Managing pain at the recipient site.
Managing pain is an issue, but not the highest initial priority. The donor site is usually more painful than recipient site because of exposed nerve endings. An autograft means a layer of the client's own unburned skin is removed and grafted to the burn wound.
Immobilizing the graft. (Correct Answer)
Graft adherence to the site is essential for vascularization and "taking" or survival of the graft. Immobilization of the graft and the limb is a priority. A thin fibrin network develops quickly after graft placement, but it takes 7 to 10 days for the graft to really adhere and longer than that to mature.
Minimizing light exposure.
There is no need for minimizing light exposure at this time. A client needs to be taught that, once donor and recipient sites have healed, direct sunlight must be completely avoided for 1 year because of the skin's increased sensitivity to ultraviolet rays.
Observing for signs of graft failure.
Graft failure is not an immediate concern. Once the pressure dressings are removed in 3 to 5 days, continual assessing of the graft for healing should be done related to vascularization, such as continued adherence to the site, absence of necrotic graft tissue, dusky color, or a sharp line of color demarcation.
Decision Tree:
This walk-through provides test-taking strategies to determine the correct answer for the different types of questions you will encounter on the NCLEX-RN exam. These strategies are based on the Kaplan Decision Tree (DT) algorithm, a technique that provides a process to determine the correct answer for NCLEX-style questions.
This is a Priority Question.
Priority questions use words such as most, best, first, immediate, etc.
STEP 1: Can you identify the topic of the question?
- Priority intervention, post split-thickness autograft placement.
STEP 2: Are the answer choices assessment or implementation?
Assessment vs. Implementation
- Managing pain at the recipient site. Implementation
- Immobilizing the graft. Implementation
- Minimizing light exposure. Implementation
- Observing for signs of rejection. Assessment
Is assessment or assessment validation needed? No, observing for signs of rejection upon returning to the unit is not necessary. This will become a priority concern after the dressing is removed in 3 to 5 days. Eliminate #4. Move to Step 3.
STEP 3: Apply Maslow: Are the answer choices physical or psychosocial?
Maslow
- Managing pain at the recipient site. Psychosocial
- Immobilizing the graft. Physical
- Minimizing light exposure. Physical
Physical answer options take priority over psychosocial answer options if they make sense with the topic. Eliminate #1. Move to Step 4.
STEP 4:Are the answer choices related to ABCs?
ABCs
- 2. Immobilizing the graft. N/A
- 3. Minimizing light exposure. N/A
Because a mix of ABC answer choices does not exist, answer choices cannot be eliminated at this step. Move to Step 5.
STEP 5: What is the outcome of each of the remaining answer choices?
Evaluate the outcome(s)
2. Immobilizing the graft. This is a priority post split-thickness autograft placement to a burn wound. Graft adherence to the site is a priority so that vascularization and ?taking? or survival of the graft can occur.
3. Minimizing light exposure. This is not a priority post split-thickness autograft placement to a burn wound. There is no need to minimize light exposure at this point in the client?s recovery. The wound will have a surgical dressing for the first 3 to 5 days. Eliminate.
Select the best choice
Is #2 the correct answer? Yes, immobilizing the graft is a priority.
Does #2 make sense? Yes, this answer will allow for vascularization and for the graft to take.
