MCQ Quiz: Enteral Nutrition

Enteral nutrition (EN), or tube feeding, is the preferred method for providing nutritional support to patients who have a functioning gastrointestinal tract but are unable to meet their needs through oral intake. The pharmacist’s role in managing patients on enteral nutrition is multifaceted and critical for patient safety. As detailed in the Professional Practice Skills Lab and Patient Care curricula, pharmacists are responsible for assessing the need for EN, recommending appropriate formulations, and, most importantly, ensuring the safe and effective administration of medications through feeding tubes. This quiz will test your knowledge on the fundamentals of enteral nutrition, medication administration techniques, and the management of common drug-nutrient interactions and complications.

1. What is the guiding principle for choosing between enteral nutrition (EN) and parenteral nutrition (PN)?

• a) Parenteral nutrition is always safer.
• b) “If the gut works, use it.”
• c) Enteral nutrition is only for long-term use.
• d) The cost of the formula.

Answer: b) “If the gut works, use it.”

2. A primary benefit of using enteral nutrition over parenteral nutrition is that EN:

• a) Has a higher risk of bloodstream infections.
• b) Helps maintain the structural and functional integrity of the gastrointestinal tract.
• c) Is more expensive.
• d) Requires sterile compounding.

Answer: b) Helps maintain the structural and functional integrity of the gastrointestinal tract.

3. Which type of feeding tube is surgically placed through the abdominal wall directly into the stomach for long-term use?

• a) Nasogastric (NG) tube
• b) Orogastric (OG) tube
• c) Percutaneous endoscopic gastrostomy (PEG) tube
• d) Nasojejunal (NJ) tube

Answer: c) Percutaneous endoscopic gastrostomy (PEG) tube

4. A patient is receiving their nutrition via a jejunostomy tube (J-tube). This means the formula is delivered directly into the:

• a) Stomach
• b) Esophagus
• c) Duodenum
• d) Small intestine (jejunum)

Answer: d) Small intestine (jejunum)

5. A patient requires fluid restriction due to heart failure. Which type of enteral formula would be most appropriate?

• a) A standard, isotonic formula (1 kcal/mL).
• b) A concentrated, calorically dense formula (e.g., 1.5 or 2.0 kcal/mL).
• c) A high-fiber formula.
• d) A disease-specific renal formula.

Answer: b) A concentrated, calorically dense formula (e.g., 1.5 or 2.0 kcal/mL).

6. A patient is receiving large volumes of formula administered over a short period (20-30 minutes) several times a day. This feeding method is known as:

• a) Continuous infusion
• b) Cyclic infusion
• c) Bolus feeding
• d) Intermittent infusion

Answer: c) Bolus feeding

7. Which is the preferred dosage form for medication administration through a feeding tube?

• a) Enteric-coated tablets
• b) Extended-release capsules
• c) Commercially available liquid formulations (e.g., solutions, suspensions)
• d) Sublingual tablets

Answer: c) Commercially available liquid formulations (e.g., solutions, suspensions)

8. A pharmacist receives an order for metoprolol succinate (Toprol XL®) for a patient with a feeding tube. The pharmacist should:

• a) Tell the nurse to crush the tablet and administer it.
• b) Recognize that this is an extended-release tablet that should not be crushed and contact the prescriber to switch to an appropriate immediate-release formulation.
• c) Dissolve the tablet in hot water.
• d) Recommend the patient swallow the tablet whole.

Answer: b) Recognize that this is an extended-release tablet that should not be crushed and contact the prescriber to switch to an appropriate immediate-release formulation.

9. What is the most critical step to perform before and after administering each medication through a feeding tube?

• a) Flush the tube with 15-30 mL of water.
• b) Flush the tube with cranberry juice.
• c) Administer all medications mixed together in one syringe.
• d) Check the patient’s blood pressure.

Answer: a) Flush the tube with 15-30 mL of water.

10. A patient on continuous tube feeds is prescribed oral phenytoin suspension. To avoid a significant drug-nutrient interaction that reduces phenytoin absorption, the pharmacist should recommend:

• a) Mixing the phenytoin directly into the feeding formula.
• b) Holding the tube feeds for 1-2 hours before and after the phenytoin dose.
• c) Doubling the dose of phenytoin.
• d) Switching to fosphenytoin IV.

Answer: b) Holding the tube feeds for 1-2 hours before and after the phenytoin dose.

