Question

The nurse is making rounds on a client who is in cervical tongs. Assessment reveals detachment of one of the pins. Which nursing action is most appropriate? A. Call for help immediately and stabilize the clients' head in the neutral position. B. Go to the nursing station and call the neurosurgeon immediately. C. Lower the head of the bed and add more weight to the traction. D. Turn the client to the left side, raising the knee gatch on the bed.

Short answer

Answer: Call for help immediately and stabilize the clients' head in the neutral position.

Step-by-step solution

Analyze Option A

A. Call for help immediately and stabilize the client's head in the neutral position. In this option, the first response is to call for help, which is important in an emergency situation. Additionally, stabilizing the client's head in the neutral position is essential to prevent further injury to the cervical spine.

Analyze Option B

B. Go to the nursing station and call the neurosurgeon immediately. In this option, the focus is on calling the neurosurgeon, which could be helpful, but not immediately addressing the client's safety can lead to further injury.

Analyze Option C

C. Lower the head of the bed and add more weight to the traction. In this option, the focus is on adjusting the bed and the traction, which doesn't directly address the issue of the detached pin or the client's head stability.

Analyze Option D

D. Turn the client to the left side, raising the knee gatch on the bed. In this option, the focus is on turning the client and adjusting the bed, which could further compromise their safety and stability.

Choose the most appropriate action

After analyzing all options, it's clear that Option A is the most appropriate action. It focuses on calling for help and stabilizing the client's head, which are crucial steps in dealing with this emergency situation. Answer: A. Call for help immediately and stabilize the clients' head in the neutral position.