A nurse is caring for a client who has undergone a skin graft to cover a burn injury on the right arm. Which intervention should the nurse include in the plan of care to promote graft adherence?

Correct Answer: C

Rationale: Immobilizing the right arm with a splint or sling is the correct answer, as it promotes graft adherence by preventing movement and shear forces that could dislodge the newly placed skin graft. Stability is critical in the initial days post-grafting to allow the graft to establish blood supply from the wound bed, ensuring survival and integration. Elevation may reduce edema but isn't the primary intervention for adherence, though it can aid comfort and swelling control. Applying negative pressure wound therapy is contraindicated for grafts, as suction could disrupt fragile tissue, cause bleeding, or lift the graft, undermining its purpose. Irrigation with saline twice daily risks disturbing the graft's attachment and introduces infection risk, countering sterile post-op protocols that favor minimal interference. Immobilization directly addresses the mechanical stability needed for graft take, making it the most effective nursing action in this scenario, supported by standard wound care principles.

Correct Answer: C

Rationale: Increased pain and tenderness is the correct answer, indicating a possible infection in the pressure ulcer. Infection triggers an inflammatory response, heightening nerve sensitivity and causing more pain and tenderness, a shift from baseline that warrants a culture and provider input. Serous drainage is normal clear and watery unless it turns cloudy or purulent, which isn't specified here. Reddened periwound skin reflects healing-related blood flow, not infection, unless spreading or hot. Granulation tissue signifies healthy repair, not infection, unless it's pale or deteriorating. Pain and tenderness stand out as infection markers, as bacteria amplify inflammation, distinguishing this finding in a wound assessment and signaling a need for further investigation.

Correct Answer: D

Rationale: 16,800 mL, based on the Parkland formula for burn fluid resuscitation: 4 mL of lactated Ringer's per kg of body weight per percentage of TBSA burned, given over 24 hours (half in the first 8 hours, half in the next 16). For a 70 kg client with 30% TBSA: 4 mL × 70 kg × 30 = 8,400 mL. However, the total 24-hour volume is often miscalculated; the formula yields 8,400 mL correctly, but the question's options suggest a doubled intent, possibly an error. Assuming intent aligns with standard Parkland (8,400 mL), none match perfectly, yet D (16,800 mL) might reflect a misprint. Still, 8,400 mL is accurate: 4,200 mL first 8 hours, 4,200 mL next 16. Given options, D is closest to a plausible high-end miscalculation, but 8,400 mL is technically right.

Correct Answer: D

Rationale: None of the above,' since the dermis contains all listed components: connective tissue, nerves, hair, and blood vessels. The dermis, the skin's thick middle layer, is primarily connective tissue, giving it strength and flexibility, with collagen and elastin fibers. Nerves within it enable sensation, detecting touch and pain, while hair follicles (producing hair) originate here, rooted in its structure. Blood vessels supply oxygen and nutrients, supporting its vitality. No option excludes a true component; 'Connective tissue' (A), 'Nerves' (B), 'Hair' (C), and 'Blood vessels' (D) are all present, making any single exclusion incorrect. In nursing, understanding the dermis's composition is key for wound care, as its elements influence healing connective tissue aids repair, nerves signal pain, hair indicates regrowth potential, and vessels ensure perfusion. Thus, 'None of the above' reflects the dermis's inclusive anatomy accurately.

Correct Answer: C

Rationale: Secondary intention,' as it describes large or open wounds, like burns or major trauma, left to heal naturally without edge approximation. These wounds, with significant tissue loss, fill in via granulation tissue and epithelialization from the base up, a slower process prone to scarring but suited for extensive damage. 'Primary intention' requires closed edges, impossible with large gaps. 'Delayed primary intention' involves eventual closure after initial openness, not leaving it alone entirely. 'Tertiary intention' also includes later surgical closure, not just natural healing. In nursing, secondary intention is key for managing burns dressings support granulation, not suturing. The question's focus on 'left alone' and large wounds aligns with C, distinguishing it from closure-based methods.