第 5 章，共 7 章12% 占考试比重

Basic Care and Comfort

Basic Care and Comfort addresses the fundamental activities of daily living: nutrition, elimination, mobility, hygiene, rest, and skin integrity. The nurse provides safe, evidence-based care that promotes comfort and prevents complications of immobility.

Nutrition and Hydration

The nurse promotes safe eating and adequate hydration, adapting to diets and swallowing ability. Aspiration prevention is a key concern.

Know clear liquids

Clear liquids include apple juice, broth, and plain gelatin, which leave little residue.

Prevent aspiration in dysphagia

Position the client upright and use chin-tuck swallowing; avoid thin liquids as ordered.

Provide comfort during NPO

Offer oral care and lip moisture without giving fluids to an NPO client.

Verify tube feeding placement

Confirm nasogastric tube placement per protocol using pH or radiographic methods before feeding.

Elimination

The nurse supports normal bowel and bladder function and monitors output for early signs of problems. Nonpharmacologic measures come first.

Treat constipation conservatively

Increase fluids, fiber, and activity before using enemas or laxatives.

Report low urine output

Output below 30 mL per hour may indicate poor perfusion or obstruction and should be reported.

Provide correct perineal care

Clean from the urethra outward toward the anus using a clean cloth section per stroke.

Maintain catheter safety

Keep the drainage bag below the bladder and the system closed to prevent infection.

Mobility and Immobility

The nurse promotes safe movement and prevents complications of immobility such as venous thromboembolism and deconditioning. Assistive devices are fitted correctly.

Fit crutches correctly

The crutch top rests about two finger-widths below the axilla with weight on the hands.

Prevent venous thromboembolism

Encourage leg exercises and apply sequential compression devices for immobile clients.

Apply antiembolism stockings correctly

Apply while the client is lying down before rising, without wrinkles or rolling.

Reposition regularly

Change position at least every two hours to maintain circulation and prevent breakdown.

Skin Integrity and Wound Care

The nurse prevents and stages pressure injuries and protects skin over bony prominences. Staging guides treatment.

Reposition to prevent injury

Turn and reposition at least every two hours and use the 30-degree lateral position.

Stage pressure injuries

Stage 1 is nonblanchable redness, stage 2 is partial-thickness loss, and deeper stages involve full-thickness loss.

Avoid harmful practices

Do not massage bony prominences or use doughnut cushions, which cause tissue damage.

Keep skin clean and dry

Manage moisture and incontinence to protect skin integrity.

Hygiene, Rest, and Comfort

The nurse provides safe hygiene and promotes rest and comfort, adapting care to the client's level of consciousness. Airway protection is essential during care.

Protect the airway during oral care

Position unconscious clients side-lying and use minimal fluid to prevent aspiration.

Promote rest

Cluster care and reduce nighttime interruptions to support sleep.

Manage pain and comfort

Use pharmacologic and nonpharmacologic measures to relieve discomfort.

Maintain dignity

Provide privacy and involve the client in hygiene decisions when possible.

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Psychosocial Integrity

Pharmacological and Parenteral Therapies

Last updated: July 2026