When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Choice A rationale Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan. Choice B rationale Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach. Choice D rationale Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications. Choice C rationale Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment. Choice E rationale Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.