NCLEX-RN · Physiological Integrity
NCLEX-RN: Reduction of Risk Potential Concepts
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Overview
This chapter is about lowering the chance that a test, procedure or treatment harms the client. It covers vital sign changes, common lab values, preparing clients for tests, and spotting early complications after surgery and procedures.
Lab ranges differ a little between labs, so learn the commonly cited adult values and what a value far outside them means. Potassium is about 3.5 to 5.0 and sodium about 135 to 145 mEq/L. Fasting blood glucose is about 70 to 99 mg/dL. Platelets are about 150,000 to 400,000 per cubic millimeter.
Before a procedure, confirm consent, allergies such as to contrast dye, and fasting status as ordered. After a cardiac catheterization, check the insertion site for bleeding and the pulses below it, and keep the limb straight. After thyroid surgery, watch for low calcium. After any surgery, encourage the incentive spirometer and early walking. If a wound opens and organs come through, cover them with sterile saline-moistened dressings and call the surgeon.
Key concepts
Potassium (K+)
Commonly cited adult range is about 3.5 to 5.0 mEq/L. Both low and high levels can cause dangerous heart rhythms.
Memory tipAny potassium problem: check the heart monitor.
Sodium (Na+)
Commonly cited adult range is about 135 to 145 mEq/L. Abnormal sodium mainly affects the brain, causing confusion and, in severe cases, seizures.
Memory tipSodium problems show up as changes in thinking and alertness.
Glucose and platelets
Fasting blood glucose is commonly cited as about 70 to 99 mg/dL. Platelets are about 150,000 to 400,000 per cubic millimeter; a low count raises bleeding risk.
Memory tipWith low platelets, use bleeding precautions: soft toothbrush, electric razor, no IM injections if possible.
Source: American Diabetes Association, Standards of Care · as of 2026
After cardiac catheterization
Check the insertion site for bleeding or swelling, and check pulses, color and warmth below the site. Keep the affected arm or leg straight as ordered.
Memory tipA cool, pale limb with a weak pulse below the site needs a report right away.
After thyroidectomy
Watch the airway and for signs of low calcium, such as tingling around the mouth or in the fingers and muscle spasms. Damage to nearby glands can cause this.
Memory tipChvostek's sign is a face twitch when the cheek is tapped; Trousseau's sign is a hand spasm with a blood pressure cuff.
Wound evisceration
Organs push out through an opened surgical wound. Cover them with sterile dressings moistened with sterile saline, keep the client calm, place in low Fowler's with knees bent, and notify the surgeon.
Memory tipNever try to push the organs back in.
Incentive spirometer
A device that helps the client take slow, deep breaths after surgery to keep the lungs open and prevent atelectasis and pneumonia.
Memory tipTeach: breathe out, seal lips, breathe in slowly and deeply, hold, then relax.
Often tested
- Know commonly cited adult ranges for potassium, sodium, glucose and platelets, and that labs vary slightly.
- Check allergies, consent and fasting status before a procedure.
- After a catheterization, check the site and the pulses below it.
- After thyroid surgery, watch the airway and for signs of low calcium.
- For evisceration, cover with sterile saline-moistened dressings and call the surgeon.
- Use the incentive spirometer and early walking to prevent lung problems after surgery.
Easy to confuse: Wound dehiscence and evisceration
| Point | Dehiscence | Evisceration |
|---|---|---|
| What happens | Wound edges separate | Organs push out through the wound |
| Nurse action | Support the wound, notify | Cover with sterile saline-moist dressing, notify |
| Position | Low Fowler's, knees bent | Low Fowler's, knees bent |
3 sample questions
Verified practice questions from this unit.
Question 1. A client returned 2 hours ago from a cardiac catheterization done through the right femoral artery. Which finding requires immediate follow-up by the nurse?
- ① The client is urinating more than usual
- ② The client is lying flat with the right leg straight
- ③ The client reports mild soreness at the puncture site
- ④ The right foot is cool and pale with a weak pedal pulse
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Answer: ④ The right foot is cool and pale with a weak pedal pulse
Key point: After femoral catheterization, check pulses and color below the site
After a catheter is placed through the femoral artery (in the groin), a clot or bleeding can block blood flow to the leg. The nurse checks the leg below the site often: pulses, color, warmth, and feeling. A cool, pale foot with a weak pulse suggests the artery is blocked. This is an emergency and must be reported right away.
Wrong choices
- "Lying flat with leg straight": this is the expected position after a femoral procedure to protect the puncture site.
- "Mild soreness": expected at a puncture site. Increasing swelling or bleeding would be a concern.
- "Urinating more": expected. The contrast dye acts like a mild diuretic, and clients are often given fluids to flush it out.
Question 2. On the second day after hip surgery, a client suddenly becomes short of breath, reports sharp chest pain when breathing in, and has a heart rate of 118 beats per minute. Which complication should the nurse suspect?
- ① Atelectasis
- ② Wound dehiscence
- ③ Paralytic ileus
- ④ Pulmonary embolism
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Answer: ④ Pulmonary embolism
Key point: Sudden dyspnea + chest pain + fast HR after surgery = suspect PE
A pulmonary embolism (PE) is a blood clot that travels to the lungs, often from a leg vein. Surgery, especially hip and leg surgery, and lying in bed raise the risk. Classic signs come on suddenly: shortness of breath, sharp chest pain on breathing in, fast heart rate, anxiety, and low oxygen. This is an emergency. The nurse stays with the client, raises the head of the bed, gives oxygen, and calls for help.
Wrong choices
- "Atelectasis": collapse of small air sacs. It is common after surgery but usually develops more gradually, with decreased breath sounds and sometimes a low-grade fever, not sudden sharp pain.
- "Wound dehiscence": the incision opens. It does not cause chest pain and shortness of breath.
- "Paralytic ileus": the bowel stops moving. It causes a swollen belly and no bowel sounds, not chest pain.
Question 3. The nurse reviews morning lab results for a client. Which result should the nurse report to the provider first?
- ① Potassium 6.2 mEq/L (reference range 3.5 to 5.0)
- ② Hemoglobin 12.6 g/dL (reference range 12.0 to 16.0)
- ③ Random glucose 118 mg/dL (reference range 70 to 140)
- ④ Sodium 138 mEq/L (reference range 135 to 145)
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Answer: ① Potassium 6.2 mEq/L (reference range 3.5 to 5.0)
Key point: High potassium can cause deadly heart rhythms; report it first
Compare each result with its reference range. Only the potassium is abnormal, and it is high. A potassium of 6.2 mEq/L (hyperkalemia) can cause dangerous heart rhythms and even cardiac arrest. The nurse reports it right away and often places the client on a heart monitor as ordered.
The nurse may also ask whether the sample could be falsely high (for example, from blood cells breaking during the draw), but this is decided with the provider. It is not a reason to delay reporting.
Wrong choices
- "Sodium 138": within the range given.
- "Hemoglobin 12.6": within the range given.
- "Random glucose 118": within the range given.