A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?

Autograft

Allograft

Xenograft

Mesh graft

Answer and Explanation

The Correct Answer is A

Correct answer: A) Autograft

Rationale: An autograft is a type of skin graft that uses the client's own skin as the donor site. This is the preferred type of graft, as it has the lowest risk of rejection and infection, and provides the best cosmetic and functional results.

Incorrect options:

B) Allograft - This is a type of skin graft that uses human skin from a cadaver or a living donor as the donor site. This type of graft is used as a temporary measure to cover large wounds until an autograft is available.

C) Xenograft - This is a type of skin graft that uses animal skin, usually from pigs, as the donor site. This type of graft is also used as a temporary measure to protect wounds from infection and fluid loss until an autograft is available.

D) Mesh graft - This is a type of skin graft that involves making small slits in the donor skin to create a mesh-like pattern. This allows the graft to cover a larger area and conform to irregular surfaces. This type of graft can be either an autograft or an allograft.

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Correct Answer is A

Explanation

Correct answer: A) Hydrocolloid

Rationale: Hydrocolloid dressings are occlusive and adhesive, forming a gel-like substance over the wound bed that maintains a moist environment and facilitates autolytic debridement. They are suitable for stage 3 pressure ulcers, as they protect the wound from contamination and reduce pain and trauma during dressing changes.

Incorrect options:

B) Transparent film - This type of dressing is semi-permeable and allows oxygen exchange, but does not absorb exudate or provide cushioning. It is suitable for stage 1 pressure ulcers, as it protects the skin from friction and moisture.

C) Calcium alginate - This type of dressing is highly absorbent and forms a gel-like substance when in contact with wound exudate. It is suitable for stage 4 pressure ulcers with heavy drainage, as it fills the dead space and promotes hemostasis.

D) Gauze - This type of dressing is inexpensive and readily available, but it can adhere to the wound bed and cause pain and bleeding during removal. It is suitable for stage 4 pressure ulcers with minimal drainage, as it provides mechanical debridement.

A. Soaking the old dressing with sterile saline before removing it B. Applying antibiotic ointment to the new dressing before placing it on the wound C. Moistening the new dressing with sterile water before wringing it out and applying it to the wound D. Covering the new dressing with an occlusive secondary dressing to prevent evaporation

Correct Answer is C

Explanation

Correct answer: C) Moistening the new dressing with sterile water before wringing it out and applying it to the wound

Rationale: Wet-to-dry dressings are used for mechanical debridement of necrotic tissue from chronic wounds. The new dressing should be moistened with sterile water (not saline, as saline can cause sodium crystals to form on the wound bed and impair healing), wrung out to remove excess moisture (to prevent maceration of surrounding skin), and loosely packed into the wound (to allow contact with necrotic tissue). The old dressing should be removed dry (not soaked, as soaking can rehydrate necrotic tissue and reduce debridement).

Incorrect options:

A) Soaking the old dressing with sterile saline before removing it - This can rehydrate necrotic tissue and reduce debridement.

B) Applying antibiotic ointment to the new dressing before placing it on the wound - This can interfere with debridement and increase the risk of infection and resistance.

D) Covering the new dressing with an occlusive secondary dressing to prevent evaporation - This can create a moist environment that promotes bacterial growth and infection.

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A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a stage 3 pressure ulcer on the sacrum. Which type of dressing should the nurse use to promote moist wound healing?

Correct Answer is A

Explanation

A nurse is preparing to change a wet-to-dry dressing for a client who has a chronic wound on the lower leg. Which action by the nurse demonstrates proper technique?

Correct Answer is C

Explanation

A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?

A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?

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A nurse is assessing a client who has a wound on the abdomen. The nurse observes that the wound edges are approximated, there is minimal drainage, and granulation tissue is visible. How should the nurse document this wound?

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