A nurse studying infection control learns that which factor is the most effective and crucial barrier to infection?
Skin and mucous membranes
Gastrointestinal secretions
Colonization by host bacteria
Inflammatory processes
The Correct Answer is A
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","F","G"]
Explanation
Rationale for A: Hemoglobin and Hematocrit
Hemoglobin (Hgb) of 6.8 g/dL is significantly below the normal range of 12-16 g/dL for women and 14-18 g/dL for men. This indicates severe anemia, which can cause several of the patient's reported symptoms, including shortness of breath, fatigue, dizziness, and intolerance to cold. It's crucial to address this promptly as severe anemia can lead to tissue hypoxia and organ damage.
Hematocrit (Hct) of 21.2% is also below the normal range of 36-46% for women and 41-50% for men. Hct measures the percentage of red blood cells in the blood, and its low value further confirms the presence of anemia.
Rationale for B: Blood Pressure 100/68, Respirations 24
Blood pressure of 100/68 mmHg is considered low, especially in a patient with a history of hypertension. This could be due to the anemia, as low red blood cell count can decrease blood volume and subsequently lower blood pressure. It's essential to monitor the patient's blood pressure closely, as hypotension can lead to dizziness, fainting, and even shock.
Respirations of 24 breaths per minute are slightly elevated above the normal adult range of 12-20 breaths per minute. This could be a compensatory mechanism for the anemia, as the body tries to increase oxygen intake. However, it could also indicate other underlying respiratory issues that need to be investigated.
Rationale for F: Shortness of breath with exertion
Shortness of breath (dyspnea) is a common symptom of anemia, as the body struggles to deliver enough oxygen to tissues during physical activity. This symptom warrants immediate attention, as it can significantly impact the patient's quality of life and could potentially signal worsening anemia or other cardiopulmonary problems.
Rationale for G: Dizziness when standing
Dizziness upon standing (orthostatic hypotension) is a sign of low blood pressure, which can be exacerbated by anemia. This can increase the risk of falls and injuries, especially in a patient with other health conditions. It's crucial to address this symptom to prevent potential complications.
Correct Answer is D
Explanation
Choice A rationale:
While PICCs are typically intended for shorter-term use (up to 12 weeks), the fact that a PICC has been in place for 4 weeks is not, in itself, an immediate cause for concern. Regular assessment of the catheter and site is crucial, but the duration of placement alone does not warrant immediate attention.
Choice B rationale:
While it's generally recommended to change PICC dressings every 7 days, a dressing that is 3 days old is not an immediate emergency. The nurse should prioritize changing the dressing as soon as possible, but it does not require the same level of urgency as other potential complications.
Choice C rationale:
A missing securement device is a concern because it can increase the risk of catheter dislodgement or migration. However, it does not necessarily indicate an immediate threat to the patient's well-being. The nurse should promptly address the missing securement device, but it would not be the most pressing issue compared to swelling in the extremity.
Choice D rationale:
Swelling in the upper extremity where the PICC is located is a significant finding that demands immediate attention. It can be a sign of several serious complications, including:
Thrombosis: A blood clot within the vein, which can obstruct blood flow and lead to pain, swelling, and potentially more severe consequences like deep vein thrombosis (DVT) or pulmonary embolism (PE).
Infection: Inflammation and infection at the insertion site or within the bloodstream, which can cause swelling, redness, warmth, and pain. If left untreated, infection can progress to sepsis, a life-threatening condition.
Phlebitis: Inflammation of the vein, which can cause pain, redness, and swelling along the vein.
Infiltration: Leakage of fluids or medications into the surrounding tissue, leading to swelling and discomfort.
Prompt action is crucial in these cases to prevent further complications and ensure patient safety. The nurse should immediately notify the appropriate healthcare provider, initiate necessary interventions, and closely monitor the patient's condition.
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