Nokea
For which of the following reasons would the nurse use the Braden Scale to assess a client?
- A. To determine if the client is suffering from delirium.
- B. To determine if the client is at risk for developing pressure sores.
- C. To determine if the client is at risk for falls.
- D. To determine if the client is at risk for substance abuse.
Correct Answer: B
Rationale: The Braden Scale assesses risk for pressure sores (B) by evaluating factors like mobility and skin moisture. It is not used for delirium (A), falls (C), or substance abuse (D).
You may also like to solve these questions
The nurse has rounded on all the assigned clients. While rounding, several health care providers have written orders on the nurse's clients. Which order would be the priority for the nurse to address?
- A. furosemide (Lasix) 80 mg IV push STAT for a client with fluid overload
- B. a new insulin sliding scale for a client with a glucose level of 242
- C. perform a dressing change on a client with a stage 2 diabetic foot ulcer
- D. discharge a client who was admitted for removal of an abdominal abscess
Correct Answer: A
Rationale: STAT orders for furosemide address acute fluid overload, a potentially life-threatening condition, making it the priority over insulin, dressing changes, or discharge.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Use of nonsteroidal anti-inflammatories
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Correct Answer: A
Rationale: Long-term smoking is a major risk factor for bladder cancer due to carcinogenic chemicals in tobacco being excreted in urine, irritating the bladder.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
A client with cocaine addiction would most likely be placed on which medication?
- A. Amantadine (Symmetrel)
- B. Methadone
- C. THC
- D. Disulfiram (Antabuse)
Correct Answer: A
Rationale: Amantadine is sometimes used to reduce cravings in cocaine addiction by modulating dopamine pathways, unlike the other options, which are used for different substance dependencies.