It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Weakened cough effort.

Hypoactive bowel sounds.

Urinary incontinence.

Plus two ankle edema.

Answer and Explanation

The Correct Answer is C

C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.

A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.

B. Bowel sounds are not included in the Braden Scale assessment criteria.

D. Ankle edema is not included as a factor in the Braden Scale assessment.

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Correct Answer is C

Explanation

C. When providing health teaching to older adult clients, using everyday language is crucial. Older adults may have varying levels of health literacy and cognitive abilities, so using simple, clear language facilitates better understanding and comprehension of the information being provided.

A. Underlining key words on the written information may be helpful for emphasizing important points, but it is not as critical as using everyday language to enhance understanding

B. Speaking loudly and facing the client may not be necessary for all older adult clients and could even be perceived as patronizing or disrespectful.

D. Providing a very well-lit meeting space is important for optimizing visual acuity, especially for older adults who may have age-related changes in vision. However, while adequate lighting is beneficial, it is not as critical

A. Uses an oral airway to keep the teeth apart. B. Places the client in a supine position. C. Tests for a gag reflex before performing oral care. D. Suctions secretions from the posterior pharynx.

Correct Answer is B

Explanation

A. Using an oral airway can be appropriate in some situations to keep the mouth open and facilitate oral care, especially in an unconscious client. This helps prevent biting and allows for easier access to the oral cavity. Therefore, this action does not indicate a need for additional training.

B. Placing an unconscious client in a supine position for oral care can be inappropriate, as it increases the risk of aspiration, especially if there are secretions in the mouth. It is generally safer to position the client in a lateral position to minimize this risk. This action may indicate a need for additional training.

C. Testing for a gag reflex before performing oral care is a standard precaution, especially for unconscious clients. This helps prevent aspiration and ensures the safety of the client during the procedure.

D. Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration, especially for unconscious clients who may have difficulty managing their secretions.

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It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

Correct Answer is B

Explanation

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

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The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

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It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?