A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible
What is the nurse's most appropriate action?
A) Document the findings as being consistent with a viable graft.
B) Promptly report these indications of venous congestion.
C) Closely monitor the patient and reassess in 30 minutes.
D) Reposition the patient to promote peripheral circulation.
Ans: B
Feedback:
A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.
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