1. 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?

a. 12

b. 13

c. 20

d. 23

ANS: D

The best sign is a perfect score of 23. The Braden Scale is composed of six

subscales: sensory perception, moisture, activity, mobility, nutrition, and friction

and shear. The total score ranges from 6 to 23, and a lower total score indicates a

higher risk for pressure ulcer development. The cutoff score for onset of pressure

ulcer risk with the Braden Scale in the general adult population is 18.

MULTIPLE RESPONSE

1. The nurse is caring for a patient with a surgical incision that eviscerates.

Which actions will the nurse take? (Select all that apply.)

a. Place moist sterile gauze over the site.

b. Gently place the organs back.

c. Contact the surgical team.

d. Offer a glass of water.

e. Monitor for shock.

ANS: A, C, E

The presence of an evisceration (protrusion of visceral organs through a wound

opening) is a surgical emergency. Immediately place damp sterile gauze over the

site, contact the surgical team, do not allow the patient anything by mouth (NPO),

observe for signs and symptoms of shock, and prepare the patient for emergency

surgery.

2. The nurse is caring for a patient with a wound healing by full-thickness

repair. Which phases will the nurse monitor for in this patient? (Select all that

apply.)