NU 311 Clinical Nursing Skills Exam 2 Questions With
Complete Solutions
Braden Scale for Predicting Pressure Ulcer Risk
Analyzes:
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Sensory Perception
Ability to respond meaningfully to pressure-related discomfort
1. Completely limited: Unresponsive (does not moan, flinch, or
grasp) to painful stimuli because of diminished level of
consciousness or sedation or Limited ability to feel pain over
most of body
2. Very limited: Responds only to painful stimuli Cannot
communicate discomfort except by moaning or restlessness or
Has a sensory impairment that limits the ability to feel pain or
discomfort over half of body 3. Slightly limited: Responds to
verbal commands but cannot always communicate discomfort or
need to be turned or Has some sensory impairment, which limits
ability to feel pain or discomfort in one or two extremities
4. No impairment: Responds to verbal commands. Has no
sensory deficit that would limit ability to feel or voice pain or
discomfort
,Moisture
Degree to which skin is exposed to it
1. Constantly: Skin kept wet almost constantly by factors such
as perspiration and urine Dampness detected every time patient
is moved or turned
2. Very: Skin often but not always wet
Linen must be changed at least once a shift
3. Occasionally: Skin occasionally wet, requiring extra linen
change approximately once a day
4. Rarely: Skin usually dry; linen requires changing only at
routine intervals
Activity
Degree of it
1. Bedfast: Confined to bed
2. Chairfast: Ability to walk severely limited or nonexistent
Cannot bear own weight and/or must be helped into chair or
wheelchair
3. Walks occasionally: Walks occasionally during day but for
very short distances with or without help. Spends most of each
shift in bed or chair
4. Walks frequently: Walks outside room at least twice a day
and inside room at least once every 2 hours during waking hours
Mobility
Ability to change and control body position
1. Completely immobile: Does not make even slight changes in
body or extremity position without help
,2. Very limited: Makes occasional slight changes in body or
extremity position but unable to make frequent or significant
changes independently 3. Slightly limited: Makes frequent,
although slight, changes in body or extremity position
independently
4. No limitations: Makes major and frequent changes in position
without help
Nutrition
Usual food intake pattern
1. Very poor: Never eats a complete meal
Rarely eats more than one third of any food offered Eats two
servings or less of protein (meat or dairy products) per day.
Takes fluids poorly; does not take a liquid dietary supplement or
Is NPO and/or maintained on clear liquids or IV infusions for
more than 5 days
2. Probably inadequate: Rarely eats a complete meal and
generally eats only about half of any food offered Protein intake
includes only three servings of meat or dairy products per day
Occasionally takes a dietary supplement or Receives less than
optimal amount of liquid diet or tube feeding
3. Adequate: Eats over half of most meals
Eats a total of four servings of protein (meat, dairy products)
each day Occasionally refuses a meal but usually takes a
supplement when offered or Is on a tube-feeding or TPN
regimen that probably meets most of nutritional needs 4.
Excellent: Eats most of every meal Never refuses a meal.
