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

Rationale: Repositioning the client to relieve pressure on the wound is the correct first intervention. Using the ABCDE framework (Airway, Breathing, Circulation, Disability, Exposure), relieving pressure addresses circulation by preventing further tissue ischemia, the root cause of pressure ulcers. Immediate repositioning halts ongoing damage, enhances blood flow, and sets the stage for subsequent care, making it the priority action. Applying a hydrocolloid dressing promotes healing but doesn't address the immediate threat of pressure, which must stop first. Assessing for infection is crucial but secondary, as it evaluates status rather than intervening to prevent worsening. Cleansing with saline removes debris but doesn't tackle the underlying pressure causing the ulcer. Repositioning is foundational, as unrelieved pressure will negate other interventions' effectiveness, aligning with evidence-based protocols to prioritize tissue perfusion and stop progression in pressure ulcer management.

Correct Answer: B

Rationale: Instructing the client to splint the incision when coughing is the correct intervention to prevent wound dehiscence the separation of wound layers. Coughing increases intra-abdominal pressure, stressing staples, and splinting with a pillow or hands reduces tension, protecting the closure. Steri-strips approximate edges but lack the strength to prevent dehiscence under pressure, used more for minor wounds. Changing dressings every 8 hours prevents infection but doesn't address mechanical stress, and frequency depends on drainage, not a fixed schedule. Irrigating with saline cleanses but risks disrupting healing tissue, unrelated to dehiscence prevention. Splinting directly counters physical strain, aligning with post-surgical care to maintain incision integrity and promote healing.

Correct Answer: A

Rationale: Autograft is the correct term for a graft taken from the client's thigh to treat an arm wound. It uses the patient's own skin, minimizing rejection and infection risks while offering superior cosmetic and functional outcomes, ideal for large wounds. Allograft involves donor human skin, typically temporary, from cadavers or living donors, not the client's own tissue. Xenograft uses animal skin (e.g., pig), also temporary, for protection until an autograft is viable. Mesh graft describes a technique, not a source, where skin is slit to expand coverage, applicable to autografts or allografts. Autograft's self-sourcing distinguishes it, ensuring compatibility and long-term healing, making it the precise term for this scenario.

Correct Answer: D

Rationale: All of the above,' as age, amount of underlying tissue, and illness all influence skin integrity resistance. Age (A) affects skin thickness and elasticity elderly skin thins, losing resilience, while youthful skin is more robust. Amount of underlying tissue (B), like subcutaneous fat, cushions and protects skin; less tissue increases vulnerability to breakdown, as in malnourishment. Illness (C) weakens skin through impaired immunity or circulation, as in diabetes or infection, reducing repair capacity. Each factor independently impacts durability, and together, they compound risk, making 'All of the above' correct. In nursing, this holistic view guides risk assessment e.g., an elderly, thin patient with chronic illness is prone to ulcers. No single factor suffices; their synergy is critical, distinguishing D as the comprehensive choice per wound care principles.

Correct Answer: C

Rationale: Neutrophil,' as neutrophils are the primary white blood cells in the inflammatory phase of wound healing. They arrive first (within hours), phagocytosing bacteria and debris to prevent infection, peaking early in this phase. 'Leukocyte' is a broad term including all white cells (neutrophils, macrophages), but the question seeks specificity neutrophils dominate initially. 'Macrophage' arrives later, clearing debris and aiding repair, but isn't first. 'A and B' is too vague, missing neutrophils' primacy. In nursing, recognizing neutrophils' role guides infection monitoring elevated counts signal inflammation. The inflammatory phase's early focus on bacterial defense highlights C, distinguishing it from broader or later-acting cells.