Physiological
Integrity
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Subcategories: |
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Basic Care and Comfort
Pharmacological and Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation |
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Basic Care and
Comfort
The concept of basic care and comfort accounts for 6-12 percent
of the questions on the NCLEX-RN® Exam. The nursing actions
included in this subcategory are:
| Assistive devices |
Elimination |
| Mobility |
Nonpharmacological comfort interventions |
| Nutrition and oral hydration |
Palliative/comfort care |
| Personal hygiene |
Rest and sleep |
Typical Question
The following is an example of a typical basic care and comfort
question:
A cast is applied to a 9-month old girl for the treatment of
talipes equinovarus. Which of the following instructions is most
essential for the nurse to give to the child's mother regarding
her care?
(1) Offer appropriate toys for her age.
(2) Make frequent visits for cast adjustment.
(3) Provide an analgesic as needed.
(4) Do circulatory checks of the casted extremity.
The correct answer is (4). A possible complication that can
occur after cast application is impaired circulation. All of
these answer choices might be included in family teaching, but
checking the child's circulation is the highest priority.
Pharmacological and Parenteral
Therapies
The concept of pharmacological and parenteral therapies accounts
for 13-19 percent of the questions on the NCLEX-RN® exam. The
nursing actions included in this subcategory are:
| Adverse effects |
Contraindications |
| Blood and blood products |
Central venous access devices |
| Chemotherapy |
Expected effects |
| Intravenous therapy |
Medication administration |
| Parenteral fluids |
Pharmacological actions |
| Pharmacological agents |
Pharmacological interactions |
| Pharmacological pain management |
Side effects |
| Total parenteral nutrition |
Typical Question
The following is an example of a typical pharmacological and
parenteral therapies question:
The home health nurse is going to start an IV with 5% dextrose
in water (D5W) for a 76-year old woman. To perform the
venipuncture the nurse should start the IV using the:
(1) veins of the client's wrist on the nondominant side.
(2) veins of the leg so it will not interfere with the client's
ability to feed herself.
(3) dorsal veins of the client's forearm on the nondominant
side.
(4) dorsal surface of the client's hand on the nondominant
side.
The correct answer is (3). This is the best site for the nurse
to use for the IV because of its easy access, availability of
elastic veins, and limited use by the client.
Reduction of Risk
Potential
The concept of reduction of risk potential accounts for 13-19
percent of the questions on the NCLEX-RN® exam. The nursing
actions included in this subcategory are:
| Diagnostic tests |
Laboratory values |
| Pathophysiology |
Potential for body system alterations |
| Potential for complications of diagnostic tests,
procedures, surgery, and health alterations. |
Therapeutic procedures |
Typical Question
The following is an example of a typical reduction of risk
potential question:
A 7-year old girl with type 1 insulin dependent diabetes
mellitus (IDDM) has been home sick for several days and is
brought to the emergency department by her parents. If the child
is experiencing ketoacidosis, the nurse would expect to see which
of the following lab results?
(1) Serum glucose 140 mg/dL.
(2) Serum creatine 5.2 mg/dL.
(3) Blood pH 7.28.
(4) Hematocrit 38%.
The correct answer is (3). Normal blood pH is 7.35—7.45. This
indicates diabetic ketoacidosis.
Physiological Adaptation
The concept of physiological adaptation accounts for 11-17
percent of the questions on the exam. The nursing actions
included in this subcategory are:
| Alterations in the body systems |
Fluid and electrolyte imbalances |
| Hemodynamics |
Infectious diseases |
| Medical emergencies |
Pathophysiology |
| Radiation therapy |
Respiratory care |
| Unexpected response to therapies |
Typical Question
The following is an example of a typical physiological adaptation
question:
The nurse is delivering external cardiac compressions to a
63-year old woman while performing cardiopulmonary resuscitation
(CPR). It is most important for the nurse to:
(1) maintain a position close to the client's side with the
nurse's knees apart.
(2) maintain vertical pressure on the client's chest through the
heel of the nurse's hand.
(3) re-check the nurse's hand position after every 10 chest
compressions.
(4) check for a return of the client's pulse after every 8
breaths by the nurse.
The correct answer is (2). the nurse's elbows should be
locked, arms straight, with shoulders directly over hands.
Incorrect pressure or improperly placed hands could cause injury
to the client.
Other Client Needs:
