Question

The nurse determines that a client has a Braden Scale score of 9. Which is the nurse's best intervention related to this assessment?

A. Increase the client's fluid intake.
B. Consult with the health care provider.
C. Reassess the client in 3 days.
D. Document the finding per protocol.

Answer 1

A Braden Scale score of 9 indicates a severe risk of pressure ulcers, requiring immediate intervention such as redistributing pressure, ensuring proper nutrition and hydration, and consulting with health care providers.

Step-by-step explanation:

The Braden Scale is utilized to predict the risk of pressure ulcers, with a lower score indicating a higher risk. A score of 9 is considered to be within the severe risk category. Therefore, the nurse's best intervention related to this assessment is both to document the finding per protocol and to take immediate action to address the patient's risk of developing pressure ulcers. These interventions may include redistributing pressure by repositioning the patient, using support surfaces, ensuring the patient has adequate nutrition and hydration, and consulting with the health care provider to develop a comprehensive care plan tailored to the patient's needs. It is important to not wait for 3 days to reassess, as the risk of skin breakdown is already high with a Braden Scale score of 9.

Answer 2

A Braden Scale score of 9 suggests a high risk for pressure ulcers, so the best intervention is to consult with the healthcare provider for immediate and appropriate preventive measures.

Step-by-step explanation:

The Braden Scale is a tool used by healthcare professionals to predict the risk of developing pressure ulcers. A score of 9 on the Braden Scale indicates that the client is at high risk of developing pressure ulcers. Therefore, the nurse's best intervention in this case would be B. Consult with the health care provider. This is imperative to discuss potential preventative measures. However, this doesn't mean that the nurse should ignore the other interventions mentioned. The nurse should also increase the client's fluid intake if necessary, document the finding as per the hospital protocol, and continually reassess the client, potentially more frequently than every 3 days due to the high risk indicated by the score.