthrombotic: drug/heparin interactions, parenteral nutrition formulations with inappropriate calcium/phosphorus ratios, and lipid residue TBW - Answer ~50-60% Fluid compartments - Answer 1. Intracellular (2/3) of TBW a. K+ primary osmole 2. Extracellular (1/3) of TBW a. Na+ primary osmole b. 2 compartments i. Interstitial (3/4) ii. Intravascular (1/4) 3. Transcellular (~3%) CNSC EXAM 2023 Distribution of 1L D5% W - Answer 2/3 (667mL) to ICF 1/3 (333mL) to ECF with 1/4 (~85mL) to Intravascular Distribution of 1L NS - Answer Fluid will remain in ECF 3/4 (750mL) to Interstitial 1/4 (250mL) to Intravascular .