A nurse is caring for a client who has undergone a skin graft to cover a burn injury on the right arm. Which intervention should the nurse include in the plan of care to promote graft adherence?
Elevate the right arm above the level of the heart
Apply negative pressure wound therapy to the graft site
Immobilize the right arm with a splint or sling
Irrigate the graft site with normal saline twice daily
The Correct Answer is C
Correct answer: C) Immobilize the right arm with a splint or sling
Rationale: Immobilizing the right arm with a splint or sling helps to prevent movement and shear forces that can dislodge or damage the graft. The nurse should also avoid applying pressure or friction to the graft site.
Incorrect options:
A) Elevate the right arm above the level of the heart - This is not necessary for graft adherence, but it may help to reduce edema and pain in the affected arm.
B) Apply negative pressure wound therapy to the graft site - This is contraindicated for skin grafts, as it can cause bleeding, infection, or graft loss. Negative pressure wound therapy is used for wounds that are difficult to heal by primary intention, such as chronic ulcers or open abdominal wounds.
D) Irrigate the graft site with normal saline twice daily - This is not recommended for skin grafts, as it can interfere with graft adherence and increase the risk of infection. The nurse should follow the provider's orders for dressing changes and use sterile technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct answer: D) Hydrogel dressing
Rationale: Hydrogel dressings are water-based or glycerin-based gels that hydrate the wound and provide a moist environment for healing. They are suitable for dry wounds, such as arterial ulcers, as they help to rehydrate the wound bed and facilitate autolytic debridement.
Incorrect options:
A) Transparent film dressing - This is not an appropriate dressing for arterial ulcers, as it does not provide moisture or cushioning to the wound. Transparent film dressings are used for superficial wounds, such as abrasions or stage I pressure ulcers, or as a secondary dressing to cover other dressings.
B) Calcium alginate dressing - This is not an appropriate dressing for arterial ulcers, as it is designed for wounds with moderate to heavy exudate, such as venous ulcers or infected wounds. Calcium alginate dressings are highly absorbent and form a gel-like substance when in contact with wound fluid.
C) Silver-impregnated dressing - This is not an appropriate dressing for arterial ulcers, unless there is evidence of infection. Silver-impregnated dressings have antimicrobial properties and are used for wounds that are infected or at high risk of infection, such as diabetic foot ulcers or surgical wounds.
Correct Answer is C
Explanation
Correct answer: C) Foul-smelling greenish discharge from the wound
Rationale: Foul-smelling greenish discharge from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
Incorrect options:
A) Serous drainage from the wound - This is a normal finding, as serous drainage is clear and watery and indicates a healthy inflammatory response.
B) Redness and warmth around the wound - This is a normal finding, as redness and warmth indicate increased blood flow to the wound site, which facilitates healing.
D) Granulation tissue forming in the wound bed - This is a positive finding, as granulation tissue is new connective tissue that fills the wound and supports epithelialization.
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