A nurse is performing pin site care to a patient in halo traction following a spinal cord injury. One of the traction pins becomes detached when the patient is turned
The nurse would be correct in implementing which of the following priority nursing actions?
A) Complete the pin site care to decrease risk of infection.
B) Notify the neurosurgeon of the occurrence.
C) Stabilize the head in a lateral position.
D) Reattach the pin to prevent further head trauma.
Ans: B
Feedback: If one of the pins becomes detached, the patient's head should be stabilized in neutral position by one person while another notifies the neurosurgeon. A torque screwdriver is used when the screws on the frame need tightening. Reattaching the pin would not be done as a nursing intervention due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurological injury is the priority.
You might also like to view...
The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parent's findings by observing the newborn, the nurse should:
A) notify the health care provider immediately B) assess the newborn for signs of respiratory distress C) reassure the parents that this is an expected pattern D) tell the parents not to worry since his color is fine
The nurse is interviewing a female client who admits to having poor coping skills, drug abuse, and a recent divorce with loss of child custody. The nurse knows the client is most at risk for:
1. Self-mutilation. 2. Bulimia. 3. Chronic fatigue syndrome. 4. Depression.
When the nurse administers pain medication to a postoperative patient, the phase of the nursing process that is occurring is which of the following phases?
A) Assessment B) Nursing diagnosis C) Planning D) Implementation
During a postpartum home visit the nurse reinforces the importance of holding the infant and having tummy time periodically through the day with the new mother. What did the nurse observe that indicated the mother needed additional teaching? Select all that apply
1. Rapid respiratory rate 2. Weak gross motor skills 3. Crusted nasal secretions 4. Positional plagiocephaly 5. Sluggish upper body strength