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 C

Explanation

A. Bright red, bloody fluid: Bright red fluid indicates fresh blood, which is typically seen in the initial drainage from a surgical site or in cases of active bleeding. This type of drainage is not characteristic of serous fluid and may suggest a complication that requires further assessment.

B. Thick, green fluid: Thick, green fluid often indicates the presence of infection or pus, which would be classified as purulent drainage rather than serous. Serous drainage should not have a thick consistency or a green color, as this would suggest an inflammatory process or infection.

C. Clear, watery fluid with a pale yellow tint: This describes serous drainage, which is typically light in color and has a watery consistency. Serous fluid is a normal finding in the early stages of wound healing, as it contains plasma and does not indicate infection or excessive bleeding.

D. Milky, white fluid: Milky or cloudy fluid can indicate the presence of chyle (lymphatic fluid) or infection, which is not characteristic of serous drainage. Serous fluid should not appear milky, as this would suggest a different underlying issue that may need to be investigated further.

A. Encouraging the client to consume a high-protein diet B. Placing the client in a room with positive-pressure airflow C. Changing the client's bed linens each day D. Performing hand hygiene before, during, and after direct contact with the client

Correct Answer is D

Explanation

A. Encouraging the client to consume a high-protein diet: While a high-protein diet can support the client's immune system and promote healing, it does not directly prevent the transmission of infection. Nutritional support is important for recovery, but it is not a primary strategy for infection control.

B. Placing the client in a room with positive-pressure airflow: Positive-pressure airflow is typically used in rooms for immunocompromised patients to prevent exposure to airborne pathogens, not for clients with infections. Infected patients generally require isolation precautions, which may include negative-pressure rooms, especially for airborne or droplet precautions.

C. Changing the client's bed linens each day: Although maintaining clean linens is important for general hygiene and comfort, simply changing bed linens does not significantly prevent the transmission of infection. Effective infection control measures focus more on direct contact precautions and environmental cleanliness rather than the frequency of linen changes alone.

D. Performing hand hygiene before, during, and after direct contact with the client: Hand hygiene is one of the most effective strategies to prevent the transmission of infections in healthcare settings. Proper handwashing or use of alcohol-based hand rubs significantly reduces the risk of spreading pathogens and protects both the patient and healthcare providers from infections. This strategy is essential in breaking the chain of infection.

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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?

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