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?

Correct Answer: D

Rationale: A Braden score of '23' best shows risk removed. Perfect score e.g., 6-23 range means no risk e.g., all 4s unlike '12' or '13' , high risk e.g., <16. '20' is safe e.g., >18 but not max. A nurse reassesses e.g., 23, no risk' per 90% intervention success, a physiological goal. The text sets 18 as cutoff, 23 as ideal, making the correct, optimal sign.

Correct Answer: B

Rationale: Jagged wound edges, uncontrolled bleeding' describes an unintentional wound, . Accidents e.g., falls tear e.g., 2 cm, 50 mL unlike 'clean edges' or 'low infection risk' , surgical e.g., planned. 'Surgery, IV' is intentional e.g., not accidental. A nurse sees e.g., Rough, bloody' per trauma type, a physiological distinction. The text contrasts this with intentional, making the correct, unintentional descriptor.

Correct Answer: B

Rationale: Implement a turning schedule every 2 hours' prevents ulcers. Q2h e.g., 30° lateral cuts pressure e.g., <32 mmHg unlike 'once per shift' , too long e.g., 8 hr risk. 'Ring cushions' pinch e.g., contraindicated. 'No turn, support surface' lacks e.g., needs both. A nurse plans e.g., Turn q2h' per 80% prevention, a physiological must. The text mandates this, making the correct, key intervention.

Correct Answer: D

Rationale: I will leave the heat packs on for an hour' needs teaching. Heat e.g., 20-30 min boosts flow e.g., 50% healing beyond risks burns e.g., 60 min, 10% chance unlike 'rebound effect' , correct e.g., vasoconstriction. 'Only on sore' and '20 minutes' align e.g., safe. A nurse reteaches e.g., Short heat' per guidelines, a physiological must. The text limits duration, making the correct, error signal.