A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis?
A) Risk for Disuse Syndrome
B) Unilateral Neglect
C) Risk for Trauma
D) Ineffective Tissue Perfusion
Ans: D
Feedback:
Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.
You might also like to view...
The nurse injecting low-molecular-weight heparin for anticoagulant therapy should:
1. give the injection as a deep IM injection. 2. aspirate to avoid injecting in a vessel. 3. leave a bubble in the syringe when giving the injection. 4. alternate dose times.
Find the flow rate for manual regulation: ________________. Ordered: Cytoxan 2 g in 100 mL D5W
over 75 min using tubing calibrated to 20 gtt/mL. Fill in the blank(s) with correct word
A client from a non-English-speaking culture refuses to accept one prescribed treatment for an acute illness. Which of the following should the nurse do to support this client's refusal of care?
1. Suggest the client be discharged since care is being refused. 2. Talk with the client about the treatment and why it is not being accepted. 3. Ask the physician to prescribe an equally effective treatment so that the client may agree. 4. Transfer the client to another care area.
Employees who are dependent on drugs or alcohol will exhibit signs that should not be ignored by the nurse manager and colleagues. Which of the following signs would alert the nurse manag-er that the employee may have a dependency problem?
a. Changes in behavior or appearance b. Requesting time off to be with a family member c. Scheduled overtime d. Dieting