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."
"Each element has a range from one to five points."
"The higher the score, the higher the pressure injury risk."
"The scale measures six elements."
The Correct Answer is D
Choice A rationale:
The client's age is not a part of the measurement in the Braden scale.
Choice B rationale:
Each element in the Braden scale has a range from one to four points, except for friction and shear, which is scored from one to three points.
Choice C rationale:
The lower the score, the higher the risk of developing pressure injuries.
Choice D rationale:
The Braden scale is a tool that helps nurses assess the risk of developing pressure injuries in clients. It consists of six elements: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ensuring the gloves in the surgical suite are powdered is not appropriate, as latex gloves with powder can aerosolize latex proteins, increasing the risk of an allergic reaction. Powder-free gloves should be used.
Choice B rationale:
Cleaning stoppers with povidone-iodine is not directly related to latex allergy and may not be necessary in the context of latex allergy.
Choice C rationale:
Scheduling the client as the first surgical procedure of the day is appropriate to minimize the client's exposure to latex in the environment.
Choice D rationale:
Removing stopcocks from IV tubing is not a standard precaution for latex allergy and may not be necessary in all cases. Minimizing latex exposure in the surgical suite is a more comprehensive approach.
Correct Answer is C
Explanation
Choice A rationale:
Choosing the most proximal site on the extremity is not recommended. Peripheral IV catheters are typically inserted in more distal sites to preserve more proximal sites for other needs.
Choice B rationale:
the nurse should place the extremity in an elevated position, to reduce blood flow and make the veins more visible.
Choice C rationale:
Placing the tourniquet above the proposed insertion site is the correct action. This helps distend the veins, making them more visible and accessible for insertion by occluding venous return thus engorging the vein.
Choice D rationale:
Applying a cool compress is not a standard practice before IV catheter insertion. Warm compresses may be used to enhance vein visibility.
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