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.

Answer and Explanation

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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Correct Answer is C

Explanation

When caring for an immunocompromised client, the nurse should prioritize infection prevention and control measures. One essential action is to cleanse hands with an alcohol-based hand rub before client contact. Hand hygiene is crucial in reducing the transmission of microorganisms and preventing infections. Using an alcohol-based hand rub is eﬀective in killing many types of germs, including bacteria and viruses.

Let's now discuss why the other

Options are not the correct answers:

a. Place the client in a semiprivate room: Placing the client in a semiprivate room increases the risk of exposure to potential infections from other individuals. Immunocompromised clients have a weakened immune system, making them more susceptible to infections. Therefore, it is recommended to provide them with a private room to minimize the risk of exposure to pathogens.

b. Have the client apply a mask when children are visiting: While it is generally important to take precautions when visitors are present, having the client wear a mask when children are visiting may not be sufficient to protect the immunocompromised client. Children can carry and transmit various infectious diseases, even without displaying symptoms. Therefore, it is more appropriate for healthcare providers and visitors, including children, to adhere to strict hand hygiene and other infection control measures to minimize the risk of infection transmission.

d. Use sterile gloves to provide perineal care: The use of sterile gloves is not necessary for routine perineal care unless there is a specific indication, such as an open wound or surgical site. For routine perineal care, clean, non-sterile gloves are sufficient. Using sterile gloves unnecessarily can contribute to the development of antimicrobial resistance and increase healthcare costs without providing any additional benefits.

In summary, when caring for an immunocompromised client, the nurse should prioritize infection prevention and control. Cleansing hands with an alcohol-based hand rub before client contact is an important action to reduce the risk of infection transmission. The other

Options, such as placing the client in a semiprivate room, having the client wear a mask when children are visiting, and using sterile gloves for routine perineal care, are not the appropriate actions in this scenario.

A. Fever B. Crackles in the lungs C. Bradycardia D. Flattened neck veins

Correct Answer is B

Explanation

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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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 B

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