The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Rationale: A. Place a foam surface on top of the mattress: A foam surface may help reduce pressure, but for a stage IV pressure injury with eschar, this alone is insufficient. More advanced pressure redistribution systems are needed for adequate management of severe wounds. B. Raise the head of the bed only to 30 degrees: Limiting the head-of-bed elevation helps reduce shear forces, which worsen pressure injuries, especially over the sacrum. This intervention is critical for preventing further tissue damage and promoting healing of deep wounds with eschar. C. Perform passive range of motion exercises: While passive ROM supports circulation and prevents contractures, it does not directly address pressure relief or eschar management. It's beneficial, but not the top priority for treating a stage IV ulcer. D. Increase the daily intake of vitamin C: Vitamin C supports collagen synthesis and immune function, aiding wound healing. However, nutrition alone cannot address mechanical factors like pressure and shear, which are primary contributors to pressure injury progression.