Question

The nurse is assessing traction of a client with a fracture who is in skeletal traction. Assessment reveals a loosened pin on the bone. Which action is appropriate? A. Notify the physician B. Remove the weight to release the pressure on the pin C. Reposition the client to the supine position D. Try to remove the pin for examination

Short answer

Answer: The most appropriate action for the nurse to take in this situation is to notify the physician.

Step-by-step solution

The role of the nurse in patient care

The nurse is responsible for assessing, planning, implementing, and evaluating patient care. This includes recognizing potential problems and reporting them to the appropriate medical professional, such as a physician.

Evaluate each possible action

A. Notify the physician - The nurse should report potential issues they observe during patient care to the physician. This action allows the nurse to take the appropriate steps and ensure the patient receives the necessary care. B. Remove the weight to release the pressure on the pin - This action might seem appropriate, but it could also potentially lead to other complications. It is better to consult the physician before making any changes to the patient's traction. C. Reposition the client to the supine position - This action does not directly address the issue of the loosened pin. Additionally, some fractures might require specific patient positioning, and altering the patient's position without consultation could cause complications. D. Try to remove the pin for examination - This option is not within the scope of the nurse's responsibilities. Only a qualified medical professional, such as a physician, should perform actions that could potentially harm the patient.

Determine the appropriate action

Based on the evaluation of each possible action, the most appropriate action for the nurse to take in this situation is to notify the physician (option A). This option allows the nurse to report the potential issue while following standard medical procedures and ensuring the safety and well-being of the patient.