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 higher the score, the higher the pressure injury risk."
The client's age is part of the measurement."
"Each element has a range from one to five points."
"The scale measures six elements."
The Correct Answer is C
A. "The higher the score, the higher the pressure injury risk":
This statement is incorrect. The lower the score on the Braden scale, the higher the risk for pressure injuries. The total score is used to assess the overall risk, and a lower score indicates a higher risk.
B. "The client's age is part of the measurement":
This statement is incorrect. The client's age is not a factor in the Braden scale. The scale focuses on specific elements related to pressure injury risk, such as sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
C. "Each element has a range from one to five points":
This response indicates an understanding of the Braden scale. The scale measures six elements (sensory perception, moisture, activity, mobility, nutrition, and friction/shear), and each element is scored on a scale from 1 to 4 or 1 to 5 points, depending on the element. The total score ranges from 6 to 23, and a lower score indicates a higher risk for developing pressure injuries.
D. "The scale measures six elements":
While this statement is correct, it does not provide specific information about the scoring range for each element. The key aspect emphasized in the Braden scale is the scoring range for each element, as it helps determine the overall risk for pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.
Correct Answer is ["B","D","E"]
Explanation
A. "I need to set my hot water heater to 140 degrees Fahrenheit":
This statement is incorrect. The recommended safe temperature for a hot water heater is generally set to 120 degrees Fahrenheit (49 degrees Celsius) to prevent scalds and burns. A setting of 140 degrees Fahrenheit increases the risk of burns, especially for vulnerable populations such as children and the elderly.
B. "I will use the grab bars when getting in and out of the bathtub":
This statement indicates an understanding of the importance of using safety features, such as grab bars, to prevent falls in the bathroom. Using grab bars provides support and stability during activities like getting in and out of the bathtub, reducing the risk of accidents.
C. "I will apply tape over frayed areas of electrical cords":
This statement is incorrect. Using tape on frayed electrical cords is not a safe or effective solution. Frayed cords should be replaced to avoid the risk of electrical shock or fire. Using tape may not adequately address the underlying safety issue and can be a hazard itself.
D. "I need to check my medications for expiration dates":
This statement reflects an understanding of the importance of medication safety. Checking medication expiration dates is crucial to ensure the efficacy and safety of the medications. Expired medications may be less effective or potentially harmful.
E. "I need to have a fire escape plan with my family":
This statement shows awareness of the importance of having a fire escape plan at home. Having a plan in place helps ensure that everyone in the household knows what to do in case of a fire, improving overall safety.
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