What's Tested on the NCLEX: Physiological Integrity

What’s Tested on the NCLEX: Physiological Integrity

The last—and largest—NCLEX category we will discuss is physiological integrity: adequately tending to the everyday activities of a patient. The category is divided into four subcategories

 

  • Basic Care and Comfort

    The first step to maintaining physiological integrity is taking basic assessment of all patients, which involves gathering information that will help you determine the kind of care they need. The most important part of the assessment is evaluating a patient’s ambulatory status (mobility):

    Can they walk on their own? Do they use a cane or walker at home? If so, did they bring it with them to the hospital? (Be prepared to assist this patient to the bathroom as they are likely at risk for falling.) Does the patient use any other assistive devices, such as hearing aids or dentures?

    Patients who are not ambulatory or semi-ambulatory may need help positioning themselves in bed and turning frequently to prevent ulcers. A nonambulatory patient will require more time from you when it comes to bathing and other forms of personal hygiene. It’s important to keep these patients clean and dry, especially the incontinent. Skin care and hygiene is essential to preventing breakdown. It is also important to stress the power of handwashing to prevent the spread of germs.

    As the RN and patient advocate, it is your job to respect the patient’s wishes of alternative therapy and help them work through their pain according to their individual needs and preferences. Thus, you should be aware of alternative methods to pain management (nonpharmacological comfort interventions). For example, not all patients want to use opioids to control pain. Some will prefer meditation, deep breathing, music, heat/cold packs, or herbal remedies.

    Being sick is very draining, and many patients don’t understand why they don’t immediately feel better after one dose of antibiotics. Education on rest and sleep will help the patient understand that recovery is a process and not instantaneous.

  • Pharmacological and Parenteral Therapies

    This section on physiological integrity on the NCLEX-RN involves medication administration, patients’ five rights of medication administration, and adverse physiological effects of each medication.

    It’s important to be aware of specific situations where medications and procedures could be detrimental to a person. Such cases are known as contraindications. Cases involving “relative contraindication”s advise caution when combining certain procedures and/or medications. Some medications enhance the effects of others making them more potent, while other medications can negate each other’s effect.

    For example, medications like Pantoprazole (Protonix), a proton pump inhibitor, should be given before eating and by itself so it can work properly to decrease acid in the stomach. We want these medications to work for the reason they have been prescribed (expected outcome).

    As previously mentioned, medications are not the only way we can improve patients’ symptoms. Patients who are short of breath may be experiencing anemia, which can be corrected with a blood transfusion. Patients with a low hemoglobin aren’t carrying enough oxygen to their cells, a blood transfusion to correct their hemoglobin can improve these symptoms. Blood Product Administration requires two RNs to confirm right patient, right blood type (usually a type, screen, and an ABO verification is required from blood bank before the product will even be sent to the RN), and a consent for the transfusion from the patient.

  • Reduction of Risk Potential

    Diagnostic testing is assistive in determining what is happening with a patient based on the physiological symptoms they are presented with. However, be aware some of these tests, like a CT scan and MRI, require contrast dyes that patients can be allergic to. It is essential to assess your patient and require about allergies prior to their scan.

    If your patient is allergic to MRI contrast, it can not be used. Additionally, MRI stands for MAGNETIC resonance imaging. Patients with any form of metal in their bodies can absolutely not go for this scan. This is includes tissue expander and pacemakers. If they are allergic to CT scan dye, barium or water is sometimes used instead. If CT contrast dye is used it is important to educate your patient on drinking fluids to flush the dye from their system afterwards, as it impacts the kidneys. Other testing methods include X-rays, EKGs, echocardiograms, and stress tests.

    Knowing what laboratory values to order is another great way to figure out what is happening with a patient. As previously mentioned, with someone who is short of breath, a hemoglobin can help diagnose anemia. In someone reporting chest pain, a troponin level can indicate injury to the heart if elevated and help diagnosis a heart attack. LFTs (liver function tests) will look at liver function and would most likely be ordered in someone appearing jaundice.

