A client had a skin graft with a pedicle flap. Which is the priority nursing intervention for this client in the early postoperative phase?
a. Monitor the donor site to detect hemorr-hage.
b. Check the flap edges for adequate perfu-sion.
c. Turn the client often to prevent pressure ulcers.
d. Perform interventions to prevent contrac-tures.
B
The most serious common complication in the early postoperative period after skin grafting is failure to engraft. If the pedicle flap demonstrates delayed capillary refill when blanching, perfu-sion is being compromised. Hemorrhage is not a common complication post skin grafting. Pres-sure ulcer formation and contracture development would not occur quickly after grafting.
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