hello future nurses welcome to the nursing Foundation crash course your ultimate guide to enclex success we've packed this course with the most frequently tested topics on the enlex so after watching this you won't need to go through multiple books plus we've included important enlex questions for every topic to sharpen your critical thinking this video is a gold mine for your exam prep so make sure to watch till the end let's get started all right let's go over ethical principles in nursing first we have veracity which means being truthful nurses must always be honest when communicating with patients families and the healthc care team for example if a patient is starting a new medication the nurse should explain both the benefits and possible side effects even if they're unpleasant next is Justice which means fair and equal treatment every patient should receive care based on their medical needs not their background race or financial status for instance a nurse should prioritize patients based on urgency not on whether they have insurance then we have accountability we which means accepting responsibility nurses must own their actions including mistakes if a nurse gives the wrong medication they should immediately report it to their supervisor and complete an incident report taking responsibility helps ensure patient safety and Trust now let's talk about non-maleficence which means Do no harm nurses must always work to prevent harm and protect patients especially those who are vulnerable for example raising bed rails for a confused elderly patient helps prevent Falls moving on to Fidelity which is about loyalty and commitment nurses must keep their promises to patients if a nurse tells a patient they'll bring pain medication at a certain time they should follow through patients rely on that trust now we have beneficence which which means promoting good nurses should always act in the best interest of their patients this can be as simple as providing emotional support to a patient who's dealing with a tough diagnosis now let's test our understanding with an enlex question a nurse is educating a patient about a new medication the patient asks if it has any side effects what is the best response a there are no side effects at all B I cannot disclose that information C this medication may cause dizziness and nausea but I will inform you how to manage it D don't worry you'll be fine the correct answer is option C it follows the principle of veracity by providing honest and helpful information to the patient all right uh class let's talk about formed consent first the surgeon's role the surgeon must explain the diagnosis procedure risks and Alternatives they also need to answer any questions the patient has and ensure the patient fully understands before obtaining voluntary consent now the nurse's role the nurse Witnesses the patient's signature makes sure the patient is competent and signing voluntarily and documents the entire consent process but what happens if additional procedures are needed during surgery in that case the medical power of attorney next of kin or legal guardian must must be contacted for consent now let's check your understanding with an enlex question which statement about informed consent is correct a the nurse is responsible for explaining the procedure B the nurse can obtain verbal consent over the phone C the nurse Witnesses the signature but does not explain the procedure D the patient is forced to sign before surgery take a moment to think the correct answer is C the nurse's role is to witness the signature not to explain the procedure that's the surgeon's responsibility let's move on triage system triage is all about prioritizing patients based on the severity of their condition in an emergency not everyone can be treated at the same time so Health Care Providers need to decide who gets help first and who can wait the goal is simple save as many lives as possible while using resources wisely now let's break it down into four categories emergent red tag Immediate Care needed think of this category as help them right now or they won't survive these patients have life-threatening conditions but if treated immediately they have a good chance of survival for example if a patient has Airway obstruction they can't breathe and without oxygen survival is impossible this needs urgent intervention severe respiratory distress like intention pneuma thorax where trapped air collapses a lung this can quickly lead to death if untreated shock whether due to severe bleeding hemorrhagic shock or infection spreading through the body sepsis needs rapid medical attention patients with major trauma like open fractures with bleeding need immediate stabilization active chest pain possibly due to a heart attack means time is critical every second counts stroke symptoms within 4.5 hours this is the golden window for thrombolytic therapy which can dissolve clots and save brain function urgent Yellow Tag can wait a few hours these patients are sick or injured but stable for now their condition is serious but it won't kill them immediately so they can wait a little while for example a closed fracture without blood vessel or nerve damage doesn't need immediate surgery but still requires treatment soon abdominal pain such as appendicitis without rupture is concerning but as long as there's no perforation it's not life-threatening moderate Burns that don't affect the airway can be painful but they don't need immediate intervention someone with high blood pressure but no signs of organ damage should be treated but it's not an emergency deep lacerations need stitches but as long as bleeding is controlled they can wait a few hours non-urgent green tag minor injuries these are the walking wounded these patients are stable and their conditions won't get worse even if treatment is delayed for several hours for example minor burns painful but not life-threatening small lacerations if they're not deep and bleeding is controlled they can be stitched later sprains or minor fractures like a finger fracture don't need Urgent Care psychological distress as long as the patient isn't at risk of harming themselves or others they can wait expectant black tag no chance of survival this is the most difficult category these are patients with injuries so severe that survival isn't possible given the resources available in a mass casualty situation the focus has to be on those who can be saved for example a patient with severe head trauma who doesn't respond to painful stimuli has a very poor prognosis someone with extensive full thickness Burns covering most of their body is unlikely to survive massive such as decapitation or a patient in Cardiac Arrest with no vital signs for a long time means survival is not possible now let's go through some practice questions a hospital is responding to a mass casualty event after a bus crash there are multiple injured patients and the medical team needs to decide who should be treated first which patient should receive immediate attention a a 50-year-old with an open femur fracture and stable vitals b a 23-year-old with Burns covering 90% of the body and no palpable pulse c a 34-year-old with paradoxical chest movement and cyanosis D A 42-year-old with a sprained ankle and minor lacerations correct answer is option C a 34-year-old with paradoxical chest movement and cyanosis let's break this down the key phrase here is paradoxical chest movement and cyanosis this suggests flail chest which can quickly lead to respiratory failure if the airway is compromised the patient needs immediate intervention to survive this makes them a red tag emergent priority now let's go over why the other choices are not the highest priority should option A open femur fracture with stable vitals is serious but not immediately life-threatening this patient is a yellow tag urgent and can wait a little longer option b 90% Burns no pulse means the patient has little to no chance of survival so they receive a black tag expectant meaning resources should be focused on those who can be saved option D sprained ankle and minor lacerations is clearly not life-threatening this patient is stable able to walk and can wait several hours making them a green tag non-urgent so in mass casualty situations always prioritize Airway and breathing first which is why the patient with flail chest and cyanosis is treated immediately now let's look at another scenario a 67-year-old patient with COPD comes to the emergency department which symptom indicates they need immediate intervention a oxygen saturation 89% on room air B barrel chest and clubbing C sudden confusion and difficulty speaking D mild shortness of breath with exertion answer C sudden confusion and difficulty speaking here's why sudden confusion and difficulty speaking suggest a neurological change which could indicate a stroke or severe CO2 retention hypercapnia crisis in a CO OPD patient both are life-threatening conditions requiring immediate intervention that's why this patient is classified as red tag IM mergent priority if now let's go over the other choices option a oxygen saturation 89% may sound concerning but for a COPD patient this is actually not critically low their body is adapted to lower oxygen levels so this does not require immediate action option b barrel chest and clubbing are chronic signs of COPD meaning they have developed over time and do not indicate an emergency option D mild shortness of breath with exertion is a common symptom of COPD but does not signal an immediate crisis so the takeaway here is sudden changes in mental status or breathing are red flags and these patients must be treated immediately now let's move on to a disaster setting imagine there's been a natural disaster and resources are extremely limited the medical team must decide decide who receives treatment and who does not in this situation which patient should be classified as expectant black tag a a 40-year-old with tension pneuma thorax B A 55-year-old with third degree