A practical nurse (PN) is assigned to care for a client who is wearing a halo vest orthosis for a cervical spine injury. The charge nurse directs the PN to laterally reposition the client, adjust the tension on the cranial pins, and inspect the skin beneath the vest. Which of the following is the most appropriate action by the PN regarding safe equipment handling and body mechanics?
- Collaborate with another staff member to logroll the client using a friction-reducing sheet, and inform the charge nurse that adjusting the cranial pins is outside the practical nursing scope of practice.Answer
- BGrasp the anterior metal struts of the halo vest to provide leverage and stabilize the client's upper body while a colleague turns the lower extremities.
- CAccept the complete delegation to ensure continuity of care, and carefully tighten the cranial pins to secure the equipment before repositioning.
- DApply soft wrist restraints to the client before the repositioning procedure to prevent the client from reaching up and dislodging the cranial pins during the turn.
Answer
The correct answer is to collaborate with another staff member to logroll the client using a friction-reducing sheet, and to inform the charge nurse that adjusting the cranial pins is outside the practical nursing scope of practice.
The most appropriate action involves using proper ergonomic techniques by enlisting a colleague and utilizing a friction-reducing sheet to logroll the client as a single unit, which maintains neutral cervical alignment. Furthermore, recognizing that adjusting the cranial pins of a halo vest is outside the scope of practice for a practical nurse is critical for patient safety. The nurse must refuse this specific delegated task and report it to the charge nurse.
Step-by-Step Solution
Key Concept
Safe equipment handling for a halo vest orthosis, proper ergonomic turning techniques, and adhering to the practical nursing scope of practice.