11. A patient on enteral nutrition is prescribed ciprofloxacin suspension. The pharmacist should advise against administering the suspension with tube feeds because:

• a) The suspension is too thick and will clog the tube.
• b) Chelation with divalent and trivalent cations in the formula can decrease ciprofloxacin absorption.
• c) The formula inactivates the antibiotic.
• d) Ciprofloxacin tastes bad.

Answer: b) Chelation with divalent and trivalent cations in the formula can decrease ciprofloxacin absorption.

12. The most common cause of a clogged feeding tube is:

• a) Using a formula that is too thin.
• b) Improper medication administration technique (e.g., inadequate flushing).
• c) The tube being too long.
• d) The patient moving around too much.

Answer: b) Improper medication administration technique (e.g., inadequate flushing).

13. What is the first-line intervention for a clogged feeding tube?

• a) Attempting to flush the tube with warm water using a syringe.
• b) Immediately replacing the tube.
• c) Using a wire to try and dislodge the clog.
• d) Instilling carbonated soda or cranberry juice.

Answer: a) Attempting to flush the tube with warm water using a syringe.

14. A common gastrointestinal complication of enteral nutrition, especially during initiation, is:

• a) Constipation
• b) Diarrhea
• c) Gastroparesis
• d) Peptic ulcer disease

Answer: b) Diarrhea

15. A patient on bolus feeds complains of nausea and bloating. An appropriate initial management step would be to:

• a) Switch to a more concentrated formula.
• b) Increase the volume of each bolus.
• c) Switch to a continuous or intermittent infusion schedule.
• d) Stop the enteral nutrition completely.

Answer: c) Switch to a continuous or intermittent infusion schedule.

16. To reduce the risk of aspiration pneumonia in a patient receiving enteral nutrition, the head of the bed should be:

• a) Kept completely flat.
• b) Elevated to at least 30-45 degrees.
• c) Lowered into the Trendelenburg position.
• d) Positioned on the left side.

Answer: b) Elevated to at least 30-45 degrees.

17. A patient being discharged home with a PEG tube requires counseling. A key point to include is:

• a) How to properly care for the skin around the tube site.
• b) How to operate the feeding pump, if applicable.
• c) How to administer medications and flush the tube.
• d) All of the above.

Answer: d) All of the above.

18. Which of the following dosage forms should NEVER be crushed for tube administration?

• a) Immediate-release tablets
• b) Enteric-coated or delayed-release tablets
• c) Hard gelatin capsules that can be opened
• d) Chewable tablets

Answer: b) Enteric-coated or delayed-release tablets

19. Why should liquid medications containing sorbitol be used with caution in patients receiving enteral nutrition?

• a) Sorbitol can cause severe constipation.
• b) Sorbitol is an osmotic laxative and can cause or worsen diarrhea.
• c) Sorbitol clogs feeding tubes.
• d) Sorbitol interacts with all medications.

Answer: b) Sorbitol is an osmotic laxative and can cause or worsen diarrhea.

20. A pharmacist receives an order to mix several liquid medications together and administer them all at once through a feeding tube. The pharmacist should:

• a) Follow the order as written.
• b) Advise the nurse that each medication should be administered separately with a water flush between each one.
• c) Mix the medications into the enteral formula bag.
• d) Refuse to dispense the medications.

Answer: b) Advise the nurse that each medication should be administered separately with a water flush between each one.

21. A patient on continuous tube feeding is also receiving warfarin. What is a potential drug-nutrient interaction?

• a) The high fat content of the formula will increase warfarin absorption.
• b) The vitamin K in many enteral formulas can decrease the INR and antagonize the effect of warfarin.
• c) The formula will cause the warfarin to precipitate in the tube.
• d) There is no interaction between warfarin and enteral formulas.

Answer: b) The vitamin K in many enteral formulas can decrease the INR and antagonize the effect of warfarin.

22. A “free-water flush” is ordered for a patient on continuous feeds. The purpose of this is to:

• a) Clean the tube.
• b) Provide additional calories.
• c) Help the patient meet their daily hydration needs.
• d) Administer medications.

Answer: c) Help the patient meet their daily hydration needs.

23. Which of the following is an example of a disease-specific enteral formula?

• a) A high-protein formula for wound healing.
• b) A formula with modified carbohydrates and fat for patients with diabetes (e.g., Glucerna).
• c) A formula with restricted electrolytes for patients with renal disease.
• d) All of the above.

