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 B

Explanation

A. Twist at the waist when she moves an object to one side: Twisting at the waist can place excessive strain on the lower back and increase the risk of injury. Instead, the client should pivot her whole body to move an object, which helps maintain spinal alignment and reduces strain.

B. Bend at the knees when picking up an object: This instruction is crucial for preventing back strain. Bending at the knees allows the client to use her legs' strength to lift the object rather than putting pressure on the back. This technique helps protect the spine and promotes safe lifting practices.

C. Hold an object away from her body as she lifts it: Holding an object away from the body increases leverage and strain on the back muscles. The client should keep the object close to her body while lifting to maintain better balance and reduce the risk of injury.

D. Relax her abdominal muscles when she lifts an object: Engaging the abdominal muscles provides support to the spine during lifting. Relaxing the abdominal muscles can lead to a lack of core stability, increasing the risk of back injury. The client should be encouraged to engage her core muscles while lifting.

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 strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Correct Answer is B

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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