A patient has recently been diagnosed with systemic lupus erythematosus and is discussing self-care strategies with the nurse. Which statement from the patient suggests a need for further review of the material?

Choice A rationale:
Skin and mucous membranes are the most effective and crucial barriers to infection. They provide a continuous physical barrier that prevents pathogens from entering the body. Here's a detailed explanation of their protective mechanisms:
1. Physical Barrier:
Skin: The outermost layer of skin, the epidermis, is composed of tightly packed cells that are difficult for pathogens to penetrate. It's also covered in a layer of sebum, an oily substance that helps to repel water and microorganisms.
Mucous membranes: These moist linings cover the openings of the body, such as the nose, mouth, eyes, and digestive, respiratory, and urogenital tracts. They produce mucus, a sticky substance that traps pathogens and prevents them from entering the body. Mucus also contains enzymes and antibodies that can kill certain pathogens.
2. Chemical Barrier:
Skin and mucous membranes secrete a variety of substances that have antimicrobial properties. These include: Sebum: Contains fatty acids that can kill bacteria and fungi.
Sweat: Contains salt and lysozyme, an enzyme that can break down bacterial cell walls. Saliva: Contains enzymes that can break down food and kill bacteria.
Gastric acid: The highly acidic environment of the stomach kills most pathogens that are ingested.
3. Immune Barrier:
Skin and mucous membranes are home to a diverse community of microbes, known as the microbiome. These microbes play an important role in protecting against infection by competing with pathogens for resources and space.
Mucous membranes contain specialized immune cells, such as M cells and dendritic cells, that can recognize pathogens and initiate an immune response.
In contrast, the other choices are less effective barriers to infection:
Choice B: Gastrointestinal secretions, such as gastric acid, do play a role in preventing infection, but they are not as effective as skin and mucous membranes. Pathogens can still enter the body through the digestive tract, even in the presence of gastric acid.
Choice C: Colonization by host bacteria can actually help to protect against infection by competing with pathogens. However, it is not a primary barrier to infection.
Choice D: Inflammatory processes are a response to infection, not a barrier to it. They occur after pathogens have already entered the body.

Rationale for Choice A: Ensuring the client is warm
While maintaining client warmth is important for comfort and to prevent hypothermia, it is not the immediate priority upon arrival in the postoperative unit. Thermoregulation can be addressed after more urgent assessments have been completed.
Rationale for Choice B: Participating in hand-off report
A thorough hand-off report is essential for continuity of care, but it does not take precedence over assessing the client's immediate physiological status. The nurse can gather information from the report while simultaneously performing essential assessments.
Rationale for Choice C: Checking the surgical dressings
Monitoring surgical dressings is a crucial aspect of postoperative care, but it does not take priority over assessing fluid and blood output. Excessive bleeding or fluid shifts can rapidly compromise the client's hemodynamic stability and require prompt intervention.
Rationale for Choice D: Assessing fluid and blood output
This is the priority action for several reasons:
Monitoring for Hemorrhage: Early detection of excessive bleeding is crucial to prevent hypovolemic shock, a life-threatening complication. Postoperative bleeding can occur internally or externally, and prompt assessment of fluid and blood output allows for timely interventions to control bleeding and maintain hemodynamic stability.

Assessing Fluid Balance: Maintaining fluid balance is essential for optimal organ function and electrolyte balance. Postoperative clients are at risk for fluid imbalances due to blood loss, fluid shifts, and the use of diuretics or IV fluids. Assessing fluid intake and output helps to identify and address fluid imbalances early.
Evaluating Renal Function: Urine output is a key indicator of renal function. Postoperative clients are at risk for acute kidney injury due to factors such as hypotension, blood loss, and nephrotoxic medications. Assessing urine output helps to detect early signs of kidney dysfunction and initiate appropriate interventions.
Guiding Fluid and Blood Product Replacement: The assessment of fluid and blood output provides essential information to guide the administration of fluids and blood products as needed. This ensures that the client's fluid status and oxygen-carrying capacity are maintained within safe parameters.
Therefore, assessing fluid and blood output takes priority as it allows the nurse to identify and address potential life- threatening complications promptly, as well as guide interventions to maintain fluid balance and organ function.