The nurse is preparing to teach a client about modifiable defense mechanisms to prevent infection. Which modifiable defense mechanism should the nurse include in the teaching?
"A fever may be an indicator that the inflammation has become systemic."
"A balanced diet helps your immune system function properly."
"Your skin acts as a barrier to microorganisms and helps prevent injury."
"Tears reduce particles entering the eye, reducing the number of organisms."
The Correct Answer is B
A. "A fever may be an indicator that the inflammation has become systemic.": Fever is a body’s non-modifiable response to infection and inflammation. While important for identifying systemic involvement, the client cannot directly modify this defense mechanism.
B. "A balanced diet helps your immune system function properly.": Nutrition is a modifiable factor that supports the immune system by providing essential vitamins, minerals, and proteins needed for immune cell production and function. Clients can take direct action through diet to enhance infection prevention.
C. "Your skin acts as a barrier to microorganisms and helps prevent injury.": Skin integrity is a natural, non-modifiable defense mechanism. While clients can care for their skin, its barrier function is inherently physiological and not directly alterable.
D. "Tears reduce particles entering the eye, reducing the number of organisms.": Tear production is a natural defense mechanism. Although hygiene can support eye health, the production and function of tears are not directly modifiable by the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will encourage him to walk daily so his muscles get stronger.": Ambulation improves circulation, reduces prolonged pressure on bony prominences, and supports muscle strength needed for repositioning. Regular movement is a key preventive strategy for pressure injury development. Mobility also enhances overall skin integrity.
B. "I will ensure he inserts his dentures so he can eat well during the day.": Adequate nutrition supports tissue repair, immune function, and skin resilience. Proper denture use promotes sufficient caloric and protein intake. Nutrition is a foundational component of pressure injury prevention.
C. "I will remind him to shift in his chair at least every two hours.": Regular repositioning redistributes pressure and restores capillary blood flow to compressed tissues. While chair-bound clients often benefit from more frequent shifts, this practice still reflects appropriate preventive awareness. Pressure relief is essential for skin protection.
D. "I will change his incontinence brief about every eight hours or so.": Prolonged moisture exposure from urine or stool increases skin maceration and susceptibility to breakdown. Incontinence care requires frequent brief changes and prompt skin cleansing. Moisture management is critical in preventing pressure injuries.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Rationale:
• Blood pressure of 120/82 mmHg: This blood pressure reading is within normal limits for an older adult. While hypotension or significant hypertension may indicate post-operative complications, a reading of 120/82 mmHg does not suggest immediate risk. It is unlikely to represent a complication and is considered stable.
• Body mass index of 26.6: A BMI of 26.6 falls into the overweight category but does not represent an acute post-operative complication. While elevated BMI may contribute to long-term risk factors, it does not indicate an immediate issue following knee replacement surgery.
• Respiration rate of 26 breaths per minute: Tachypnea in a post-operative client may indicate early hypoxia, pulmonary embolism, atelectasis, or pneumonia. After knee replacement surgery, immobility increases the risk of pulmonary complications. Monitoring respiratory status is critical because early detection of pulmonary compromise can prevent severe outcomes.
• Heart rate of 115 beats per minute: Tachycardia can be a compensatory response to hypoxia, pain, anxiety, or early infection. In post-operative clients, elevated heart rate may also indicate blood loss, dehydration, or pulmonary embolism. Continuous monitoring is warranted because persistent tachycardia can precede hemodynamic instability.
• Oxygen saturation of 88% on room air: An oxygen saturation below 90% is clinically significant hypoxemia. After orthopedic surgery, hypoxemia may result from anesthesia effects, atelectasis, or pulmonary embolism. Immediate interventions, such as supplemental oxygen and monitoring for respiratory compromise, are essential.
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