An older patient has a Braden Scale pressure ulcer risk score of 18. What does this score mean to the nurse?
1. The patient is at a low risk for the development of a pressure ulcer.
2. This patient is at a high risk for the development of a pressure ulcer.
3. The score is inconclusive and the assessment repeated within 3 days.
4. This score is inconclusive and shows no significant risk pressure ulcer development.
2
Rationale: The Braden Scale is used to evaluate a patient's risk for the development of pressure ulcers. A score of 16 or less indicates a pressure sore risk and the need for a prevention plan.
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Place the steps performed during the administration of otic medications in the appropriate order
Click on the down arrow for each response in the right column and select the correct choice from the list. Response 1. Ask client to remain in side-lying position for a few minutes. Response 2. Instill prescribed drops, holding dropper at least 1 cm above ear canal. Response 3. If cerumen or drainage occludes the outermost portion of the ear canal, wipe out gently with a cotton-tipped applicator. Response 4. For adults and children older than 3 years, gently pull the pinna up and outward. Response 5. Have client assume side-lying position with ear to be treated facing up. Response 6. Perform hand hygiene, apply gloves, and gather supplies.
Why would the nurse anticipate an adverse reaction in an older adult who is taking the protein-bound drug warfarin (Coumadin)?
a. Unbound active drug molecules continue to circulate in the bloodstream. b. The bleeding and clotting times will decrease. c. The drug becomes ineffective and does not deliver its intended therapeutic action. d. Renal damage can occur from the altered drug molecules.
A unit is having a staff meeting to discuss a recent incident that occurred involving a family member, a client, and two of the nurses. One nurse sustained injuries. Another nurse was held by the client as a shield
Other staff members witnessed the escalation of this situation. What is important for the entire staff to remember concerning this incident? A) Workplace violence occurs primarily in acute care settings. B) Most persons view workplace violence in the same way. C) Each person's experience with violence is unique. D) Categorizing the types of violence experienced is difficult.
The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?
1. "Do you have a safe place where you can go?" 2. "What did you do to make your spouse so angry?" 3. "How many times has this happened in the past?" 4. "Will you be pressing charges against your spouse?"