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.

Question

Quizplus · Accepted Answer

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.

A Nurse Is Caring for a Client Who Had a Musculocutaneous