The new nurse and experienced nurse are changing a dressing for a client with a burn injury who has had a skin graft.
The new nurse asks the experienced nurse why the grafted skin appears lattice-like. How should the experienced nurse respond?
Fluids that seep through the client's tissues cause the new skin to stretch and separate, as it heals, the skin shrinks together.
The lattice-like appearance is from the indentations of the bulky dressing applied after the grafting procedure.
The skin is an allograft from a cadaver donor, and the freezing of the skin causes this appearance.
The skin is an autograft from an unburned area of the client's body, the skin was meshed so it would stretch to cover more area.
The Correct Answer is D
Understanding skin grafting techniques is essential for postoperative burn care. Knowledge of autograft processing, specifically meshing, is required to explain how small donor skin samples are expanded to cover large wound areas while allowing for fluid drainage during healing.
Choice A rationale
While edema occurs during burn healing, the lattice pattern is a mechanical result of graft preparation rather than tissue stretching from fluid seepage. Tissue expansion occurs naturally but does not create a systematic, geometric mesh-like appearance.
Choice B rationale
Bulky dressings protect the graft site and maintain moist environments but do not cause permanent indentations in the skin. The lattice structure is a deliberate surgical modification of the donor tissue before it is applied.
Choice C rationale
Allografts are temporary covers from donors, but the lattice appearance is not caused by freezing. Meshing can be done on various graft types, but it is a physical process, not a byproduct of cryopreservation techniques.
Choice D rationale
Meshing an autograft involves cutting the skin in a geometric pattern to allow expansion. This allows a donor site to cover a larger recipient area and provides openings for exudate to escape, preventing graft displacement by fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Prioritizing interventions for a client on anticoagulant therapy presenting with neurological changes requires recognizing high-risk complications. Knowledge of anticoagulation side effects and the signs of intracranial hemorrhage is essential to ensure rapid stabilization and prevent irreversible neurological damage or death from bleeding.
Choice A rationale: New blurred vision and delayed responses in a client receiving anticoagulants are hallmark signs of potential intracranial hemorrhage. Notifying the provider immediately is the priority action to facilitate urgent diagnostic imaging and potential reversal of anticoagulation therapy.
Choice B rationale: Administering acetaminophen may mask a worsening headache and ignores the underlying life-threatening cause of the neurological changes. Furthermore, some formulations can interfere with coagulation, and clinical focus must remain on identifying the source of the vision changes.
Choice C rationale: Documentation and monitoring are insufficient when a client displays acute neurological decline while on blood thinners. Delaying intervention allows for continued intracranial bleeding and brain herniation, making passive monitoring a dangerous and inappropriate response in this emergency.
Choice D rationale: Waiting one hour to reassess a client with suspected intracranial bleeding is a critical failure in nursing judgment. Neurological status can deteriorate within minutes during a hemorrhagic event, requiring immediate medical evaluation rather than delayed observation and assessment.
Correct Answer is ["7"]
Explanation
Step 1 is 350 mg ÷ 250 mg × 5 mL.
Step 2 is 1.4 × 5 mL.
Step 3 is 7 mL.
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