A nurse is providing education to a group of caregivers about preventing pressure ulcers in bedridden patients.

Which interventions should the caregivers implement? (Select three).

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:

The wound's warmth to the touch is not a primary factor to consider when selecting a dressing for a pressure ulcer.

The choice of dressing should primarily be based on the wound's characteristics, such as its depth, exudate level, and tissue involvement.

Choice B rationale:

The presence of a foul odor from the wound is an important factor to consider when selecting a dressing.

Malodorous wounds may indicate infection or necrotic tissue, and appropriate wound dressings can help manage odor and promote healing.

Choice C rationale:

The extent of tissue damage, including muscle and bone involvement, is a critical factor in choosing an appropriate dressing for a pressure ulcer.

Dressings should be selected based on the depth of the wound and the extent of tissue damage to support healing and prevent complications.

Choice D rationale:

The patient's mobility and pressure on vulnerable areas are essential considerations when selecting a dressing.

Dressings should help offload pressure from vulnerable areas and promote mobility while providing optimal wound care.

The choice of dressing should support the overall management of the patient's condition.