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 A
Explanation
A nurse should apply a bath blanket between the client and a cooling blanket when caring for a client who has a high fever.
This can help regulate the temperature of the environment and make it more comfortable for the patient.
Choice B is wrong because placing ice packs on the client’s neck and behind the knees is not recommended as it can cause further problems.
Choice C is wrong because giving the client a sponge bath using an alcohol-water solution is not recommended.
Choice D is wrong because covering the client with heavy blankets after the shivering subsides is not recommended as it can increase body temperature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today