An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

B Determine the size and depth of skin breakdown over the sacral area. A Apply a barrier ointment to intact areas that may be exposed to moisture. D Establish a toileting schedule to decrease episodes of incontinence. C Complete a functional assessment of the client's self-care abilities.