burns covering 80% of the body c a 30-year-old with a closed femur fracture d a 70-year-old with an asthma exacerbation requiring nebulizers answer B A 55-year-old with third degree burns covering 80% of the body let's think about this logically black tag expectant is given to patients who are not expected to survive even with treatment in mass casualty or disaster settings medical resources are limited so care is focused on saving those who have the best chance of survival here's why the correct answer is option b a patient with third degree burns over 80% of the body has a very low survival rate even with Advanced Medical Care in a disaster situation the chances of saving this patient are almost zero so they are classified as expectant black tag meaning they receive Comfort Care not aggressive treatment now let's see why the other choices are not black tag option a tension pneumothorax red tag emergent this is life-threatening but treatable with a chest decompression option C closed femur fracture Yellow Tag urgent this is a serious injury but not life-threatening the patient can wait for treatment option D Asma requiring nebulizers green or yellow tag depending on severity this patient could be stable enough to wait and would not be classified as expectant so in disaster triage the focus is on using resources wisely if a patient has injuries that are Beyond medical help they are given a black tag allowing Medical Teams to prioritize those who can be saved vyl triage tips for inlex always prioritize Airway breathing and circulation ABCs this helps helps determine who needs the most Urgent Care red tag emergent patients are treated first because they have life-threatening conditions but can still be saved black tag expectant patients receive Comfort Care they are not the priority in resource limited situations it if a patient is stable and able to walk they get a green tag minor injuries because they can wait for care before moving to the next topic I want to share something exciting you can now enroll in our enlex review crash course where you'll get hours of animated crash lessons 300 hours of recorded classes on high yield topics PDF notes 5,000 previously asked anac questions 15 practice tests and an exclusive ebook all with one-year access and a 99% passing rate don't miss this chance to boost your ankx prep join now leadership styles play a crucial role in shaping team performance patient outcomes and workplace culture one of the most rigid forms is autocratic leadership authoritarian where the leader makes all decisions without team input this style is characterized by strict control and a lack of collaborative decision-making while it may seem restrictive it is highly effective in emergencies or high-risk situations for instance during a cardiac arrest a nurse leader swiftly delegates tasks without discussion to ensure immediate and efficient patient care in contrast Democratic Leadership participative Fosters a more inclusive approach by encouraging team input and discussion this leadership style promotes collaboration and shared decision-making leading to higher Staff satisfaction however the downside is that it may slow down the decision-making process a common example is when a nurse manager consults staff members before making changes to scheduling this style is often tested in anx exams with questions such as a nurse leader encourages team input on a new patient safety protocol which leadership style is this the correct answer is a democratic on the other end of the spectrum L aair leadership hands off takes a minimalistic approach providing little direction or supervision this style works best with highly skilled independent professionals who require little oversight however in teams with inexperienced members it can lead to disorganization and inefficiency an example of this is a nurse manager who tells staff you can handle things however you see fit leaving decision-making entirely up to the team for those aiming to inspire and drive positive change transformational leadership is an ideal approach this leadership style focuses on long-term goals motivation and professional development transformational leaders encourage Innovation and mentorship helping staff grow while improving patient care a prime example is a nurse leader who actively promotes staff education and mentorship programs to enhance Health Care Quality lastly transactional leadership rewards and Punishment relies on a structured system of rewards and consequences to maintain order this style is practical for managing day-to-day operations but does not emphasize long-term growth or innovation it works well in environments where clear guidelines and expectations are necessary for instance bin a nurse leader may offer bonuses for meeting patient satisfaction targets while issuing warnings for excessive tardiness let's discuss some questions a nurse manager offers extra paid time off as an incentive for meeting infection control goals which leadership style is being used a democratic B transformational C transactional D le answer C transactional let's move to the next question in an emergency a nurse leader takes full control giving orders without consulting the staff which leadership style is being demonstrated a democratic B autocratic c l a fair D transformational answer B autocratic now let's look at another scenario a nurse leader provides minimal supervision and allows staff to make most decisions which leader ship style does this describe a democratic B autocratic c lir d transformational answer c l wait before we move to the next topic if you want the ultimate study Advantage check out our enlex review crash course with 100 hours of engaging animations 300 hours of recorded lectures covering high yield topics PDF notes 5,000 real enlex questions 15 fulllength practice tests and a musthave anx eBook you'll have everything you need to pass plus you get onee access and a 99% passing rate don't leave your success to chance enroll Now personal protective equipment PPE plays a crucial role in ensuring the safety of healthcare workers and preventing the spread of infections when putting on PPE it is important to follow the correct sequence which follows a reverse alphabetical order with one exception the mask is put on second the correct Dawning sequence is gown first followed by The Mask then goggles and finally gloves this order ensures maximum protection while minimizing contamination risks on the other hand when removing PPE the process follows an alphabetical order to safely prevent self-contamination the correct doing sequence is gloves first followed by goggles then the gown and finally The Mask this method ensures that the most contaminated items are removed first while preventing exposure to harmful pathogens to reinforce this concept consider the following enlex style question a nurse is about to remove PP e after caring for a patient under contact precautions what is the correct sequence a mask gloves gown goggles B gloves goggles gown mask C goggles mask gown gloves D gown goggles mask gloves the correct answer is B gloves goggles gown mask as it follows the proper doing sequence based on alphabetical order ensuring safe removal and reducing the risk of contamination delegation in nursing is essential for ensuring efficient p patient care while maintaining safety and adherence to professional roles registered nurses are responsible for assessing teaching evaluating and managing unstable patients as these tasks require critical thinking and advanced clinical judgment in contrast licensed practical nurses primarily care for stable patients and administer medications except for intravenous push medications in most cases meanwhile unlicensed assisted Personnel focus on activities of daily living such as bathing feeding ambulation and measure ing vital signs in stable patients understanding these roles is crucial for making appropriate delegation decisions to apply this knowledge consider the following enlex style question which task is appropriate to delegate to a UAP with a teaching a diabetic patient how to administer insulin B assessing pain level in a postop patient C measuring a stable patient's Vital Signs D administering oral pain medication the correct answer is C measuring a stable patient's vital signs as this Falls within the UAP scope of practice tasks requiring assessment education or medication administration should not be delegated to uaps another scenario further highlights the importance of proper delegation an LPN is assigned a patient with newly diagnosed diabetes which task is most appropriate for the RN to perform a administering insulin B teaching the patient how to monitor blood glucose C collecting a urine sample D monitoring the patient's oral intake the correct answer is B teaching the patient how to monitor blood glucose as teaching falls under the RN's responsibilities while LPNs and uaps can assist with various tasks patient education and evaluation require the expertise of an RN to ensure accurate understanding and safe management of the condition using a cane correctly is essential for maintaining balance and Mobility especially for individuals with weakness on one side of the body the proper technique begins with holding the cane on the strong side which provides better support and stability while walking when moving the cane should be Advanced first followed by the weak leg and finally the strong leg stepping forward to complete the movement this sequence ensures a steady gate and prevents Falls to reinforce this concept consider the following enlex style question a nurse is teaching a Pati with right-sided weakness how to use a cane which instruction is correct a hold the cane in your right hand for better support B move the cane and the strong leg together C move the cane first then the weak leg followed by the strong leg D move the strong leg first then the cane and weak leg together the correct answer is C move the cane first then the weak leg followed by the strong leg this