Question

The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"?

1. Monitor temperature every 4 hours.

2. Leave the dressing intact for 3 to 5 days.

3. Apply an ice pack to the site to decrease edema formation.

4. Maintain the right lower extremity in a dependent position.

Answer 1

Dear students the answer of this question is below:

The correct answer is 2.

Grafting is done for the burn patients. The most priority intervention of a nurse for the patient is leave the dressing intact for 3 to 5 days so that the pressur dressing will help the graft to vascularise or take of the newly grafted tissue. The dressing should not be disturbed because the grafted area is required to allow blood vessels to connect graft with the wound bed. Any movement of the dressing can cause loosening of the graft.

Now option 1 is for hyperpyrexia, heat stroke

Option 3 is for sekaltal injuries ( The skeletal injuries causes edema which is relieved by cold compressions)

Option 4 is for relieving muscle pain ,and increase circulation.