    The potential for complications during surgical procedures can be prevented during a timeout. Timeout is a period before surgery begins in which everyone is operating room stops what they are doing and confirms the right patient, correct body part being operated on—including the correct side (ie left vs right knee)—and confirms the procedure planned. Often, the surgeon will mark the body part being operated on with a marker before surgery while the patient is still awake.

  • Physiological Adaptation

    Fluid and electrolyte imbalances can occur for various reasons. For example, diarrhea or vomiting can cause a drop in potassium. Each time you experience diarrhea or emesis you are losing some of the potassium in your cells.

    It then becomes important to replete your potassium as it is key in cardiac function. A person who is dehydrated may have an elevated BUN and creatinine, indicating injury involving kidney function, which hydration can correct. This is considered pre-renal failure, because there isn’t any injury directly to the kidney, there is an issue with blood flow to the kidney (pathophysiology).

    Hemodynamics refers to blood pressure and blood flow throughout the body. There is a reason we do vital signs every four hours in the hospital and sometimes even more frequently on sicker patients. We want to ensure patients are maintaining a blood pressure required to sustain blood flow and oxygenation to the body organs.

Basic Care and Comfort

The first subcategory for this client need is Basic Care and Comfort, which accounts for 9 percent of the questions on the exam. Nursing actions that are covered in this subcategory include:

•Assistive devices

•Elimination

•Mobility/immobility

•Non-pharmacological comfort interventions

•Nutrition and oral hydration

•Personal hygiene

•Rest and sleep

The following question is representative of the Basic Care and Comfort subcategory:

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 clinic visits for cast adjustment.

3.Provide an analgesic as needed.

4.Do circulatory checks of the casted extremity.

Answer

The correct answer is (4). A possible complication that can occur after cast applica-tion 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 second subcategory for this client need is Pharmacological and Parenteral Therapies, which accounts for 15 percent of the questions on the exam. Nursing actions that are covered in this subcategory include:

•Adverse effects/contraindications/side effects/interactions

•Blood and blood products•Central venous access devices

•Dosage calculation

•Expected actions/outcomes

•Medication administration

•Parenteral/intravenous therapies

•Pharmacological pain management

•Total parenteral nutrition

Try this question from the Pharmacological and Parenteral Therapies subcategory:

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 with which of the following?

1.The veins of the client’s wrist on the nondominant side

2.The veins of the leg so it will not interfere with the client’s ability to feed herself

3.The dorsal veins of the client’s forearm on the nondominant side

4.The dorsal surface of the client’s hand on the nondominant side

Answer

The correct answer is (3). This is the best site for the nurse to use for the IV because of its ease of access, availability of elastic veins, and limited use by the client.

 

Reduction of Risk Potential

The third subcategory for this client need is Reduction of Risk Potential, which accounts for 12 percent of the questions on the exam. Nursing actions that are covered in this subcategory include:

•Changes/abnormalities in vital signs

•Diagnostic tests

•Laboratory values

•Potential for alterations in body systems

•Potential for complications of diagnostic tests/treatments/procedures

•Potential for complications from surgical procedures and health alterations

•System specific assessments

•Therapeutic procedures

This is an example of a question from the Reduction of Risk Potential subcategory:

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%

Answer

The correct answer is (3). Normal blood pH is 7.35–7.45. A blood pH of 7.28 indicates diabetic ketoacidosis.

 

Physiological Adaption

The fourth subcategory for this client need is Physiological Adaptation, which accounts for 13 percent of the questions on the exam. Nursing actions that are covered in this subcategory include:

•Alterations in body systems

•Fluid and electrolyte imbalances

•Hemodynamics

•Illness management

•Medical emergencies

•Pathophysiology

•Unexpected response to therapies

The following question is an example of the Physiological Adaptation subcategory:

The nurse delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which of the following actions by the nurse is BEST?

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.

Answer

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.

 

NCLEX Practice Quiz: Physiological Integrity