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."

Answer and Explanation

The Correct Answer is D

A. "The higher the score, the higher the pressure injury risk.": The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.": The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.": Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

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Correct Answer is C

Explanation

a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.

b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.

c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.

d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.

A. Assist the client with a bowel cleansing. B. Ensure the client is free of metal objects. C. Monitor the client for pain in the suprapubic region. D. Administer 240 mL. (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

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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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