Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
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 became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.
You might also like to view...
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)
a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension
The trauma nurse monitoring a patient who has just arrived after a burn injury sustained in a fire is aware that the major cause of death in most burn patients is:
A) Decreased urinary output B) Infection C) Inhalation injury D) Sodium deficit
Which of the following factors is most important for the nurse to consider when recommending different types of contraceptives to a female client?
A) Client's partner's desire for pregnancy B) Sexual orientation of the client C) Client's ability to tolerate side effects D) Desire for protection against sexually transmitted infections (STIs)
A good meal for a patient with ascites would be
a. canned minestrone soup with saltine crackers. b. baked chicken with a roll and steamed green beans. c. bacon, sausage, eggs, and toast. d. tortilla chips with nacho cheese and salsa.