A nurse is caring for a patient with an unstageable pressure ulcer. What is an appropriate nursing intervention based on the information in the text?

Choice A rationale:

Using specialized mattresses to offload pressure (Choice A) is an appropriate nursing intervention for a patient with an unstageable pressure ulcer.

Unstageable ulcers have necrotic tissue or eschar covering the wound, making it impossible to assess the depth and stage of the ulcer.

Specialized mattresses can help relieve pressure on the ulcer and promote healing.

Choice B rationale:

Assessing the patient's pain level and providing appropriate pain management (Choice B) is important for the comfort of the patient but should not be the primary intervention for an unstageable pressure ulcer.

Wound management and offloading pressure (Choice A) take precedence.

Choice C rationale:

Educating the patient on the importance of mobility exercises (Choice C) is a valuable aspect of pressure ulcer prevention but may not be immediately applicable to an unstageable ulcer.

The focus should be on wound management and pressure reduction (Choice A).

Choice D rationale:

Collaborating with the healthcare team to address underlying medical conditions (Choice D) is essential for comprehensive patient care but may not be the most immediate action needed for an unstageable pressure ulcer.

Wound management and offloading pressure (Choice A) should be the initial priority.

Choice A rationale:

Measuring the wound size and depth is an essential action during the assessment of a pressure ulcer.

It helps in determining the severity of the ulcer, tracking its progress, and planning appropriate wound care interventions.

Choice B rationale:

Administering pain management as needed is not specifically related to the assessment phase but is an important aspect of pressure ulcer management overall.

Pain management is crucial to ensure the patient's comfort and adherence to the treatment plan, but it is not a direct assessment action.

Choice C rationale:

Checking vital signs for signs of infection is an appropriate action during the assessment of a patient with a pressure ulcer.

Fever and other vital sign abnormalities may indicate the presence of an infection in the wound, which requires immediate attention.

Choice D rationale:

Assessing the patient's nutritional status is a critical part of the assessment process for a patient with a pressure ulcer.

Malnutrition can delay wound healing, so assessing nutritional needs and addressing deficiencies is essential.

Choice E rationale:

Ensuring proper mobility to prevent pressure on vulnerable areas is an appropriate action during the assessment.

Assessing the patient's mobility status helps in identifying areas at risk for pressure ulcers and developing preventive strategies.

However, this action may also extend beyond the assessment phase and involve ongoing care.