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Med-Surg Nursing (AH 52) All Nurses Nclex Study Guide

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John Marsh
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All nurses Nclex Study Guide

Gavilan College

Med-Surg Nursing (AH 52)

CONTACT PRECAUTION
MRS.WEE
M – multidrug resistant organism
R – respiratory infection
S – skin infections *
W – wound infxn
E – enteric infxn – clostridium difficile
E – eye infxn – conjunctivitis
SKIN INFECTIONS
VCHIPS
V – varicella zoster
C – cutaneous diphtheria
H – herpez simplex
I – impetigo
P – pediculosis
S – scabies
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) –> turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal
bradycardia, etc) –> turn on left side (and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC –> position pt on right side (promotes emptying of the
stomach) with the HOB elevated (to prevent aspiration)
4. During Epidural Puncture –> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)–> pt lies in flat supine (to prevent
headache and leaking of CSF)
6. Pt w/ Heat Stroke –> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) –> catheter is taped to thigh so leg should be
kept straight. No other positioning restrictions.
8. After Myringotomy –> position on side of affected ear after surgery (allows drainage of
secretions)
9. After Cataract Surgery –> pt will sleep on unaffected side with a night shield for 1-4
weeks.
10. After Thyroidectomy –> low or semi-Fowler’s, support head, neck and shoulders.
11. Infant w/ Spina Bifida –> position prone (on abdomen) so that sac does not rupture
12. Buck’s Traction (skin traction) –> elevate foot of bed for counter-traction
13. After Total Hip Replacement –> don’t sleep on operated side, don’t flex hip more than 45-
60 degrees, don’t elevate HOB more than 45 degrees. Maintain hip abduction by separating
thighs with pillows.
14. Prolapsed Cord –> knee-chest position or Trendelenburg
2
15. Infant w/ Cleft Lip –> position on back or in infant seat to prevent trauma to suture line.
While feeding, hold in upright position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) –> eat in
reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low
CHO and fiber diet, small frequent meals)
17. Above Knee Amputation –> elevate for first 24 hours on pillow, position prone daily to
provide for hip extension.
18. Below Knee Amputation –> foot of bed elevated for first 24 hours, position prone daily to
provide for hip extension.
19. Detached Retina –> area of detachment should be in the dependent position
20. Administration of Enema –> position pt in left side-lying (Sim’s) with knee flexed

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Med-Surg Nursing (AH 52) All Nurses Nclex Study Guide

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