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?

"The scale measures six elements."

"The client's age is part of the measurement."

"The higher the score, the higher the pressure injury risk."

"Each element has a range from one to five points."

Answer and Explanation

The Correct Answer is A

A.   The Braden scale does evaluate six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
B.   The client's age isn't directly part of the Braden scale; it assesses various risk factors, but age isn't one of them.
C.   In contrast, the lower the Braden scale score, the higher the risk of pressure injuries.
D.   Each element in the Braden scale is rated on a scale from one to four or one to three, depending on the element, not from one to five points.

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Correct Answer is C

Explanation

A. Weighing oneself once weekly may not be frequent enough to monitor changes related to heart failure or medication effects.
B. Taking hydrochlorothiazide in the evening is not usually a crucial safety consideration; it is typically taken in the morning due to its diuretic effects.
C. Leaving a light on in the bathroom at night can prevent falls, which are a significant concern in older adults with heart failure.
D. Taking a hot bath before bedtime might not be a safety consideration related to heart failure or medication use and could potentially cause issues with temperature regulation or dehydration.

A. Assess skin temperature and color before applying the restraints. B. Attach the client's restraints to the bed rail. C. Ensure that the client's bed is in the lowest position. D. Pad bony prominences before applying the restraints. E. Secure restraints to allow three fingers to slide under the restraints.

Correct Answer is ["A","C","D"]

Explanation

A. Assessing skin temperature and color is crucial to ensure circulation and skin integrity before applying restraints.
B. Attaching restraints to the bed rail isn't considered best practice, as it can lead to entrapment and injury.
C. Ensuring the client's bed is in the lowest position is essential to prevent falls and reduce the risk of injury if the client attempts to leave the bed.
D. Padding bony prominences helps prevent skin breakdown and discomfort.
E. Securing restraints to allow two fingers and not three,to slide under them ensures proper fit and prevents excessive tightness that could impair circulation.

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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

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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