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 D

Explanation

The nurse should encourage the client to make choices regarding hygiene, as this respects the client's autonomy and dignity. Suctioning the client's airway every hour is incorrect because it may cause discomfort and distress to the dying client. Offering the client sips of a citrus flavored soda is incorrect because it may irritate the client's mouth and throat, which are often dry and sensitive at the end of life. Positioning the client supine in bed is incorrect because it may increase the risk of aspiration and airway obstruction, as well as pressure ulcers.

A. Secure restraints to allow three fingers to slide under the restraints. B. Assess skin temperature and color before applying the restraints. C. Ensure that the client's bed is in the lowest position. D. Attach the client's restraints to the bed rail. E. Pad bony prominences before applying the restraints.

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

Explanation

The nurse should secure restraints to allow three fingers to slide under the restraints to prevent circulation impairment and nerve damage. The nurse should also assess skin temperature and color before applying the restraints to establish a baseline and monitor for signs of ischemia. The nurse should ensure that the client's bed is in the lowest position to reduce the risk of injury from falls. The nurse should pad bony prominences before applying the restraints to prevent skin breakdown and pressure ulcers. The nurse should not attach the client's restraints to the bed rail because this can cause injury if the bed is moved or adjusted. The nurse should attach the restraints to a part of the bed frame that moves with the client, such as the mattress support platform.

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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

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

Explanation

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