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.
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The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
NURSE CARING BEHAVIORS AS
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Standard Precautions for the Care of all Patients in All Health Care Settings
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