Answer: d) All of the above.

24. The skills lab objective “Recommend appropriate medication administration methods” for EN patients emphasizes the pharmacist’s role in:

• a) Choosing the correct feeding tube size.
• b) Ensuring medications are prepared and given in a way that preserves their efficacy and avoids tube complications.
• c) Surgically placing the feeding tube.
• d) Writing the diet order.

Answer: b) Ensuring medications are prepared and given in a way that preserves their efficacy and avoids tube complications.

25. A patient on long-term enteral nutrition should be monitored for deficiencies in:

• a) Calories and protein.
• b) Fluid status.
• c) Electrolytes and micronutrients.
• d) All of the above.

Answer: d) All of the above.

26. A patient with a J-tube has a medication order for an antacid. The pharmacist should be concerned because:

• a) Antacids are best absorbed in the jejunum.
• b) The jejunum is distal to the stomach, and the antacid will not be able to neutralize gastric acid.
• c) Antacids will clog the J-tube.
• d) The patient does not need an antacid.

Answer: b) The jejunum is distal to the stomach, and the antacid will not be able to neutralize gastric acid.

27. What is the best way to prepare a hard gelatin capsule for administration via a feeding tube?

• a) Crush the entire capsule, including the shell.
• b) Open the capsule and mix the powder contents with water.
• c) Dissolve the entire capsule in warm water.
• d) This dosage form cannot be given via a feeding tube.

Answer: b) Open the capsule and mix the powder contents with water.

28. A patient is experiencing constipation while on a standard enteral formula. An appropriate first step might be to:

• a) Recommend a stimulant laxative.
• b) Switch to a formula that contains fiber.
• c) Stop the enteral nutrition.
• d) Decrease the free-water flushes.

Answer: b) Switch to a formula that contains fiber.

29. Gastric residual volumes (GRVs) are sometimes checked in patients on continuous gastric feeds to assess:

• a) The patient’s hydration status.
• b) The nutritional content of the formula.
• c) Tolerance and the risk of aspiration.
• d) The pH of the stomach.

Answer: c) Tolerance and the risk of aspiration.

30. Which dosage form is particularly problematic for tube administration because the small beads can easily clog the tube?

• a) An oral solution
• b) An elixir
• c) Pellets from an opened extended-release capsule.
• d) A finely crushed immediate-release tablet.

Answer: c) Pellets from an opened extended-release capsule.

31. A patient with a history of pancreatitis might require which type of specialized enteral formula?

• a) A high-fat formula.
• b) A formula containing hydrolyzed proteins and medium-chain triglycerides (MCTs) for easier digestion.
• c) A standard polymeric formula.
• d) A high-fiber formula.

Answer: b) A formula containing hydrolyzed proteins and medium-chain triglycerides (MCTs) for easier digestion.

32. The pharmacist’s role in enteral nutrition therapy fits into which step of the Pharmacists’ Patient Care Process (PPCP)?

• a) Collect
• b) Assess
• c) Plan and Implement
• d) All of the above

Answer: d) All of the above

33. Before crushing a tablet, a pharmacist should first check resources to confirm:

• a) That it is a crushable, immediate-release formulation.
• b) The cost of the tablet.
• c) The color of the tablet.
• d) The manufacturer of the tablet.

Answer: a) That it is a crushable, immediate-release formulation.

34. A patient is receiving continuous feeds at 75 mL/hr of a 1.2 kcal/mL formula. How many total kilocalories will they receive in 24 hours?

• a) 1800 kcal
• b) 2160 kcal
• c) 2400 kcal
• d) 2700 kcal

Answer: b) 2160 kcal

35. A “closed system” enteral formula is one that:

• a) Is prepared by the pharmacist in a sterile clean room.
• b) Comes in a pre-filled, ready-to-hang container, reducing the risk of contamination.
• c) Requires the nurse to transfer formula from a can to a feeding bag.
• d) Is only used for bolus feeds.

Answer: b) Comes in a pre-filled, ready-to-hang container, reducing the risk of contamination.

36. A patient receiving enteral nutrition develops hyperglycemia. An appropriate intervention would be:

• a) Switching to a formula with a lower carbohydrate content or one designed for glycemic control.
• b) Adding a sliding scale insulin regimen.
• c) Decreasing the infusion rate.
• d) All of the above could be appropriate interventions.

Answer: d) All of the above could be appropriate interventions.

