A nurse is caring for a client who has a pressure ulcer on the sacrum. Which intervention should the nurse perform first?

Correct answer: D) Hydrogel dressing

Rationale: The nurse should use a hydrogel dressing to promote autolytic debridement of the wound. Autolytic debridement is a natural process that uses the body's own enzymes and moisture to liquefy and remove necrotic tissue from a wound. Hydrogel dressings provide hydration and moisture to dry wounds and facilitate autolytic debridement.

Incorrect options:

A) Alginate dressing - This is not an appropriate dressing for autolytic debridement, as alginate dressings are used for wounds with moderate to heavy exudate that need absorption and hemostasis. Alginate dressings form a gel-like substance when in contact with wound fluid and help to maintain a moist environment for wound healing.

B) Foam dressing - This is not an appropriate dressing for autolytic debridement, as foam dressings are used for wounds with moderate to heavy exudate that need insulation and protection. Foam dressings have a soft and absorbent layer that cushions the wound and prevents maceration of the surrounding skin.

C) Gauze dressing - This is not an appropriate dressing for autolytic debridement, as gauze dressings are used for wounds with minimal to moderate exudate that need cleansing and packing. Gauze dressings can adhere to the wound surface and cause trauma and bleeding when removed.

Correct answer: D) Reposition the client to relieve pressure on the wound.

Rationale: The nurse should follow the ABCDE priority-setting framework when caring for a client with a pressure ulcer. The first priority is to address airway, breathing, and circulation (ABC) issues, which include relieving pressure on the wound to prevent further tissue damage and promote blood flow to the area. The other interventions are also important, but they are not the first priority.

Incorrect options:

A) Apply a hydrocolloid dressing to the wound. - This is an appropriate intervention, as hydrocolloid dressings provide a moist environment that promotes wound healing and prevents bacterial contamination. However, this is not the first priority, as it does not address ABC issues.

B) Assess the wound for signs of infection. - This is an appropriate intervention, as assessing the wound for signs of infection, such as redness, swelling, warmth, drainage, odor, or increased pain, is essential to monitor the wound healing process and identify any complications. However, this is not the first priority, as it does not address ABC issues.

C) Cleanse the wound with normal saline solution. - This is an appropriate intervention, as cleansing the wound with normal saline solution helps to remove debris and bacteria from the wound and prevent infection. However, this is not the first priority, as it does not address ABC issues.