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 higher the score, the higher the pressure injury risk.".
"Each element has a range from one to five points.".
"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.
“The higher the score, the higher the pressure injury risk”: This statement is incorrect.
The lower the score on the Braden scale, the higher the risk for pressure injury.
“Each element has a range from one to five points”: This statement is incorrect.
Each element has a range from one to four points, except for friction/shear which has a range from one to three points.
“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: The correct answer is choice c. Ensure the client is free of metal objects.
Here's the rationale for each choice:
- Choice A: Rationale: Bowel cleansing is not routinely performed before an intravenous pyelogram (IVP) unless there is a specific concern about fecal matter obscuring the urinary tract on the X-rays.
- Choice B: Rationale: While pain in the suprapubic region (lower abdomen) is not a common side effect of an IVP, the nurse should be aware of this possibility and assess the client for any discomfort. However, monitoring for pain is not a specific action to include in preparation for the procedure.
- Choice C: Rationale: Metal objects can interfere with the X-ray images during an IVP. Ensuring the client removes any jewelry or clothing with metal fasteners is an important step in preparation.
- Choice D: Rationale: Oral contrast is not typically used in an IVP. The contrast material for this procedure is administered intravenously.
Correct Answer is A
Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client’s prior coping mechanisms.
This can help the nurse understand how the client has dealt with difficult situations in the past and can provide insight into how the client may cope with their current diagnosis.
Choice B is wrong because while teaching the client to use progressive relaxation techniques may be helpful in managing stress and anxiety, it is not the priority intervention.
Choice C is wrong because while helping the client find a local support group may provide emotional support, it is not the priority intervention.
Choice D is wrong because while developing a list of goals with the client may provide direction and focus, it is not the priority intervention.
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