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?
Each element has a range from one to five points.
The higher the score, the higher the pressure injury risk.
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. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse effects from the rapid infusion of fluids.
Option a is incorrect because notifying the primary care provider is important but not the first intervention.
Option c is incorrect because calculating the infused volume is important but not the first intervention.
Option d is incorrect because completing an incident report is important but not the first intervention.
Correct Answer is D
Explanation
The client's statement that they will place the suppository as far inside their vagina as they can reach indicates an understanding of the teaching. This ensures that the medication is delivered to the site of infection.
a. The client should continue to use the medication for the full course of treatment, even if their symptoms improve before the treatment is complete.
b. The client can lie on their back or side to insert the suppository; there is no specific requirement to lie on their left side.
c. Lubricant is not typically necessary for the insertion of a vaginal suppository.
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