method provides the ne necessary stability and support allowing the patient to walk safely while minimizing the risk of imbalance or Falls prioritization in nursing is a fundamental skill that ensures patient safety by addressing the most critical conditions first when prioritizing care it is important to note that age and gender are not criteria for prioritization instead nurses must focus on the severity and urgency of a patient condition in general acute conditions take priority over chronic conditions as they pose an immediate threat to the patient's Health similarly post-operative patients within the first 12 hours are prioritized over those Beyond 12 hours as they are at higher risk for complications a key Concept in prioritization is distinguishing between stable and unstable patients stable patients who require lower priority include those with chronic illnesses postop recovery Beyond 12 hours local or Regional anesthesia or expected symptoms of a known disease in contrast unstable patients require immediate attention and include those with acute illnesses or injuries posttop recovery within the first 12 hours general anesthesia or unexpected symptoms additionally certain conditions are always considered unstable and high priority such as Hemorrhage high fevers exceeding 105° Fahrenheit severe hypoglycemia such as dka hhns and pulselessness or breathlessness which necessitate immediate CPR to further refine prioritization problems are classified into three levels based on sever ity first level prioritization involves life-threatening emergencies such as Airway obstruction respiratory distress Cardiac Arrest severe bleeding and anaphylaxis these require immediate intervention to prevent death second level prioritization includes serious but not immediately life-threatening conditions such as altered mental status severe pain acute urinary retention uncontrolled blood sugar and critical abnormal lab values such as dangerously high or low potassium levels finally third level prioritization deals with long-term problems and routine care such as patient education mobility issues and psychosocial needs to apply these Concepts consider the following enlex style questions a 72-year-old patient with chronic kidney disease reports mild leg swelling while a 50-year-old patient has an active GI bleed who should the nurse see first answer is the 50-year-old patient with an active GI bleed since this is an unstable acute condition requiring immediate intervention next question is a nurse receives four patients which one should be seen first a a patient with pneumonia reporting mild shortness of breath b a posttop patient with a mild fever a patient with a history of COPD experiencing severe dpia d a diabetic patient with a fasting blood sugar of 150 migr per deciliter correct answer is option C the patient with severe dpia due to COPD has acute respiratory distress takes priority over other conditions a modified radical myectomy is a surgical procedure that involves the removal of the breast axillary lymph nodes and Superior appical nodes while preserving the chest muscles this approach helps in managing breast cancer while maintaining some structural Integrity of the chest however a significant post-operative concern is the risk of lymphadema a condition caused by lymph fluid buildup due to the removal of lymph nodes to prevent lymphadema certain precautions must be followed the affected arm should be kept elevated on pillows to promote proper drainage and reduce swelling additionally it is crucial to avoid blood pressure measurements intravenous insertions or blood draws on the affected arm as these can increase the risk of complications proper postmastectomy positioning also plays a vital role in recovery patients should be positioned in semi fowers position with the affected arm elevated to further Aid in fluid drainage and prevent swelling to reinforce this concept consider the following enlex style question a postmastectomy PTI is at risk for lymphadema what should the nurse avoid a elevating the arm on pillows B applying compression bandages C drawing blood from the affected arm D encouraging hand and arm exercises the correct answer is option C drawing blood from the affected arm as any medical procedures on the affected side can contribute to lymphadema and should be strictly avoided positioning clients for procedures proper patient positioning is essential for ensuring successful proced procedures and preventing complications different procedures require specific positions to optimize safety and Effectiveness for instance patients undergoing paracentesis should be placed in high fowers position as this allows fluid to accumulate in the lower abdomen for easier drainage in cases of suspected air embolism trendelenberg position is recommended to trap the embolism in the right ventricle and prevent it from traveling to the brain or lungs for chest tube placement raising the arms above the head helps expand the rib cage and provides better access access to the insertion site after a liver biopsy patients should be positioned on their right side to apply pressure to the puncture site minimizing the risk of bleeding meanwhile for thoracentesis an upright position with the patient leaning forward allows for better lung expansion and facilitates fluid removal to reinforce this concept consider the following enlex style question a patient just had a liver biopsy how should they be positioned a on their left side B on their right side C supine D in high Fowlers the correct answer is option b on their right side as this position helps prevent bleeding by applying pressure to the biopsy site Jehovah's Witness patients caring for Jehovah's Witness patients requires understanding their religious beliefs regarding medical treatment one of their fundamental principles is the refusal of blood transfusions even in life-threatening situations however they can accept IV fluids such as normal saline and lactated ringers which help maintain circulation without violating their religious beliefs additionally they may receive a poon Alpha a medication that stimulates red blood cell production as an alternative to blood transfusion to apply this knowledge consider the following enlex style question a Jehovah's Witness patient has severe anemia what treatment is appropriate a blood transfusion B normal saline infusion C platelet transfusion D administer EPO Alpha the correct answer is D administer aoan Alpha as it enhances red blood cell production without the need for a transfusion aligning with the patient beliefs Good Samaritan law the Good Samaritan law protects Health Care Providers from civil liability when they render Emergency Care outside of a clinical setting this legal protection applies as long as the care is provided in good faith and without gross negligence however it is crucial that the provider acts within their scope of practice and follows standard medical guidelines importantly nurses cannot accept payment for services rendered under the Good Samaritan law as it is intended to encourage voluntary assistance in emergencies for example if a nurse Witnesses a car accident and performs CPR on an unresponsive victim resulting in broken ribs the nurse is protected from legal consequences because the care was given in an emergency in good faith and without negligence to test this understanding consider the following enlex style question a nurse driving home witnesses an elderly man collapse on the sidewalk the nurse initiates CPR and continues until EMS arrives which statement is true regarding the nurse's legal protection under the Good Samaritan law a the nurse can be held liable if the man does not survive B the nurse must accept payment from the family for the provided care C the nurse is protected as long as they acted within their scope of practice D the nurse should have waited for EMS to arrive before intervening the correct answer is C the nurse is protected as long as they acted within their scope of practice ensuring that emergency care is provided safely and ethically abuse reporting nurses have a legal obligation to report any suspected or confirmed cases of abuse this responsibility ensures the protection of vulnerable individuals especially children who may not be able to advocate for themselves child abuse can occur at any age but it is particularly common in infants and toddlers due to their dependence on caregivers in many cases perpetrators of child abuse struggle with low self-esteem and often have a history of growing up in domestic violence making abuse a recurring cycle additionally substance abuse is a common contributing factor among Those who commit child abuse further increasing the risk of harm for instance if a nurse notices multiple bruises on a child's arms and back during a routine checkup and the parent casually States they just fall a lot the nurse is legally required to report the situation for further investigation failure to report could result in continued harm to the child to reinforce this concept consider the following ankle style question a nurse in the Pediatric unit notices bruises in various stages of healing on a child's body what is the best nursing action a confront the parents about the bruises and demand an explanation B document the findings and Report the suspected abuse to Child Protective Services C ask the child to describe how the bruises occurred and take no further action d notify the physician only if the child confirms being physically abused the correct answer is option b document the findings and Report the suspected abuse to Child Protective Services this ensures proper intervention and protects the child from further harm Advanced Care planning Advanced Care planning is a crucial process that helps individuals determine their future health care preferences in case they become unable to make medical decisions this planning includes two key components a healthc care proxy and a living will a health care proxy also known as a durable power of