A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

"The scale measures six elements."

"The client's age is part of the measurement."

"The higher the score, the higher the pressure injury risk."

"Each element has a range from one to five points."

Answer and Explanation

The Correct Answer is A

A.   The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B.   The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C.   In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D.   Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

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Correct Answer is A

Explanation

A. Eyelashes that curl slightly outward is a normal finding.
B. An involuntary blink rate of 30 to 35 times per minute might be within the normal range but is not typically assessed during a routine eye examination.
C. Pupils of 8 to 9 mm in diameter might indicate dilation, which is not a normal finding during a regular eye assessment.
D. Corneas with an opaque appearance could indicate issues such as corneal edema or opacity, which are abnormal findings.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Recheck the client's BP in her other arm for comparison. C. Request that another nurse check the client's BP in 30 min. D. Reposition the client supine and recheck her BP.

Correct Answer is B

Explanation

A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.

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A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

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