The nurse determines that a client has adequate physiological barriers

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client?

1. Intact and dry skin
2. Intact oral mucous membranes
3. Bowel sounds present in all four quadrants
4. Nasal congestion
5. Urinary retention

ANSWER

Correct Answer: 1, 2, 3
Rationale 1: Intact skin is the body’s first line of defense against microorganisms.
Rationale 2: Intact mucous membranes are the body’s first line of defense against microorganisms.
Rationale 3: Peristalsis tends to move microbes out of the body.
Rationale 4: Nasal congestion would mean that the nasal passages would be ineffective in filtering microorganisms from inspired air.
Rationale 5: Urinary retention would cause the urine to remain in the body, possibly leading to an infection.