NCLEX-RN · Physiological Integrity
NCLEX-RN: Basic Care and Comfort Concepts
Importance ★★★★☆ · 19% (estimate)
Written by AI. Only units that passed a separate AI check (re-reading facts and numbers) are published. Tell us if you find a mistake.
Overview
This chapter covers everyday care that keeps clients comfortable and prevents problems. It includes moving and positioning, elimination, eating and drinking safely, hygiene, sleep and comfort measures that do not use medicine.
Lying still for long periods harms almost every body system. It can cause pressure injuries, blood clots, pneumonia, constipation and weak muscles. Turn and reposition clients regularly, help them walk as early as allowed, and teach coughing and deep breathing. When using a cane, hold it on the strong side and move it with the weak leg.
Aspiration happens when food or fluid goes into the lungs. Sit the client upright to eat, have clients with swallowing problems tuck the chin, and use thickened liquids if a swallowing specialist orders them. Comfort can also come from non-drug methods such as heat or cold, position changes, massage, music, guided imagery and distraction.
Key concepts
Complications of immobility
Problems caused by staying still too long: pressure injuries, blood clots in the legs, pneumonia, constipation, muscle loss and stiff joints.
Memory tipPrevent them with regular turning, early walking, fluids, and coughing and deep breathing.
Pressure injury prevention
Relieve pressure over bony areas, keep skin clean and dry, use pressure-relieving surfaces and support good nutrition. Do not massage reddened bony areas.
Memory tipLook at heels, hips and the tailbone area at every skin check.
Aspiration precautions
Steps to keep food and fluid out of the lungs: sit upright to eat, small bites, chin tuck for swallowing problems, thickened liquids as ordered, and staying upright after meals.
Memory tipCoughing, choking or a wet, gurgly voice while eating suggests aspiration; stop and assess.
Cane use
Hold the cane on the strong side. Move the cane and the weak leg together, then step through with the strong leg.
Memory tipOn stairs: 'Up with the good, down with the bad.'
Walker use
Lift or roll the walker forward, step into it with the weak leg first, then bring the strong leg forward. Do not climb stairs with a standard walker.
Memory tipStand inside the walker frame, not behind it.
Non-drug comfort measures
Ways to ease pain or stress without medicine: heat or cold, repositioning, massage of non-injured areas, music, guided imagery, breathing exercises and distraction.
Memory tipUse them together with prescribed pain medicine, not as a replacement when strong pain is present.
Often tested
- Name the complications of immobility and how to prevent each one.
- Do not massage reddened skin over a bony area.
- Sit the client upright to eat and use a chin tuck for swallowing problems.
- Hold a cane on the strong side; on stairs, up with the good, down with the bad.
- Non-drug comfort measures add to pain medicine, not replace it.
Easy to confuse: Cane and walker
| Point | Cane | Walker |
|---|---|---|
| Where to hold | Strong side | Both hands, inside the frame |
| Which leg moves with the device | Weak leg | Weak leg steps in first |
| Stairs | Up with good, down with bad | Not with a standard walker |
3 sample questions
Verified practice questions from this unit.
Question 1. A client who has had a stroke cannot move in bed without help. Which action helps prevent pressure injuries?
- ① Change the client's position at least every 2 hours
- ② Use a donut-shaped cushion under the hips
- ③ Keep the head of the bed raised to 60 degrees at all times
- ④ Massage reddened areas over bony parts firmly
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ① Change the client's position at least every 2 hours
Key point: Reposition immobile clients at least every 2 hours
Pressure injuries happen when pressure cuts off blood flow to the skin, often over bones like the tailbone and heels. Turning the client at least every 2 hours (or more often if needed) relieves the pressure. Keeping the skin clean and dry, good nutrition, and pressure-relief mattresses also help.
Wrong choices
- "Massage reddened areas firmly" can damage tissue that is already injured.
- "Use a donut-shaped cushion" puts pressure on the ring around the area and reduces blood flow.
- "Keep the head of the bed at 60 degrees at all times" makes the client slide down, causing shear injury to the skin over the tailbone. Keep it at 30 degrees or lower when possible.
Question 2. A client has weakness in the left leg and is learning to walk with a cane. Which statement by the client shows correct understanding?
- ① "I will lean the cane far out to the side for balance."
- ② "I will move the cane forward after my right leg."
- ③ "I will hold the cane in my left hand."
- ④ "I will hold the cane in my right hand."
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ④ "I will hold the cane in my right hand."
Key point: Hold the cane on the strong side; move it with the weak leg
The cane is held on the strong (unaffected) side. For weakness in the left leg, the cane goes in the right hand. The client moves the cane forward at the same time as the weak left leg, then steps through with the strong right leg. This spreads the weight and gives the most support.
Wrong choices
- "Hold the cane in my left hand" puts the cane on the weak side, which gives less support and makes the client lean toward the weak side.
- "Move the cane forward after my right leg" is wrong. The cane moves with the weak leg, not the strong leg.
- "Lean the cane far out to the side" makes the client unsteady. The cane should be close to the body, about 15 cm (6 inches) to the side of the foot.
Question 3. A client with dysphagia (trouble swallowing) after a stroke is about to eat lunch. How should the nurse position the client?
- ① Lying flat on the back
- ② Sitting upright at 90 degrees
- ③ Sitting with the head tilted back
- ④ Reclining with the head of the bed at 30 degrees
▼ Show answer and explanation▲ Hide answer and explanation
Answer: ② Sitting upright at 90 degrees
Key point: Dysphagia: sit fully upright to eat to prevent aspiration
Sitting fully upright (about 90 degrees) helps food move down into the stomach and lowers the risk of food or liquid going into the lungs (aspiration). Clients often also tuck the chin slightly when swallowing, as taught by the speech therapist. The client should stay upright for a while after eating.
Wrong choices
- "Lying flat on the back" greatly raises the risk of choking and aspiration.
- "Reclining at 30 degrees" is not upright enough for eating safely.
- "Head tilted back" opens the airway and makes it easier for food to enter the lungs.