It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Weakened cough effort.

Hypoactive bowel sounds.

Urinary incontinence.

Plus two ankle edema.

Answer and Explanation

The Correct Answer is C

C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.

A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.

B. Bowel sounds are not included in the Braden Scale assessment criteria.

D. Ankle edema is not included as a factor in the Braden Scale assessment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A chart by exception system requires nurses to document deviations from the expected or normal findings rather than documenting every single detail.

D All lung zones should have clear vesicular breath sounds. The presence of diminished sounds indicated lung consolidation which can occur in pneumonic processes or pleural effecusion.

A This finding indicates a normal response known as a consensual response, where the left pupil constricts when light is shone into the right eye.

B Active bowel sounds are considered normal and indicate proper gastrointestinal motility.

C Capillary refill is a quick bedside test used to assess peripheral circulation and tissue perfusion. A refill time of 2 seconds is within the normal range (typically 2 seconds or less), indicating adequate perfusion.

A. Take an afternoon nap to make up for missed sleep. B. Avoid drinking caffeinated beverages late in the day. C. Establish a regular time for going to bed and getting up. D. Ask the healthcare provider for a mild sedative for bedtime. E. Drink a mixture of warm water, whiskey, and honey at bedtime.

Correct Answer is ["B","C"]

Explanation

B. Caffeine can interfere with sleep, especially if consumed close to bedtime. Opt for decaffeinated options in the evening. Avoiding caffeinated beverages late in the day can help promote better sleep by reducing the stimulant effects of caffeine, which can interfere with falling asleep or staying asleep.

C. Establish a regular time for going to bed and getting up. Consistency helps regulate your

body’s internal clock. Try to maintain the same sleep schedule even on weekends.

A. Taking an afternoon nap to make up for missed sleep is not recommended, as napping during the day can disrupt nighttime sleep patterns and make it harder to fall asleep or stay asleep at night, especially for older adults.

D. Asking the healthcare provider for a mild sedative for bedtime may not be the first-line recommendation, as sedatives can have side effects and potential risks, especially for older adults. Non-pharmacological interventions are typically preferred for improving sleep quality.

E. Alcohol consumption before bedtime can disrupt sleep patterns and interfere with restorative sleep, particularly when combined with other substances like caffeine or sugar.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is D

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. Which action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["B","C"]

Explanation

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Patient Data History and Physical The nurse calls the provider to notify them that the digoxin level is above therapeutic range. Place the nurse statements in Situation, Background, Assessment, Recommendation (SBAR) format.

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ: Which instruction should the nurse include?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via masal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?