A client with a full-thickness burn to the front of the left leg underwent skin grafting.
The nurse notes pain 6/10, dressing dry and intact, and slight edema at the graft site. Which action is the priority?
Elevate the affected extremity.
Inspect the graft site.
Ensure the patient does not lie on the newly grafted skin area.
Administer prescribed analgesic.
The Correct Answer is A
Post-operative skin graft care focuses on maximizing graft take by reducing edema and preventing shearing. Knowledge of tissue perfusion and fluid dynamics is necessary to prioritize actions that minimize swelling, which can lift the graft from the bed.
Choice A rationale
Elevating the affected extremity reduces edema at the graft site by promoting venous return. Excessive swelling can separate the new graft from the underlying vascular bed, preventing necessary revascularization and leading to graft failure or necrosis.
Choice B rationale
Inspecting the graft site is important, but the nurse should generally not disturb the initial surgical dressing. Frequent inspection increases the risk of shearing or dislodging the delicate graft before it has successfully adhered to the site.
Choice C rationale
Ensuring the patient does not lie on the graft is a standard intervention to prevent pressure and shearing. However, in the presence of noted edema, elevation is the priority action to ensure the graft remains viable.
Choice D rationale
Administering analgesics addresses the pain level of 6/10, which is important for comfort. However, pain is expected, whereas reducing edema through elevation is functionally more critical to the physiological success and survival of the graft.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Intermaxillary fixation involves wiring the jaws together, creating a significant airway risk if emesis occurs. Nursing knowledge must prioritize airway patency and the prevention of aspiration by using gravity and mechanical clearing before employing irreversible measures like wire cutting.
Choice A rationale
Cutting fixation wires is a rescue action if the airway cannot be cleared by other means. It should not be the first step because it compromises the surgical repair of the mandible and requires specific tools.
Choice B rationale
Side-lying positioning uses gravity to prevent emesis from entering the trachea, while suctioning clears the oropharynx. This immediate intervention maintains airway patency and prevents aspiration pneumonia in a client whose jaws are immobilized by wires.
Choice C rationale
Notifying the provider is necessary after the client is stabilized. During an acute gagging episode, the nurse must act independently to secure the airway before spending time communicating, as delay increases the risk of fatal aspiration.
Choice D rationale
Antiemetics are used for prevention but cannot treat an active gagging and vomiting episode. Administering medication takes too long to take effect and does not address the immediate physical obstruction of the airway by emesis.
Correct Answer is D
Explanation
Post stroke education focuses on secondary prevention through risk factor modification. Applying knowledge of pharmacology and lifestyle changes is necessary to ensure the patient understands how to manage hypertension, smoking cessation, and safe medication use to avoid recurrence.
Choice A rationale
Daily exercise is a recommended lifestyle modification that helps manage weight and lower blood pressure. It improves cardiovascular health and reduces the risk of recurrent ischemic events by enhancing vascular tone and reducing systemic inflammation.
Choice B rationale
Smoking cessation is critical because nicotine causes vasoconstriction and accelerates atherosclerosis. Stopping tobacco use significantly lowers the risk of thrombus formation and further ischemic damage to the cerebral vasculature in post stroke patients.
Choice C rationale
Reducing high fat intake and increasing fruits and vegetables helps manage cholesterol levels. Lowering low density lipoprotein levels prevents the progression of carotid artery plaque, which is a major contributor to the occurrence of ischemic strokes.
Choice D rationale
While aspirin is often prescribed for its antiplatelet properties, clients should not self medicate with over the counter versions without clinical supervision. Aspirin increases bleeding risks, and its use must be coordinated with other prescribed anticoagulants..
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