The nurse uses the Braden Scale to determine the patient's risk for pressure injury development.
Which subscales are used in calculating the score? Select all that apply.

Choice A rationale

Ciprofloxacin absorption can be significantly impaired by antacids containing aluminum, magnesium, or calcium. These antacids bind to ciprofloxacin, forming insoluble complexes that reduce the antibiotic's bioavailability, thus diminishing its effectiveness in treating the infection.

Choice B rationale

Ciprofloxacin, a fluoroquinolone antibiotic, carries a black box warning for increased risk of tendinitis and tendon rupture. Patients should be instructed to monitor for tendon pain, especially in the Achilles tendon, and report it immediately to prevent severe and permanent injury.

Choice C rationale

Limiting fluid intake is contraindicated when taking ciprofloxacin for a UTI. Adequate hydration is crucial to help flush bacteria from the urinary tract and prevent crystalluria, a potential side effect where drug crystals form in the urine, which can lead to kidney damage.

Choice D rationale

Ciprofloxacin does not typically cause urine to turn dark orange. This side effect is more commonly associated with other medications, such as rifampin or phenazopyridine (a urinary analgesic), and is not an expected or normal finding when taking ciprofloxacin.

Choice A rationale

Inserting an indwelling urinary catheter prematurely without assessing for bladder distension or attempting other less invasive interventions is not the first step. Catheterization carries risks like infection and trauma. A bladder scan provides objective data to guide further interventions.

Choice B rationale

Positioning the patient on their left side is not a primary intervention for urinary retention after catheter removal. While position can sometimes aid voiding, it is not a direct solution for a patient who has not voided for 8 hours and does not address the underlying issue of bladder fullness.

Choice C rationale

Performing a bladder scan is the most appropriate next nursing action. A bladder scan non-invasively measures the volume of urine in the bladder. If the bladder volume is significant (e.g., >200-400 mL, normal post-void residual is <50-100 mL), it indicates urinary retention, guiding further interventions.

Choice D rationale

Instructing the patient to drink fluids without assessing for bladder distension can exacerbate the problem if the patient is already experiencing retention. Increasing fluid intake without adequate outflow can lead to overdistension of the bladder, causing further discomfort and potential bladder damage.