The client states, "Why am I getting protein supplements while I'm healing from a bed sore?" What is the best response by the nurse?

Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.

Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.

Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.

Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.

Choice A reason: This is the highest risk client because surgery can cause trauma, blood loss, and infection, which can weaken the immune system and increase the susceptibility to complications. The immune system is the body's defense mechanism that protects against foreign invaders, such as bacteria, viruses, or fungi. Surgery can damage the skin and tissues, which are the first line of defense, and cause inflammation, which can impair the function of the white blood cells, which are the second line of defense. The nurse should monitor the client's vital signs, wound healing, and signs of infection and administer antibiotics, fluids, and pain medication as ordered.

Choice B reason: This is not the highest risk client, but it is a moderate risk client because extreme anxiety can cause stress, which can affect the immune system and increase the vulnerability to illness. Stress is the body's response to a perceived threat or challenge, which can activate the sympathetic nervous system and the hypothalamicpituitaryadrenal (HPA) axis. Stress can cause the release of hormones, such as cortisol and adrenaline, which can suppress the immune system and reduce the production and activity of the white blood cells. The nurse should assess the client's anxiety level and provide coping strategies, such as relaxation, breathing, or counseling.

Choice C reason: This is not the highest risk client, but it is a low risk client because awaiting surgery can cause anxiety, which can affect the immune system and increase the vulnerability to illness. However, the client's anxiety level may not be as high as the client with extreme anxiety, and the client's immune system may not be as compromised as the client who has just had surgery. The nurse should assess the client's anxiety level and provide education, reassurance, and support.

Choice D reason: This is not the highest risk client, but it is a low risk client because delivering a baby can cause blood loss, hormonal changes, and fatigue, which can affect the immune system and increase the risk of infection. However, the client's immune system may not be as compromised as the client who has just had surgery, and the client may have some protection from the antibodies that are passed from the mother to the baby through the placenta and breast milk. The nurse should monitor the client's vital signs, lochia, and signs of infection and provide hygiene, nutrition, and rest.