attorney for Health Care is a designated person who makes medical decisions on behalf of the patient meanwhile a living will or Advanced Directive is a written document that outlines specific Medical Treatments the person wishes to accept or refuse in certain situations it is important to note that providing oxygen via nasal canula is considered a comfort measure not a resuscitation method therefore it can still be administered to a patient even if they have a do not resuscitate DN R order for example if a terminally ill cancer patient with a DNR order is experiencing shortness of breath the nurse can provide oxygen as it enhances Comfort without violating the patient's endof life wishes to apply this concept consider the following enlex style question a patient has a living will stating they do not want mechanical ventilation the healthcare provider suggests intubation for respiratory distress what is the nurse's priority action a follow the physician's order and prepare for intubation B verify the living will and discuss the patient's wishes with the health care provider C inform the patient that intubation is necessary and cannot be refused D ignore the living will and allow the family to make the decision the correct answer is option b verify the living will and discuss the patient's wishes with the healthc care provider this ensures the patient autonomy is respected while also facilitating ethical decision- making in their care local organ procurement Services play a vital role in coordinating organ donations and must be notified for every clinical death as per Hospital protocol during this process cardiac and respiratory support must be maintained while organ donation is discussed or performed ensuring the viability of the organs for transplantation one critical aspect of organ donation is that family consent is not required if the patient is a registered organ donor the patient's prior decision takes precedence reinforcing the ethical and legal importance of respecting their wishes additionally concerns about postmortem appearance are unnecessary because organ donation does not disfigure the body allowing funeral arrangements to proceed as usual without any visible alterations for instance consider the scenario where a brain dead patient has assigned organ donor card but the family refuses to proceed with the donation in this case the hospital must honor the patient's document consent as their decision legally and ethically overrides the family's objections an nlex style question highlights this principle a patient is declared brain dead and is a registered organ donor the family refuses to consent to organ donation what is the best nursing action a respect the family's wishes and cancel the donation B inform the family that the patient's prior consent allows organ donation to proceed C wait until the family changes their mind before proceeding D contact the legal team to obtain a court order for organ donation the correct answer is option b inform the family that the patient's prior consent allows organ donation to proceed ensuring that the patient wishes are fulfilled while maintaining legal and ethical standards before we dive into the next topic here's a game changer for your enlex prep our enlex review crash course is now open for enrollment but spots are limited get 100 hours of animated crash courses 300 hours of recorded high yield lectures PDF notes 5 ,000 pass enlex questions 15 practice tests and an exclusive ebook plus you'll enjoy one-year access and a proven 99% passing rate don't wait until it's too late secure your spot today now we will discuss about arterial blood gas interpretation is an essential diagnostic tool used to assess a patient's oxygenation ventilation and acidbase balance proper analysis helps in identifying respiratory and metabolic disturbances guiding appropriate treatment strategies to determine the type of acid base imbalance a simple rule applies if pH and bicarbonate move in the same direction both increasing or both decreasing it indicates a metabolic imbalance however if pH and CO2 move in opposite directions the cause is respiratory in nature understanding these patterns allows for quick identification of underlying conditions affecting acidbase homeostasis the key components of an ABG and their normal values are as follows pH 7.35 to 7.45 partial pressure of CO2 35 to 45 mm of mercury bicarbonate 22 to 26 M equivalence per liter partial pressure of o2 80 to 100 mm of mercury oxygen saturation greater than 95% changes in PH significantly impact the body leading to specific symptoms when pH increases means alkalosis occurs the patient may become irritable hyper excitable restless and tacac cardic a classic example is anxiety induced hyperventilation leading to respiratory alkalosis additionally in alkalosis potassium levels drop causing hypokalemia conversely when pH decreases means acidosis occurs the patient may present with lethargy weakness Brady cardia and obtundation a common cause is chronic obstructive pulmonary disease which leads to CO2 retention resulting in respiratory acidosis unlike alkalosis acidosis is associated with hyperemia due to the shift of potassium out of cells respiratory versus metabolic imbalances respiratory alkalosis occurs when the pH increases and carbon dioxide levels decrease occurs due to hyperventilation which may result from anxiety pain pulmonary embolism PE or high altitude exposure patients often experience tachypnea dizziness tingling and tetany management involves slowing the breathing rate such as using a paper bag method for anxiety related cases and addressing the underlying cause respiratory acidosis occurs when the pH decreases and carbon dioxide levels increase is caused by hypoventilation leading to CO2 retention common causes include COPD narcotic overdose and Airway obstruction symptoms range from confusion and lethargy to decreased respiratory drive treatment focuses on improving ventilation oxygen therapy and using Bronco dilators when necessary metabolic alkalosis occurs when the pH increases and bicarbonate levels rise results from Acid loss commonly due to vomiting nasogastric NG suctioning or diuretic use symptoms include hypokalemia muscle cramps and cardiac arrhythmias management involves treating the underlying cause and replacing electrolytes to restore balance metabolic acidosis occurs when the pH decreases and bicarbonate or hco3- also decreases occurs due to excess acid production or bicarbonate loss common causes include diarrhea H3 loss diabetic keto acidosis dka lactic acidosis shock sepsis and renal failure patients may present with cusm small respirations deep rapid breathing hyperkalemia and confusion treatment depends on the cause insulin for dka IV fluids for dehydration and dialysis for renal failure by following a systematic approach examining pH first then identifying whether Paco 2 or hco3 is responsible you can determine the underlying condition a 45-year-old patient with COPD presents with confusion and lethargy the ABG results are pH 7.28 low indicating acidosis pakao 2 55 mm of mercury High suggesting CO2 retention and a respiratory cause hco3 24 mil equivalents per liter normal ruling out a metabolic issue given these findings the most likely acid base imbalance is a a metabolic acidosis B metabolic alkalosis C respiratory acidosis D respiratory alkalosis answer C respiratory acidosis since the pH is low the patient has acidosis the elevated pco2 indicates that the acidosis is due to CO2 retention a Hallmark of respiratory acidosis commonly seen in COPD patients who have difficulty expelling carbon dioxide a patient experiencing severe vomiting for 3 Days presents with the following ABG results pH 7.49 High indicating alkalosis pac2 42 mm of mercury normal meaning the issue is not respiratory H3 30 mil equivalents per liter high suggesting a metabolic cause based on these values the most likely cause of this imbalance is a diabetic keto acidosis B hyperventilation C excessive NG suctioning D narcotic overdose answer C excessive NG suctioning since the pH is high the patient has alkalosis the elevated hco3 Dash confirms a metabolic origin vomiting and NG suctioning remove gastric acid leading to metabolic alkalosis due to excessive acid loss question three a patient with sepsis presents with confusion and deep rapid breathing cous small respirations the ABG results are pH 7.30 low indicating acidosis pco2 33 mm of mercury low suggesting the lungs are compensating H3 18 mil equivalents per liter low pointing to a metabolic issue which condition is most likely a respiratory acidosis B metabolic acidosis C metabolic alkalosis D respiratory alkalosis answer B metabolic acidosis the low PH confirms acidosis and the low HC o3- indicates a metabolic cost the pay CO2 is also low showing that the body is compensating with C Small respirations a deep and Rapid breathing pattern typical in metabolic acidosis seen in conditions like sepsis final tip for enlex if partial pressure of carbon dioxide is abnormal the problem is respiratory if bicarbonate is abnormal the problem is metabolic always analyze the pH first then determine whether the issue is related to CO2 or bicarbonate to correctly identify the imbalance the cranial nerves play a vital role in sensory and motor functions and their assessment is crucial in identifying neurological abnormalities the olfactory nerve also known as cranial nerve one is a sensory nerve responsible for the sense of smell to assess its function one nostril is occluded at a time and the patient is asked to identify familiar Aromas such as coffee vanilla or peppermint a loss of smell also called anosmia can indicate neurological conditions like Parkinson's disease or a head injury next the optic nerve also known as cranial nerve 2 controls visual Acuity and pupil reaction it is assessed using the Snell and chart where the patient reads at a distance of 20 ft keeping their glasses on except for reading glasses additionally pupils equal round reactive to