37. Which of the following is an example of a mechanical complication of enteral nutrition?

• a) Diarrhea
• b) Hyperglycemia
• c) Nasal irritation or erosion from a nasogastric tube.
• d) Refeeding syndrome.

Answer: c) Nasal irritation or erosion from a nasogastric tube.

38. The general rule for administering medications with continuous feeds is to:

• a) Mix all medications directly into the formula bag.
• b) Stop the feeding, flush the tube, give the medication, flush the tube, and then restart the feeding.
• c) Never give medications to a patient on continuous feeds.
• d) Give all medications at once without flushing.

Answer: b) Stop the feeding, flush the tube, give the medication, flush the tube, and then restart the feeding.

39. A patient with a J-tube cannot receive medications that require an acidic environment for absorption because:

• a) The jejunum is an acidic environment.
• b) The feeding tube bypasses the stomach.
• c) The formula will neutralize the acid.
• d) The J-tube is made of a special plastic.

Answer: b) The feeding tube bypasses the stomach.

40. To prevent a drug-nutrient interaction with warfarin, a pharmacist could recommend:

• a) Switching the patient to a formula with a consistent amount of vitamin K.
• b) More frequent INR monitoring, especially when the formula or rate is changed.
• c) Holding feeds around the warfarin dose if clinically feasible.
• d) Both A and B are appropriate strategies.

Answer: d) Both A and B are appropriate strategies.

41. Which of the following is a sign of GI intolerance to enteral feeds?

• a) High gastric residual volumes.
• b) Vomiting or diarrhea.
• c) Abdominal distention.
• d) All of the above.

Answer: d) All of the above.

42. A pharmacist counsels a family member on how to unclog a PEG tube at home. The counseling should emphasize:

• a) Using a stiff wire to clear the obstruction.
• b) The “push-pull” technique with warm water and a syringe.
• c) The importance of calling the provider if the clog cannot be cleared easily.
• d) Both B and C are correct.

Answer: d) Both B and C are correct.

43. A patient with end-stage renal disease on hemodialysis requires enteral nutrition. They would likely need a formula that is:

• a) High in protein, low in potassium and phosphorus, and calorically dense.
• b) Low in protein and high in fluid.
• c) A standard, isotonic formula.
• d) High in fiber.

Answer: a) High in protein, low in potassium and phosphorus, and calorically dense.

44. What is the most reliable way to confirm the placement of a newly inserted nasogastric tube before initiating feeds?

• a) Auscultating over the stomach while injecting air.
• b) Checking the pH of an aspirate.
• c) Obtaining an abdominal X-ray.
• d) Asking the patient if it feels like it is in the right place.

Answer: c) Obtaining an abdominal X-ray.

45. Which of the following should not be administered via a feeding tube?

• a) An oral suspension
• b) A sublingual tablet
• c) An elixir
• d) An immediate-release tablet crushed and mixed with water

Answer: b) A sublingual tablet

46. A “polymeric” enteral formula contains:

• a) Individual amino acids.
• b) Hydrolyzed proteins.
• c) Intact, whole proteins.
• d) Only fat and carbohydrates.

Answer: c) Intact, whole proteins.

47. A patient with compromised GI function (e.g., malabsorption) might require what type of formula?

• a) A standard polymeric formula.
• b) A semi-elemental or elemental formula with hydrolyzed nutrients.
• c) A high-fiber formula.
• d) A blenderized diet.

Answer: b) A semi-elemental or elemental formula with hydrolyzed nutrients.

48. When administering multiple medications, how much water should be used to flush between each one?

• a) None, they can all be mixed.
• b) At least 50 mL.
• c) 5-15 mL.
• d) A full glass of water.

Answer: c) 5-15 mL.

49. The skills lab module on enteral nutrition prepares students to:

• a) Counsel patients and caregivers on how to use EN at home.
• b) Recommend appropriate medication administration methods.
• c) Assess the need for an EN product.
• d) All of the above.

Answer: d) All of the above.

50. The ultimate goal of enteral nutrition support is to:

• a) Provide a long-term alternative to eating.
• b) Prevent malnutrition and support the patient’s metabolic needs when oral intake is inadequate or unsafe.
• c) Increase the pharmacy’s revenue.
• d) Test the patient’s tolerance for feeding tubes.

Answer: b) Prevent malnutrition and support the patient’s metabolic needs when oral intake is inadequate or unsafe.