A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
A) Perform mechanical débridement to remove the exudate and prevent further infection.
B) Inform the primary care provider promptly because the graft may need to be removed.
C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing.
D) Document this finding as an expected phase of graft healing.
Ans: B
Feedback:
An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform débridement.
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