light and accommodation abbreviated as p r r l a is checked damage to the optic nerve can result in vision loss or blurring commonly seen in conditions like glaucoma and optic neuritis the ocul motor nerve also known as cranial nerve 3 is responsible for vertical eye movement and pupil constriction it is tested by asking the patient to track an object moving up and down while also using a pen light to check pupil reaction if damaged it may lead to drooping of the eyelid also called tosis or fixed dilated pupils similarly the trar nerve also known as cranial nerve four controls downward and inward eye movement and is assessed by tracking an object in those directions a lesion in this nerve can cause double vision also called diplopia specifically vertical diplopia the trigeminal nerve also known as cranial nerve five is a mixed nerve responsible for facial sensation and mastication which means chewing assessment includes a light touch test on the forehead cheeks and Chin with the patient's eyes closed along with palpation of the temporal and masser muscles while they clench their teeth damage to this nerve can result in trigeminal neur neuralgia which causes severe Facial Pain the ABD descence nerve also known as cranial nerve 6 is responsible for lateral eye movement it is tested by asking the patient to move their eyes laterally while following an object damage can lead to crossed eyes also called strabismus or double vision also called diplopia the facial nerve also known as cranial nerve 7 controls facial expression and taste in the front 2/3 of the tongue it is assessed by asking the patient to smile frown and raise their eyebrows as well as identify sweeter salty tastes on the tip of the tongue disorders like Belle's paly affect this nerve causing facial droop the acoustic nerve also called the vestibul colear nerve and known as cranial nerve 8 governs Hearing and Balance it is evaluated using the whisper test and Weber and Ryan tests with a tuning fork damage to this nerve can cause vertigo ttis or hearing loss the glossop ferial nerve also known as cranial nerve 9 plays a role in taste in the back onethird of the tongue and swallowing the assessment involves checking the gag reflex with the tongue depressor and asking the patient to say ah while observing uula movement an absent gag reflex increases the risk of aspiration which means food or liquid entering the airway the Vegas nerve also known as cranial nerve 10 is involved in speech and swallowing it is assessed by asking the patient to speak and swallow checking for heness or difficulty damage may lead to difficulty swallowing also called dysphasia or voice changes the spinal accessory nerve also known as cranial nerve 11 controls shoulder and head movements assessment involves asking the patient to shrug their shoulders and turn their head against resistance if damaged it may cause shoulder droop or weakness finally the hypoglossal nerve also known as cranial nerve 12 is responsible for tongue movement it is tested by asking the patient to stick out their tongue and move it side to side as well as say light tight Dynamite to assess articulation damage can result in tongue deviation to one side Healthcare is categorized into different levels based on the type and complexity of services provided understanding these levels is essential for nurses as they play a crucial role in promoting Health preventing disease and providing care across all stages of illness and Recovery these levels range from preventative measures to highly specialized treatments and Rehabilitation ensuring comprehensive care for individuals at different points in their health Journey the first level preventative health care focuses on educating and equipping clients to reduce and control risk factors for disease before health issues arise this includes screenings such as blood pressure checks cholesterol level monitoring and cancer screenings like mammograms or colonoscopies additionally immunization such as flu shots HPV vaccines and tetanus shots help prevent infectious diseases lifestyle counseling including Stress Management smoking cessation programs and weight management also plays a significant role in prevention furthermore injury prevention education such as promoting seat belt use fall prevention for the elderly and helmet use for cyclists is essential in reducing the risk of accidents nurses play a key role in patient education ensuring individuals understand how to maintain Health through lifestyle changes and routine checkups next Primary Health Care focuses on health promotion and early disease detection through routine medical visits and screenings this includes prenatal care and well bab checkups as well as routine physical exams and vaccinations to prevent illness other examples include Family Planning and birth control counseling vision and hearing screenings and nutrition counseling for managing chronic conditions like diabetes or hypertension in this setting nurses provide education administer vaccines and collaborate with healthc care providers to ensure early intervention and optimal patient outcomes moving forward secondary Healthcare involves the diagnosis and treatment of acute conditions illnesses or medical emergencies this level includes emergency room visits for conditions such as trauma stroke or myocardial infarction it also encompasses Hospital admissions for infections like pneumonia kidney infections or fractures as well as diagnostic services like MRI scans CT scans and laboratory tests additionally surgical procedures such as appendectomies gallbladder removal or Orthopedic surgeries fall under this category nurses and secondary Healthcare settings play a critical role in assessing and stabilizing ing patients administering medications performing procedures and coordinating care with the medical team to ensure efficient treatment and recovery for more complex health conditions tertiary Health Care provides highly specialized and Advanced Medical Care this includes intensive care units ICU for ventilator dependent patients oncology centers for chemotherapy or radiation therapy and burn centers for managing severe burns and skin grafting additionally specialized surgical units such as neurosurgery and cardiac surgery departments cater to patients requiring Advanced procedures nurses working in tertiary care settings require expert Knowledge and Skills to care for critically ill patients manage complex treatments and provide life-saving interventions finally restorative Health Care focuses on Rehabilitation and follow-up care to restore function and quality of life after illness or injury this level includes home health care for postsurgical Recovery rehabilitation centers for stroke patients undergoing physical therapy and skilled nursing facilities for wound care I V therapy and Pain Management additionally inhome respit care provides support to caregivers of chronically ill patients nurses and restorative care settings are essential in patient education discharge planning and Rehabilitation ensuring long-term recovery and improved quality of life injury prevention and Emergency Care carbon monoxide Co poisoning is a serious and often fatal condition caused by exposure to a colorless odorless and tasteless Gas Co binds to hemoglobin with an affinity 200 to 250 times greater than oxygen reducing oxygen transport to tissues and leading to hypoxia common sources of Co exposure include faulty furnaces gas stoves water heaters fireplaces and car exhaust in enclosed spaces to prevent Co poisoning it is essential to install carbon monoxide detectors in homes and regularly check their batteries additionally ensuring proper ventilation when using fuel burning appliances and avoiding running a car engine in a closed garage can help reduce the risk of exposure despite preventive measures Coop poisoning can still occur with early symptoms including headache dizziness nausea vomiting and confusion if left untreated severe cases can progress to loss of consciousness cherry red skin seizures and even death immediate management of coop poisoning involves moving the patient to fresh air and administering 100% oxygen via a non-rebreather mask in severe cases hyperbaric oxygen therapy may be required to rapidly remove Co from the bloodstream first aid measures in cases of bleeding Hemorrhage applying direct pressure using sterile gauze is crucial to control blood loss however if an impaled object is present it should not be removed instead it must be stabilized to prevent further injury for fractures immobilization is key to preventing further damage the affected limb should be splinted and the neurovascular status should be assessed using the five PS pain poor pulse paresthesia and paralysis to detect potential complications sprains which involve ligament injuries are best managed using the rice method rest the affected area apply ice for 20 minutes every 2 hours use compression with an elastic bandage and keep the limb elevated above Heart level to reduce swelling frostbite requires careful rearming of the affected area with lukewarm water at 98.6 to 108° fah or 37 to 42° c as using hot water can cause additional tissue damage a tetanus vaccine should be administered to prevent infection and rubbing the frostbit area should be avoided to prevent worsening the injury for burns stopping the burning process is the first priority which may involve removing the source of the burn such as flames chemicals or electricity elevating extremities helps reduce swelling while IV fluids should be administered to prevent hypovolemic shock if necessary a tetanus vaccine should also be given to prevent infection the inflammatory response is the body's natural defense mechanism against injury or infection occurring in three distinct stages the first stage known as the vascular response is characterized by athema redness warmth edema and pain these symptoms occur due to increased blood flow to the affected area which helps deliver immune cells and essential nutrients to