A client undergoing chemotherapy develops severe abdominal pain, nausea, and a rapid increase in serum uric acid levels.
What is the most likely diagnosis?

Post-operative skin graft care focuses on maximizing graft take by reducing edema and preventing shearing. Knowledge of tissue perfusion and fluid dynamics is necessary to prioritize actions that minimize swelling, which can lift the graft from the bed.

Choice A rationale

Elevating the affected extremity reduces edema at the graft site by promoting venous return. Excessive swelling can separate the new graft from the underlying vascular bed, preventing necessary revascularization and leading to graft failure or necrosis.

Choice B rationale

Inspecting the graft site is important, but the nurse should generally not disturb the initial surgical dressing. Frequent inspection increases the risk of shearing or dislodging the delicate graft before it has successfully adhered to the site.

Choice C rationale

Ensuring the patient does not lie on the graft is a standard intervention to prevent pressure and shearing. However, in the presence of noted edema, elevation is the priority action to ensure the graft remains viable.

Choice D rationale

Administering analgesics addresses the pain level of 6/10, which is important for comfort. However, pain is expected, whereas reducing edema through elevation is functionally more critical to the physiological success and survival of the graft.

The nurse must utilize knowledge of thoracic drainage mechanics and equipment troubleshooting. A three-chamber system requires consistent suction to maintain negative pleural pressure. Identifying the cause of suction failure involves systematic assessment of the external vacuum source and tube integrity.

Choice A rationale

Suction control chambers in wet systems require active external suction to function. Bubbling indicates vacuum application. Verifying the regulator is on ensures the system has the mechanical force necessary to maintain the ordered negative pressure for lung re-expansion.

Choice B rationale

Milking or stripping chest tubes creates high levels of negative pressure that can damage delicate lung tissue. This practice is generally contraindicated unless specifically ordered by a surgeon, as it increases the risk of pleural trauma and tension pneumothorax.

Choice C rationale

Absence of bubbling in the suction control chamber of a wet system is an abnormal finding. It signifies a lack of active suctioning. The nurse cannot ignore this, as effective pleural drainage depends on continuous atmospheric pressure regulation.

Choice D rationale

While water levels dictate suction intensity, adding water will not resolve a lack of bubbling if the suction source is off. Bubbling is caused by air passing through water via the suction regulator, not the volume itself.