A nurse is selecting a dressing for a patient's pressure ulcer based on wound characteristics. What factors should the nurse consider when making this decision?

Choice A rationale:

Consulting with the healthcare team to address underlying medical conditions (Choice A) is the most appropriate nursing action for a client with a pressure ulcer and signs of infection.

Pressure ulcers can develop or worsen due to underlying medical conditions such as diabetes, vascular disease, or immunosuppression.

Addressing these underlying conditions is essential for effective wound management and preventing further complications.

Choice B rationale:

Encouraging frequent position changes and mobility exercises (Choice B) is a valuable intervention to prevent pressure ulcers, but in a client with an existing pressure ulcer and signs of infection, addressing the infection and underlying medical conditions take precedence.

Choice C rationale:

Using specialized mattresses to offload pressure (Choice C) is an important part of pressure ulcer prevention and management, but it may not be the most immediate action needed for a client with signs of infection.

Addressing infection and underlying medical conditions (Choice A) should be the priority.

Choice D rationale:

Providing education on proper wound care and prevention strategies (Choice D) is an essential nursing action but may not be the most immediate priority for a client with an active infection.

Managing the infection and addressing underlying medical conditions (Choice A) should come first.

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.