begin the healing process and following this the second stage called the cellular response involves the activation of white blood cells CH wbcs that attack pathogens as a result exudate forms consisting of fluid wbcs dead cells and bacteria this exate can vary in appearance with different types indicating the nature of the inflammation Cirrus exate is clear such as the fluid found in blisters sanguinous exate contains blood commonly seen in fresh wounds serosanguinous exate is a mix of clear fluid and blood while purulent exate is thick yellow green and contains pus indicating an infection finally the third stage known as tissue repair and Healing Begins when the damaged tissue is replaced by Scar Tissue this stage restores structural int to the affected area completing the body's inflammatory response and promoting recovery fall prevention seizure precautions and restraint use in nursing preventing Falls is a key priority in patient safety especially for individuals at risk due to conditions such as orthostatic hypotention to minimize the risk of Falls patients should be encouraged to sit at the side of the bed before standing and be instructed to change positions slowly to prevent dizziness or sudden drops in blood pressure for patients who are particularly vulnerable to fall additional precautions should be taken these include regular toileting schedules to prevent rushing to the restroom providing skidproof socks for better grip and ensuring the bed is in the lowest position with brakes locked hourly rounding by healthc Care staff can further reduce fall risks as it allows for timely assistance additionally keeping essential items like the call button water and phone within reach can prevent unnecessary movement that could lead to Falls however it is important to avoid using all four side rails as this can lead to entrapment or increase the risk of injury if the patient attempts to climb over them in addition to fall prevention seizure precautions and management are crucial for patients with a history of seizures before seizure occurs preventative measures should be in place such as padding the bed rails to prevent injury and keeping suction and oxygen equipment at the bedside in case of Airway compromise during a seizure immediate actions should be taken to ensure patient safety the priority is to lower the patient to the floor or bed and turn them to their side to prevent aspiration the area should be cleared of any hard or sharp objects and any restrictive clothing should be loosened to avoid constriction it is essential to never restrain the patient or put anything in their mouth as this can cause further harm after the seizure postical phase the nurse should assess Vital Signs and neurological status reorient the patient as they may be confused or drowsy and identify possible triggers such as M medication stress or flashing lights to prevent future seizures another important aspect of patient safety is the appropriate use of restraints restraints should always be a last resort and used only when necessary to prevent the patient from harming themselves or others they can be classified as physical restraints such as vests belts and mittens or chemical restraints which include sedatives and antis psychotic medications before applying restraints alternative strategies should be attempted first these include reorientation where the patient is reminded of their surroundings time and situation supervision such as assigning a sitter or using video monitoring and diversions like engaging the patient in activities such as folding towels or listening to music these measures can help reduce agitation and promote patient safety without the need for restraints creating a safe and comfortable environment for patients is essential in healthcare settings simple modifications such as reducing noise adjusting lighting or positioning the patient near the nursing station can help improve their well-being and prevent agitation however in some situations restraints may be necessary to ensure patient and staff safety but they must be applied according to strict guidelines in emergencies a registered nurse can apply restraints immediately but a provider's prescription must be obtained within 1 hour the duration of restraint orders varies based on the patient's age for adults the maximum duration is 4 hours for ages 9 to 17 it is 2 hours and for children under 9 years it is limited to 1 hour additionally restrain orders must be Rewritten every 24 hours and PRN as needed orders are not permitted to ensure continuous reassessment of the patient's condition proper restraint placement is crucial to prevent complications the padded portion should be applied to the wrist to protect the skin from injury and neurovascular checks must be performed every 2 hours to assess circulation movement and sensation regular Skin Integrity assessments frequent range of motion ROM exercises and the use of the least restrictive restraint necessary help minimize harm for examp example mittens are a less restrictive option than wrist restraints and may be preferable when preventing IV removal additionally restraints should never be too tight ensuring that two fingers can fit between the restraint and the patient's limb helps prevent circulation issues for safety and quick removal a quick release slip knot should be used instead of a square knot restraints must be secured to the movable part of the bed frame never to the side rails or fixed parts of the bed to prevent injury when using belt restraints they should always be placed over clothing or gowns to avoid direct skin damage to illustrate these principles consider the following situations one a confused elderly patient with dementia repeatedly pulls out their intravenous and attempts to climb out of bed in this case the first approach should be non-restrictive interventions such as reorientation diversions and supervision if these fail mittens may be a better option than risk restraints since they prevent intravenous removal while allowing some Mobility two a patient with schizophrenia becomes aggressive and tries to harm staff members in this situation chemical restraints such as an antis psychotic or sedative may be considered before physical restraints if physical restraints are necessary they should only be used as a last resort and removed as soon as possible to avoid unnecessary restriction of movement before we move to the next topic I have great news for you our enlex review crash course is now open for enrollment this comprehensive program includes 100 hours of animated crash lessons 300 hours of recorded lectures covering high yield topics PDF notes 5,000 previously asked enlex questions 15 full length practice tests and an exclusive ebook all with one-year access and a 99% passing rate if you're serious about passing the enlex this is the course for you join now and take the next step towards success fire safety procedures are essential in healthcare settings to ensure the protection of patients staff and Facilities the ra Ace protocol is a structured approach to fire response guiding Healthcare professionals through the necessary steps to manage a fire emergency effectively the first step in race is R rescue which involves moving patients to a safe location the priority is horizontal evacuation meaning patients should be relocated within the same floor if possible if the situation escalates a lateral evacuation to a different floor may be required next a alarm emphasizes the importance of activating the fire alarm system to alert emergency responders promptly once the alarm is raised C contain comes into play by closing doors and windows to prevent the fire from spreading additionally any Oxygen sources should be turned off to reduce fire intensity the final step e extinguish involves using a fire extinguisher to put out the fire but only if it is small and safe to do so when using a fire extinguisher the P technique ensures its proper operation the first step P pull requires pulling the PIN to unlock the extinguisher then a a G directs the user to Target the base of the fire not the Flames for maximum Effectiveness following this s squeeze instructs the user to press the handle to release the extinguishing agent finally s sweep involves moving the nozzle side to side until the fire is completely out understanding different bed positions and their uses is essential in patient care as each position serves a specific purpose in promoting Comfort recovery and medical intervention one commonly used position is sims's position where the patient lies on their left side with the left hip and lower extremity straight while the right hip and knee are bent this position is primarily used for enas rectal examinations and rectal medication administration for instance when a nurse needs to administer a suppository placing the patient in sims's position ensures proper medication delivery another important position is the trendelenberg position where the entire bed is tilted so that the head of the bed a b is lower than the foot this position is is beneficial for promoting Venus return and is commonly used in cases of hypotension shock or postural drainage for example a patient experiencing hypmic shock may be placed in trendelenberg to improve blood flow to vital organs conversely the reverse trendelenberg position involves tilting the bed with the foot lower than the head which is particularly useful for promoting gastric emptying and preventing acid reflux patients with gastro esophageal reflux disease gird may be positioned this way to reduce reflux symptoms another variation is the modified trendelenberg position where the patient lies flat with legs elevated above Heart level this position is beneficial in cases of hypovolemia as it promotes Venus return for instance a patient who experiences Syncopy fainting can be placed in this position to restore blood flow in cases where aspiration prevention and improved ventilation are necessary the semi fowers position 15 to 45° usually 