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.".
"Each element has a range from one to five points.".
"The scale measures six elements.".
"The client's age is part of the measurement.".
The Correct Answer is C
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
“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 injury.
“Each element has a range from one to five points”: This statement is incorrect.
Each element has a range from one to four points, except for friction/shear which has a range from one to three points.
“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Change the tubing set every 72 hr:Continuous enteral feeding tubing sets should generally be changed every 24 hours to reduce the risk of bacterial contamination. Changing every 72 hours is too long and increases infection risk.
B. Aspirate residual volume every 4 hr:Aspiration of residual volume every 4 hours is standard practice when providing continuous enteral feedings. This ensures the client is tolerating the feedings and helps prevent aspiration or overfeeding. Large residual volumes may indicate poor gastric emptying.
C. Flush the tubing with 10 mL of water every 2 hr:The tubing should be flushed with 30 mL of water every 4-6 hours (depending on protocol), not just 10 mL, to maintain tube patency and prevent clogging.
D. Heat the formula to 40.5° C (105° F):Formula should not be heated to such a high temperature. It should be administered at room temperature to avoid discomfort and potential damage to the gastrointestinal tract.
Correct Answer is D
Explanation
This is important to prevent urine from flowing back into the bladder, which can cause infection 1.
Choice A is incorrect because the catheter should be secured to the outer side of the thigh, not taped to the lower abdomen 2.
Choice B is incorrect because attaching the drainage bag to the side rails of the bed can cause it to be above the level of the bladder.
Choice C is incorrect because it is important to empty the drainage bag regularly, not just when it is three-quarters full.
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