Usually eats a total of four or more servings of meat and dairy
products. Occasionally eats between meals. Does not require
supplementation
, Friction and Shear
1. Problem: Requires moderate-to-maximum help to move.
Complete lifting without sliding against sheets impossible
Frequently slides down in bed or chair; repositioning with
maximal help
Spasticity, contractions, or agitation leads to almost constant
friction
2. Potential problem: Moves feebly or requires minimal help.
During a move skin probably slides to some extent against
sheets, chair, restraints, or other devices. Maintains relatively
good position in chair or bed most of the time but occasionally
slides down
3. No apparent problem: Moves in bed and chair independently
and has sufficient muscle strength to sit up completely during
move. Maintains good position in bed or chair
hazards of immobility
often restricts a patient's ability to change and control body
position, thus increasing the pressure over bony prominences
which can lead to pressure ulcers
Gauze Dressings
Cotton or synthetic material; woven or nonwoven construction
Indications for Use:
Protection of surgical incision
Mechanical debridement (moist-to-dry)
Secondary dressing for other wound products
Packing wounds
Complete Solutions
Braden Scale for Predicting Pressure Ulcer Risk
Analyzes:
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Sensory Perception
Ability to respond meaningfully to pressure-related discomfort
1. Completely limited: Unresponsive (does not moan, flinch, or
grasp) to painful stimuli because of diminished level of
consciousness or sedation or Limited ability to feel pain over
most of body
2. Very limited: Responds only to painful stimuli Cannot
communicate discomfort except by moaning or restlessness or
Has a sensory impairment that limits the ability to feel pain or
discomfort over half of body 3. Slightly limited: Responds to
verbal commands but cannot always communicate discomfort or
need to be turned or Has some sensory impairment, which limits
ability to feel pain or discomfort in one or two extremities
4. No impairment: Responds to verbal commands. Has no
sensory deficit that would limit ability to feel or voice pain or
discomfort
,Moisture
Degree to which skin is exposed to it
1. Constantly: Skin kept wet almost constantly by factors such
as perspiration and urine Dampness detected every time patient
is moved or turned
2. Very: Skin often but not always wet
Linen must be changed at least once a shift
3. Occasionally: Skin occasionally wet, requiring extra linen
change approximately once a day
4. Rarely: Skin usually dry; linen requires changing only at
routine intervals
Activity
Degree of it
1. Bedfast: Confined to bed
2. Chairfast: Ability to walk severely limited or nonexistent
Cannot bear own weight and/or must be helped into chair or
wheelchair
3. Walks occasionally: Walks occasionally during day but for
very short distances with or without help. Spends most of each
shift in bed or chair
4. Walks frequently: Walks outside room at least twice a day
and inside room at least once every 2 hours during waking hours
Mobility
Ability to change and control body position
1. Completely immobile: Does not make even slight changes in
body or extremity position without help
,2. Very limited: Makes occasional slight changes in body or
extremity position but unable to make frequent or significant
changes independently 3. Slightly limited: Makes frequent,
although slight, changes in body or extremity position
independently
4. No limitations: Makes major and frequent changes in position
without help
Nutrition
Usual food intake pattern
1. Very poor: Never eats a complete meal
Rarely eats more than one third of any food offered Eats two
servings or less of protein (meat or dairy products) per day.
Takes fluids poorly; does not take a liquid dietary supplement or
Is NPO and/or maintained on clear liquids or IV infusions for
more than 5 days
2. Probably inadequate: Rarely eats a complete meal and
generally eats only about half of any food offered Protein intake
includes only three servings of meat or dairy products per day
Occasionally takes a dietary supplement or Receives less than
optimal amount of liquid diet or tube feeding
3. Adequate: Eats over half of most meals
Eats a total of four servings of protein (meat, dairy products)
each day Occasionally refuses a meal but usually takes a
supplement when offered or Is on a tube-feeding or TPN
regimen that probably meets most of nutritional needs 4.
Excellent: Eats most of every meal Never refuses a meal.
Usually eats a total of four or more servings of meat and dairy
products. Occasionally eats between meals. Does not require
supplementation
, Friction and Shear
1. Problem: Requires moderate-to-maximum help to move.
Complete lifting without sliding against sheets impossible
Frequently slides down in bed or chair; repositioning with
maximal help
Spasticity, contractions, or agitation leads to almost constant
friction
2. Potential problem: Moves feebly or requires minimal help.
During a move skin probably slides to some extent against
sheets, chair, restraints, or other devices. Maintains relatively
good position in chair or bed most of the time but occasionally
slides down
3. No apparent problem: Moves in bed and chair independently
and has sufficient muscle strength to sit up completely during
move. Maintains good position in bed or chair
hazards of immobility
often restricts a patient's ability to change and control body
position, thus increasing the pressure over bony prominences
which can lead to pressure ulcers
Gauze Dressings
Cotton or synthetic material; woven or nonwoven construction
Indications for Use:
Protection of surgical incision
Mechanical debridement (moist-to-dry)
Secondary dressing for other wound products
Packing wounds