30° is often used a post operative patient receiving tube feeds would benefit from this position to prevent aspiration Fowler's position 45 to 60° is slightly more elevated and is commonly used during procedures like suctioning and to improve ventilation as seen in patients recovering from pneumonia a further increase in elevation leads to high fowers position 60 to 90° which is crucial for patients with severe dpia or those at risk of aspiration during meals such as individuals with COPD and respiratory distress when full body support is needed the Supine position where the patient lies flat on their back is recommended especially for post-operative care and spinal surgery recovery in contrast the prone position where the patient lies on their stomach is often used to prevent hip flexion contractures after lower extremity amputation and is particularly beneficial for patients with acute respiratory distress syndrome ards during the co9 pandemic many patients in severe respiratory distress were placed in a prone position to improve oxygenation finally for patients experiencing breathing difficulties the orthopneic position is highly effective in this position the patient sits on the side of the bed with their arms resting on an overbed table which helps promote lung expansion patients with COPD often adopt this position to facilitate easier breathing proper bed positioning is essential for patient care as it helps prevent complications and promotes recovery in various medical conditions and procedures for a myectomy the affected arm should be elevated on a pillow and the patient should turn only to the unaffected side or remain on their back this positioning helps prevent lymphatic fluid accumulation lymphadema reducing swelling and complications similarly for head injuries or postsurgical patients a semi's position 30 to 45 degrees with the head in midline and no flexion is recommended this helps reduce intracranial pressure ICP and promotes Venus drainage preventing further brain injury patients with COPD or respiratory distress benefit from a high fowers or tripod position as this helps increase lung expansion and maximize oxygenation when administering an enema the left lateral or Sims position is preferred because it facilitates the natural flow of the solution into the colon by gravity ensuring effective cleansing in the case of leg amputation the affected limb should be elevated for the first 24 hours to reduce swelling but after that the patient should lie prone twice daily for 20 to 30 minutes to prevent contractures following a thyroidectomy the patient should be in a semi fowers position with neck support while turning which helps reduce swelling and prevent Airway obstruction for patients in shock a modified trendelenberg position is used to improve profusion to vital organs meanwhile during a thoracentesis the patient should be seated upright and leaning over an overbed table ensuring better access to the plural space for fluid removal a liver biopsy requires specific positioning during the procedure the p patient lies on their left side and after the procedure they must be positioned on their right side to prevent postprocedure bleeding similarly for paracentesis a semi fowers or upright position allows for an optimal needle insertion angle ensuring efficient fluid drainage patients undergoing nasogastric NG or gastrostomy tube GT placement should be in a high fowers position during insertion and in a semi fowers 30° position during feeding to prevent aspiration at after a laminectomy spinal surgery the patient must be kept straight and log rolled for turning to prevent spinal twisting and further injury for stroke patients positioning depends on the type of stroke in esic stroke a flat position is recommended to optimize cerebral profusion while in hemorrhagic stroke the head of the bed should be elevated to 30° to reduce intracranial pressure following a cardiac catheterization the patient should remain on bed rest for 6 hours with the affected limb kept straight and the hob should not be elevated Beyond on 30° to prevent bleeding at the insertion site finally for maternal patients experiencing dizziness due to supine hypotension syndrome the left lateral position is advised as it prevents compression of the inferior venacava by the uterus ensuring adequate blood flow to both mother and baby proper use of crutches is essential for mobility and preventing further injury when positioning crutches the crutch tips should be placed 6 in laterally and 6 in in front of the patient's feet to provide stability additionally the crutch pads must be positioned 1.5 to 2 in or approximately 2 to three finger widths below the ailla to prevent nerve damage and discomfort to ensure proper support and maneuverability the elbows should be slightly flexed at around 30° while using crutches different crutch gate patterns are used depending on the patient's condition and Mobility needs the two-point gate involves moving a crutch and the opposite leg together providing a balanced and steady motion the three point gate requires moving both crutches and the affected leg forward together followed by moving the unaffected leg making it suitable for patients with one injured limb in the four-point gate movement is more gradual as the patient moves one crutch then the opposite leg followed by the other crutch and the remaining leg for individuals with paraplegia the swing to or swing through gate is used where both crutches are moved forward first followed by swinging the legs forward to meet or past the crutches when using crutches on stairs the technique varies depending on whether the patient is ascending or descending when going up the stairs the patient should step up with the unaffected leg first then move the affected leg and crutches up together in contrast when descending stairs the process is reversed the patient must move the affected leg and crutches down first followed by stepping down with the unaffected leg using a walker correctly is essential for ensuring both patient safety and effective Mobility support when using a walker the elbows should be flexed at a 30° angle to provide stability and prevent strain additionally when taking steps it is crucial to step with the weaker leg first followed by the stronger leg to maintain balance and reduce the risk of Falls one important safety precaution is to never pull on the Walker to stand up instead the patient should push up from the chair first before gripping The Walker to avoid instability for the anx understanding safe patient handling is key to preventing injuries for both the patient and the nurse using proper body mechanics is essential this includes keeping the back straight bending the knees rather than the waist and avoiding twisting movements additionally nurses must be familiar with the correct use of assistive devices such as crutches canes and Walkers to ensure patients use them safely and effectively another critical aspect of patient care is knowing how to transfer and position patients correctly such as moving them safely from a bed to a wheelchair and preventing complications like foot drop above all safety and fall prevention should always be the top priority as proper techniques and precautions can significantly reduce the risk of injury understanding The Chain of Infection is essential for infection prevention the process begins with an infectious agent such as bacteria viruses fungi or parasites including staphilococcus orius and the influenza virus these pathogens reside in a reservoir which may be the human body soil water or contaminated surfaces the portal of exit refers to how the pathogen leaves the host such as Through Blood respiratory droplets feces or skin wounds the infection then spreads via a mode of transmission including contact droplet or Airborne Roots such as hand-to-hand contact coughing or contaminated surfaces next the pathogen enters a new host through a portal of entry which may include breaks in the skin inhalation or mucous membranes finally a susceptible host becomes infected particularly those at higher risk such as imuno compromised individuals the elderly infants and people with chronic diseases several risk factors increase susceptibility to infection a weakened immune system due to chemotherapy or organ transplants significantly raises the risk chronic and acute diseases such as diabetes chronic obstructive pulmonary disease cancer and autoimmune disorders further contribute to vulnerability poor personal hygiene and hand hygiene crowded living conditions such as in nursing homes prisons and dormitories intravenous drug use unprotected sex and poor sanitation including contaminated water and improper waste disposal also increase infection risk infection progress through four distinct stages the incubation period is the time between exposure and the first appearance of symptoms which varies depending on the infection for example chickenpox has an incubation period of 10 to 21 days during the prodromal stage non-specific symptoms such as mild fever fatigue and malaise appear making this the most infectious stage the illness stage follows where disease specific symptoms become evident such as a rash in measles or a severe cough in pneumonia fin finally the convalescence stage marks the recovery phase during which symptoms gradually resolve to prevent the spread of infections infection control measures must be followed standard precautions applicable to all patients include hand hygiene before and after patient contact wearing gloves when contact with body fluids is expected and ensuring the proper disposal of Sharps and biohazard materials in cases requiring additional protection transmission based precautions are necessary for Airborne infections such as measles vericella and tuberculosis patients should be placed in a private room with negative pressure and healthc care providers must wear an n95 respirator mask along with gloves gowns and eye protection as needed droplet precautions required for