A client is scheduled for a skin graft surgery to treat a large wound on the arm. The nurse explains to the client that the graft will be taken from the thigh. What term should the nurse use to describe this type of graft?

Correct answer: B) Instruct the client to splint the incision when coughing

Rationale: Splinting the incision when coughing or sneezing helps to reduce tension and stress on the wound edges and prevent wound dehiscence, which is the partial or total separation of the wound layers. The nurse should also instruct the client to avoid lifting heavy objects or straining during bowel movements.

Incorrect options:

A) Apply steri-strips along the incision line - Steri-strips are thin adhesive strips that are used to approximate wound edges and enhance healing by primary intention. They are not used to prevent wound dehiscence, as they do not provide enough support for the wound closure.

C) Change the dressing every 8 hours using sterile technique - Changing the dressing frequently using sterile technique helps to prevent wound infection but not wound dehiscence. The frequency of dressing changes depends on the type and amount of drainage, the condition of the wound, and the type of dressing used.

D) Irrigate the wound with normal saline twice daily - Irrigating the wound with normal saline helps to cleanse the wound and remove debris but not prevent wound dehiscence. Irrigation should be done gently and carefully to avoid disrupting granulation tissue or causing trauma to the wound.

Correct answer: A) Eschar

Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.

Incorrect options:

B) Slough - This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.

C) Fibrin - This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.

D) Exudate - This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.