A nurse is caring for a client who had a musculocutaneous flap reconstruction. The nurse assesses the flap to be cool with dark dermal blood on lancing. The most appropriate action by the nurse is to
a. document the findings and continue care.
b. elevate the affected body part if possible.
c. notify the surgeon immediately.
d. rewrap the pressure dressing.
C
The major concern with flap reconstruction is establishing and/or maintaining the blood flow to the flap. A cool, pale flap with decreased capillary refill, or dark dermal blood on lancing, indicate perfusion problems and the surgeon should be notified at once. The body part should already be elevated if possible unless that interferes with arterial flow.
You might also like to view...
A physician is preparing to suture a patient who has a superficial stab wound in the leg. The physician asks the nurse for lidocaine with epinephrine
The nurse understands that concurrent administration of lidocaine with epinephrine results in the epinephrine having which effect on the lidocaine? a. Epinephrine prolongs anesthesia and reduces the risk of toxicity. b. Epinephrine delays absorption of the lidocaine, which results in a longer anesthetic effect. c. Epinephrine increases perfusion by increasing blood flow to the area. d. Epinephrine causes an antiadrenergic effect.
When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which of the following?
A) Superficial structures above the muscle B) Through the perineal muscles C) Through the anal sphincter muscle D) Through the anterior rectal wall
A female relative of a licensed nurse wants to pursue a degree in practical nursing. What
type of school is most likely to provide this type of training? A) American Red Cross B) Young Women's Christian Association (YWCA) C) Vocational or community college D) Local public library
A 4-year-old diagnosed with diabetes insipidus is being discharged. Which information below is most important to emphasize to the parents?
What will be an ideal response?