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 D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Obtain a random blood glucose daily. B. Change the PN infusion bag every 48 hr. C. Prepare the client for a central venous line. D. Administer the PN and fat emulsion separately.

Correct Answer is C

Explanation

A. Obtaining a random blood glucose daily is important for monitoring glucose levels but might not be specifically related to the introduction of PN in this context.
B. Changing the PN infusion bag every 48 hours might not be universally applicable; the frequency of changing PN bags depends on institutional policies and the stability of the solution being administered.
C. PN with high concentrations of dextrose and fat emulsions typically requires a central venous line for administration to prevent peripheral vein irritation or damage.
D. Administering PN and fat emulsion separately might not be practical as PN usually includes all necessary components in a single infusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

Correct Answer is C

Explanation

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