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. Vigorously brush the client's teeth: Vigorous brushing is not appropriate for an unconscious client. It can cause trauma to the gums or teeth and increase the risk of aspiration if the client has any residual secretions or fluids in the mouth. Gentle brushing should be employed to avoid injury.

B. Hold the toothbrush at a 90° angle: Holding the toothbrush at a 90° angle is not necessary for clients who are unconscious. A more effective angle may be around 45° to effectively clean the surfaces of the teeth while minimizing the risk of gagging or aspiration.

C. Place two fingers in the client's mouth: This action could be harmful, as placing fingers in the mouth of an unconscious client poses a risk of injury or could inadvertently trigger a gag reflex. Instead, proper oral care should be conducted using appropriate tools without placing fingers inside the mouth.

D. Turn the client to the side: Turning the client to the side is the best action as it helps prevent aspiration of secretions or fluids during oral care. This position allows for safer access to the mouth while also promoting drainage of any excess fluids, reducing the risk of choking or aspiration pneumonia.

A. Twist at the waist when she moves an object to one side. B. Bend at the knees when picking up an object. C. Hold an object away from her body as she lifts it. D. Relax her abdominal muscles when she lifts an object.

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.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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