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Chapter 23: Problem 17

The nurse is observing a student nurse performing pin care on a client with skeletal traction. Which action by the student nurse requires intervention? A. Using a sterile cotton applicator to cleanse the pin site B. Administering ordered analgesic prior to the procedure C. Instructing the client that weights will be removed prior to pin care being performed D. Pouring hydrogen peroxide into a sterile container for cleansing per hospital protocol

Short Answer

Expert verified
Answer: Instructing the client that weights will be removed before pin care is performed.

Step by step solution

01

Analyze option A

Option A states that the student nurse is using a sterile cotton applicator to cleanse the pin site. The use of a sterile cotton applicator is appropriate in this situation, as it helps maintain the cleanliness and sterility of the pin site. Therefore, this action does not require intervention.
02

Analyze option B

Option B says that the student nurse administers the ordered analgesic before the procedure. Administering pain relief before the procedure is appropriate, as it helps to manage the client's pain during pin care. So, this action does not require intervention.
03

Analyze option C

Option C states that the student nurse is instructing the client that weights will be removed before pin care is performed. This action is incorrect. Removing weights from skeletal traction can cause disruption in the alignment and length of the affected limb, leading to potential complications. Also, it is unnecessary to remove weights for pin care. Therefore, this action requires intervention.
04

Analyze option D

Option D mentions that the student nurse pours hydrogen peroxide into a sterile container for cleansing as per the hospital protocol. Following the hospital protocol is crucial in ensuring proper care and maintaining sterility in a clinical setting. This action does not require intervention.
05

Identify the correct option

From the analysis of the four options, option C is the action by the student nurse that requires intervention. Hence the correct answer to the problem is option C.

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