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 A

Explanation

A. Droplet: Pertussis, also known as whooping cough, is transmitted through respiratory droplets when an infected person coughs or sneezes. Therefore, droplet precautions are necessary to prevent the spread of the infection to others. This includes wearing a surgical mask when within 3 feet of the client and ensuring the client wears a mask when outside of their room.

B. Contact: Contact precautions are used for infections that can be spread through direct or indirect contact with the patient or contaminated surfaces. While there may be some overlap, contact precautions are not the primary focus for pertussis transmission.

C. Protective: Protective precautions (also known as reverse isolation) are utilized to protect immunocompromised patients from infections. This is not applicable for a patient with pertussis, as the focus is on preventing the spread of the infection rather than protecting the patient from pathogens.

D. Airborne: Airborne precautions are used for infections that are transmitted via airborne droplet nuclei, such as tuberculosis or measles. Pertussis does not fall under this category, as it is primarily transmitted through larger respiratory droplets.

E. Full semen: This option is not a recognized type of precaution. The correct term should focus on standard and transmission-based precautions relevant to infectious diseases.

A. The client faces the direction of movement when sliding an object across the floor. B. When moving an object to one side, the client puts his weight on his heels. C. When pushing an object, the client moves his front foot backward. D. The client stands with his feet close together when lifting an object.

Correct Answer is A

Explanation

A. The client faces the direction of movement when sliding an object across the floor: This finding indicates that the client is using proper body mechanics. Facing the direction of movement helps maintain balance and reduces the risk of injury when sliding or moving objects.

B. When moving an object to one side, the client puts his weight on his heels: Putting weight on the heels can lead to a loss of balance and stability. Proper body mechanics involve distributing weight evenly and maintaining a stable base, which is not reflected in this finding.

C. When pushing an object, the client moves his front foot backward: This action is not a proper body mechanic. When pushing, the client should maintain a stable stance with feet positioned appropriately to provide support and leverage. Moving the front foot backward may compromise stability.

D. The client stands with his feet close together when lifting an object: Standing with feet close together can decrease stability and increase the risk of falls. Proper body mechanics recommend a wider stance for better support and balance when lifting or moving objects.

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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 admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

Correct Answer is A

Explanation

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

Correct Answer is A

Explanation

Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

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The client has protective precautions (reverse isolation) in place due to a severely depressed neutrophil count. Which statement by the client demonstrates a good understanding of the precautions?

A nurse in reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

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