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 client's age is part of the measurement."

The scale measures six elements."

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

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

Answer and Explanation

The Correct Answer is B

This response shows that the newly licensed nurse knows the components of the Braden scale, which are sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

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Correct Answer is C,D,A,B

Explanation

The first step in addressing a client's problem is to identify possible nursing interventions that are relevant and appropriate for the situation. The next step is to determine how likely each intervention is to cause complications or adverse effects for the client, such as drug interactions or allergies. The third step is to review how beneficial each intervention is in terms of relieving symptoms, improving outcomes, or preventing complications, as well as how feasible each intervention is in terms of availability, cost, or preference. The final step is to select an intervention that provides greatest benefit and least risk for the client based on evidence-based practice and clinical judgment.

A. Suction the client's airway every hour. B. Offer the client sips of a citrus flavored soda. C. Position the client supine in bed. D. Encourage the client to make choices regarding hygiene.

Correct Answer is D

Explanation

The nurse should encourage the client to make choices regarding hygiene, as this respects the client's autonomy and dignity. Suctioning the client's airway every hour is incorrect because it may cause discomfort and distress to the dying client. Offering the client sips of a citrus flavored soda is incorrect because it may irritate the client's mouth and throat, which are often dry and sensitive at the end of life. Positioning the client supine in bed is incorrect because it may increase the risk of aspiration and airway obstruction, as well as pressure ulcers.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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