Which intervention should the nurse plan for a patient who has a sheet skin graft covering a burn on the forearm?
1. Scrub the graft site with mild soap and water twice daily.
2. Perform range-of-motion exercises twice each shift.
3. Use aseptic technique for all contact with the graft.
4. Lift the edges of the graft twice each shift to allow fluid to escape.
3
Rationale 1: The graft should be protected from friction.
Rationale 2: The graft site should be immobilized.
Rationale 3: Aseptic technique should be used when caring for the graft.
Rationale 4: The edges of the graft should not be lifted.
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