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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["F"]
Explanation
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Correct Answer is C
Explanation
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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