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 D
Explanation
A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.
B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.
C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.
D. Use distractions when bathing the client.Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.
Correct Answer is B
Explanation
The correct answer is that the nurse should turn off the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.
Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.
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