The nurse is caring for four patients during a shift. Which of ...

[mp14]

The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer?
 
  a. The patient who is bedridden, but who turns himself randomly
  b. The patient whose Braden Scale score is 8
  c. The patient who can ambulate to the bathroom independently
  d. The patient whose Braden Scale score is 18

Question 2

For a patient in the final stages of dying, a nurse expects to:
 
  a. keep the patient's room cool.
  b. avoid catheterizing the patient.
  c. elevate the head of the bed as tolerated.
  d. encourage the patient to eat and drink more.

[smrtceo]

Answer to Question 1

B
Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient's ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.

Answer to Question 2

C
Poor circulation of body fluids, immobilization, and inability to expectorate secretions cause rattles and bubbling. Elevate the head with a pillow or raise the head of the bed; gently turn the head to the side to drain secretions. Coolness, color, and temperature change in the hands, arms, legs, and feet. Place socks on the feet. Cover with a light cotton blanket. Keep warm blankets on the patient. Decreased muscle tone and consciousness may lead to incontinence of urine and/or bowel. Change bedding as appropriate. Use an indwelling catheter for patient comfort. Do not force the patient to eat or drink; give ice chips, soft drinks, or juice, as possible. Provide mouth care.

[mp14]

Correct answers!

[smrtceo]

Great! Please up vote