NCLEX-RN

Category - Reduction of Risk

A nurse is evaluating a client with dysphagia and anorexia due to cancer. The client is receiving continuous feeding. Which of the following parameters is monitored as it is the best indicator of good response to the management?
  1. Tolerates tube feedings
  2. No signs of aspiration
  3. Absence of weight loss
  4. Expresses a desire to take food orally
Explanation
Answer: C - A good response to tube feeding is the absence of apparent weight loss. If a client has weight loss of more than 10% of his or her previous body weight, supplementation and a re-evaluation of nutrition is required. Another excellent parameter of response to tube feeding is a positive nitrogen balance in the blood. This means that anabolic metabolism did not occur. The nurse should include assessment of tolerance to feeding and absence of aspiration to prepare the client for oral intake of food and fluids.
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