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
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Correct Answer is D
Explanation
The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.
Correct Answer is B
Explanation
The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.
Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.
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