The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Answer and Explanation

The Correct Answer is A

A. 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. The Braden Scale scores range from 6 to 23, with lower scores indicating higher risk. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment, making this the best sign that the risk for skin breakdown has been removed.

B. 13: A score of 13 indicates moderate risk for skin breakdown. While this is an improvement from a score of 15, it still shows that the patient remains at risk and requires ongoing monitoring and intervention.

C. 23: A score of 23 indicates very low risk for skin breakdown; however, it is not a feasible score for patients who were initially assessed at 15. Achieving this score would likely suggest an unrealistic improvement in the patient's condition based solely on nursing interventions.

D. 12: A score of 12 indicates a high risk for skin breakdown. This score signifies that the risk has not been effectively addressed, and the patient continues to be vulnerable to skin impairment.

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Correct Answer is D

Explanation

A. "I will keep my walker at the end of my bed.": Storing a walker at the end of the bed may not be the safest option. The walker should be kept within easy reach to ensure the client can access it promptly when getting up, reducing the risk of falls.

B. "I will place an area rug at the entry of my bathroom.": Placing an area rug in a high-traffic area like the bathroom can create a tripping hazard, increasing the risk of falls. It is important to keep walking paths clear and free from obstacles to ensure safety.

C. "I will keep the fluorescent ceiling light in my room at night.": While having adequate lighting is important, keeping the light on at night may not address the need for easy access to light sources. The client should consider using nightlights or ensuring that light switches are easily accessible to avoid navigating in the dark.

D. "I will place a bath seat in my shower to use when I bathe.": This statement indicates an understanding of safety measures to prevent falls while bathing. Using a bath seat can provide stability and allow the client to bathe safely while reducing the risk of slipping or losing balance in the shower. This reflects the client's awareness of their needs related to fall prevention.

A. Clean the client's dentures with regular toothpaste. B. Place the client's dentures on a washcloth in a sink. C. Rinse the client's dentures in hot water. D. Remove the client's dentures with a moist glove.

Correct Answer is B

Explanation

A. Clean the client's dentures with regular toothpaste: Regular toothpaste can be too abrasive for dentures and may cause scratches or damage. It is better to use a cleanser specifically designed for dentures to avoid harming the surface while effectively cleaning them.

B. Place the client's dentures on a washcloth in a sink: This is a proper action to take when cleaning dentures. Placing the dentures on a washcloth in the sink provides a cushioned surface to prevent them from breaking if they slip out of the nurse's hands. Additionally, it helps to prevent them from rolling around in the sink, which can lead to damage.

C. Rinse the client's dentures in hot water: Rinsing dentures in hot water can warp the material or alter the fit, potentially leading to discomfort or ineffective cleaning. It is recommended to rinse dentures with lukewarm or cool water instead to maintain their integrity.

D. Remove the client's dentures with a moist glove: While using gloves is important for maintaining hygiene, removing the client's dentures with moist gloves is not necessary. The dentures should be removed carefully with clean, dry hands or gloves, and moisture is not required for this process.

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The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer is D

Explanation

A nurse is preparing to clean a client's dentures. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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