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 client's age is part of the measurement."
"The higher the score, the higher the pressure injury risk
The scale measures six elements
The Correct Answer is D
The Braden scale is a commonly used tool for assessing a patient's risk of developing pressure injuries (also known as pressure ulcers or bedsores). It evaluates six specific elements to determine the patient's risk level. These elements include sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element is assessed and assigned a score, with a lower score indicating a higher risk for developing pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Mixing medications in a syringe can lead to potential drug interactions, changes in medication efficacy, or altered drug absorption. Each medication should be administered separately to maintain their individual therapeutic effects.
B. Each medication should be diluted with sterile water to ensure it can pass through the NG tube without clogging and to facilitate proper absorption.
C.Flushing the NG tube with 5 mL of sterile water is generally not enough. The tube should be flushed with a sufficient amount of water (usually 15-30 mL) before and after administering medications to ensure that the medications are delivered properly and to prevent clogging.
D.Medications should not be combined with the formula in the feeding bag. This can alter the effectiveness of both the medications and the feeding formula.
Correct Answer is C
Explanation
A. Schedule postural drainage after meals.
Postural drainage should be performed at least 1 hour before or 2 hours after meals to avoid discomfort or aspiration.
B. Instruct the client to exhale quickly during vibration.
The client should exhale slowly during vibration to avoid forcing air too quickly into the lungs, which can be uncomfortable.
C. Cover the area of percussion with a towel
Percussion should be done with a towel or soft cloth to avoid skin irritation or injury while still allowing the vibrations to pass through.
D. Perform percussion over the lower back.
Percussion should not be performed over bony areas such as the spine or kidneys. The nurse should focus on the upper chest, lower chest, and upper back but avoid the lower back area.
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