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 client's age is part of the measurement."

The scale measures six elements."

"Each element has a range from one to five points.

"The higher the score, the higher the pressure injury risk."

Answer and Explanation

The Correct Answer is B

This response shows that the newly licensed nurse knows the components of the Braden scale, which are sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

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Correct Answer is ["A","C","E"]

Explanation

Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.

A. Wearing gloves when performing perineal care B. Failing to don a mask when entering a client's isolation room C. Cleansing visibly fecal-soiled hands with alcohol-based hand rub D. Putting on a protective gown before entering a client's room

Correct Answer is C

Explanation

Cleansing visibly fecal-soiled hands with alcohol-based hand rub is a possible source of infection because alcohol-based hand rubs are not effective against Clostridium difficile spores. The nurse should wash his or her hands with soap and water for at least 15 seconds after contact with fecal material or surfaces contaminated with feces.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse manager is performing a quality improvement assessment to determine the source of a recurrence of Clostridium difficile on a unit. The nurse manager should identify that which of the following nursing actions is a possible source of infection?

Correct Answer is C

Explanation

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

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