infections like influenza menitis rubella MPS and diptheria involve private rooms or cohorting with the same infection and require masks within 3 ft of the patient contact precautions used for infections such as meth cin resistant staphilococcus orius Vancomycin resistant enterococus clides defal wound infections and respiratory sensial virus include wearing gloves and gowns preferring a private room and Performing hand hygiene with soap and water for clides defal infections maintaining a sterile field is essential to prevent contamination during medical procedures to uphold sterility it is crucial to avoid coughing sneezing or talking over the sterile field as airborne contaminants can compromise its Integrity Additionally the outer 1in edge of the sterile field is not sterile so any item that touches this area must be discarded furthermore objects held below the waist or above the chest are considered contaminated and should not be used to maintain sterility while adding objects they must be dropped onto the field from at least 6 in above to prevent accidental contamination additionally Healthcare professionals must never turn their back on a sterile field or reach across it as doing so inre es the risk of introducing contaminants lastly any sterile item that comes into contact with moisture is considered non-sterile as moisture can carry microorganisms onto the field success in the enlex isn't about luck it's about preparation before we move on I want to invite you to enroll in our anx review crash course and take control of your journey you'll get 100 hours of engaging animated lessons 300 hours of recorded lectures on essential topics PDF notes 5,000 real enlex questions 15 practice tests and a must-have ebook all designed to give you oneyear access and a 99% passing rate give yourself the best chance at success sign up today and make your nlex dream a reality when performing a physical assessment 4 key techniques are used the first is inspection which relies on site to assess the size shape color and symmetry of body structures next is palpation which involves using touch to evaluate temperature texture and tenderness the dorsal surface of the hand is best for assessing temperature while the Palmer surface is ideal for detecting vibrations the third technique percussion involves tapping body parts to assess size tenderness and density of underlying structures the final technique is oscilation which requires listening to body sounds such as those from the heart lungs and bowels typically assessments follow the order of inspection palpation percussion oscilation except in abdominal assessments where the order changes to inspection oscilation percussion palpation to prevent disrupting bowel sounds for an eye assessment several key evaluations help determine eye function and Alignment the extraocular muscles include the inferior and Superior oblique lateral medial inferior and superior rectus muscles which control eye movement the corneal light reflex test involves shining a light at the patient's eyes to check for a symmetrical reflection on the corneas indicating proper alignment another important test is the cover and uncover test which detects St business by observing for movement when one eye is uncovered Additionally the six cardinal gaze positions test eye muscle function by having the patient follow a finger in an H pattern lastly the p r rla acronym is used to assess pupil function pupils should be clear equal in size round reactive to light and able to accommodate to near and far objects ear assessment and blood pressure measurement proper ear assessment is essential for identifying any abnormalities and ensuring accurate diagnosis when evalu ating ear alignment the oracles should be level with the inner canthus of the eyes to indicate normal positioning when using an otoscope technique varies based on the patient's age for adults the Oracle should be pulled up and back and whereas for children under 3 years old the Oracle should be pulled down and back to straighten the ear canal the otoscope should be inserted 1 to 1.5 cm into the canal without touching the walls to prevent discomfort and injury equally important is the proper measurement of blood pressure which includes assessing pulse pressure the difference between systolic and diastolic blood pressure a normal pulse pressure ranges from 30 to 50 mm of mercury a widened pulse pressure greater than 50 mm of mercury May indicate conditions such as hypertension ortic regurgitation or increased intracranial pressure in contrast a narrow pulse pressure less than 30 mm of mercury could be a sign of hypmic shock heart failure or cardiac tamponade all of which require immediate Medical attention accurate BP measurement also depends on using the correct cuff size the cuff width should be 40% of the arm's circumference while the bladder length should cover 80% of the arm using an incorrect cuff size can lead to inaccurate readings a cuff that is too large results in a falsely low BP while a cuff that is too small leads to a falsely High BP additionally BP should not be measured on an arm with an IV infusion running a history of myectomy on that side or an AV fistula used for dialysis as this can cause complications to estimate systolic blood pressure using palpation follow these steps one palpate the radial pulse two inflate the cuff until the pulse disappears three add 30 mm of mercury morph for accuracy four slowly release the pressure and note when the pulse returns lastly proper patient positioning is crucial for an accurate BP reading the patient should be seated with feet flat on the floor and legs uncrossed to prevent any false variations in blood pressure readings blood pressure classification is essential in assessing cardiovascular health and guiding appropriate interventions blood pressure is measured using two values systolic blood pressure which represents the pressure in the arteries when the heart contracts and diastolic blood pressure which indicates the pressure when the heart relaxes between beats a normal blood pressure reading is less than 120 mm of mercury for systolic and less than 80 mm of mercury for d diastolic when blood pressure starts to rise but has not yet reached hypertensive levels it falls into the prehypertension category with systolic readings between 120 and 139 mm of mercury and diastolic readings between 80 and 89 mm of mercury this stage signals an increased risk for hypertension making lifestyle modifications crucial if blood pressure continues to rise it is classified as stage one hypertension where systolic pressure ranges from4 to 159 mm of mercury and diastolic pressure from 90 to 99 mm of mercury this stage often requires medical intervention in addition to Lifestyle Changes more severe elevation leads to stage two hypertension defined by a systolic pressure of 160 mm of mercury or higher and a diastolic pressure of 100 mm of mercury or higher requiring more intensive treatment to prevent complications such as stroke or heart disease on the other hand hypotension occurs when systolic pressure Falls below 90 mm of mercury which can lead to inadequate blood flow to organs causing dizziness fainting or shock in severe cases recognizing these classifications helps healthc Care Professionals manage blood pressure effectively and reduce the risk of serious cardiovascular conditions pulses and nasogastric Tube care assessing pulses is a fundamental part of patient evaluation providing critical insights into cardiovascular function a normal pulse rate varies by age with adults typically ranging from 60 to 100 beatss per minute while infants have a faster rate of 120 to 160 beats per minute when performing a pulse assessment it is essential to evaluate rate to identify normal Rhythm bardia or tacac cardia Rhythm determining if it is regular or irregular and a quality comparing pulses on both sides of the Body for consistency Additionally the pulse strength scale is used to classify pulse intensity a pulse rate zero is absent one plus is weak or diminished to 2 plus is normal 3 plus is strong and four plus is bounding which may indicate conditions such as hypertension or fluid overload different methods of pulse measurement include the radial and appical pulses the radial pulse located on the thumb side of the wrist should be counted for 30 seconds and multiplied by two if regular but for a full minute if irregular in contrast the appical pulse found at the fifth inner costal space at the left midclavicular line must always be counted for a full minute if irregular or if the patient is on cardiac medications a crucial Concept in pulse assessment is the pulse deficit which is calculated by subtracting the radial pulse from the appical pulse a difference greater than two beats May indicate atrial fibrillation heart failure or an arhythmia requiring further evaluation shifting Focus to nasogastric tube care proper technique and precautions are essential for patient safety during insertion the patient should be placed in a high Fowler's position to reduce the risk of aspiration clear patient communication a is necessary and a signal system should be established so the patient can indicate discomfort before insertion a towel should be placed across the chest to prevent messes and a water-based lubricant should be used to facilitate smooth passage as the tube is inserted the patient should be encouraged to sip water aiding the tube's passage into the esophagus if gagging or choking occurs the insertion should be paused slightly to allow recovery before proceeding proper placement confirmation is critical the gastric pH should be checked and an x-ray should could be obtained before the first feeding additionally prefeeding checks involve verifying the presence of bowel sounds and reassessing gastric content pH to ensure safe administration of nutrition or medications thank you for watching this lecture I appreciate your time and dedication to learning I hope this session helped deepen your understanding of the topic