MCA 1 - Cline - Exam 1 Samuel Merritt University MCA 1 - Test #1 Inflamation, immune response, infection, fluid & electrolytes, diabetes, delegation Questions With Complete Solutions

MCA 1 - Cline - Exam 1 Samuel
Merritt University MCA 1 - Test #1
Inflamation, immune response,
infection, fluid & electrolytes,
diabetes, delegation Questions
With Complete Solutions
Course
MCA 1
Question 1
A nurse is assessing a client with acute inflammation following a soft tissue injury. Which
assessment finding is primarily caused by vasodilation?
A. Purulent drainage
B. Redness and warmth at the injury site
C. Decreased capillary permeability
D. Tissue necrosis
Correct Answer: B. Redness and warmth at the injury site
Complete Solution
Inflammation is characterized by the classic signs:
 Redness (rubor)
 Warmth (calor)
 Swelling (tumor)
 Pain (dolor)
 Loss of function
Vasodilation increases blood flow to the affected area, producing redness and warmth. Increased
capillary permeability contributes to swelling, while white blood cell migration helps eliminate
pathogens.


Question 2

,A patient with a bacterial infection has a white blood cell (WBC) count of 18,000/mm³. How
should the nurse interpret this finding?
A. The immune system is responding to infection.
B. The patient is severely immunocompromised.
C. The WBC count is within normal limits.
D. The patient has developed anemia.
Correct Answer: A. The immune system is responding to infection.
Complete Solution
Normal WBC count: 4,500–11,000/mm³
An elevated WBC count (leukocytosis) commonly indicates:
 Bacterial infection
 Acute inflammation
 Stress response
 Tissue injury
The finding should be correlated with temperature, cultures, and clinical symptoms.


Question 3
Which patient is most at risk for developing a healthcare-associated infection (HAI)?
A. A healthy 20-year-old admitted overnight
B. An older adult with diabetes who has an indwelling urinary catheter
C. A patient discharged after an outpatient procedure
D. A teenager with a minor ankle sprain
Correct Answer: B. An older adult with diabetes who has an indwelling urinary catheter
Complete Solution
Risk factors for HAIs include:
 Indwelling devices (urinary catheters, central lines)
 Advanced age

,  Diabetes mellitus
 Immunosuppression
 Prolonged hospitalization
Catheters increase the risk of catheter-associated urinary tract infections (CAUTIs).


Question 4
A client with persistent vomiting has the following laboratory results:
 Sodium: 138 mEq/L
 Potassium: 2.9 mEq/L
 Chloride: 95 mEq/L
Which nursing intervention is the priority?
A. Encourage increased sodium intake.
B. Administer prescribed potassium replacement.
C. Restrict fluid intake.
D. Begin insulin therapy.
Correct Answer: B. Administer prescribed potassium replacement.
Complete Solution
Normal potassium: 3.5–5.0 mEq/L
Hypokalemia may cause:
 Cardiac dysrhythmias
 Muscle weakness
 Ileus
 Fatigue
Vomiting commonly causes potassium loss. Potassium replacement should be administered as
prescribed while monitoring cardiac rhythm and renal function.


Question 5

, Which assessment finding is most consistent with hyperglycemia?
A. Diaphoresis, tremors, and confusion
B. Polyuria, polydipsia, and blurred vision
C. Bradycardia and hypotension
D. Cool, clammy skin
Correct Answer: B. Polyuria, polydipsia, and blurred vision
Complete Solution
Classic signs of hyperglycemia include:
 Polyuria
 Polydipsia
 Polyphagia
 Blurred vision
 Fatigue
 Dry mucous membranes
In contrast, diaphoresis and tremors are more commonly associated with hypoglycemia.


Question 6
A nurse is preparing to delegate care. Which task is appropriate to assign to an experienced
unlicensed assistive personnel (UAP)?
A. Assess a newly admitted patient's pain level.
B. Reinforce discharge teaching.
C. Obtain routine vital signs on a stable patient.
D. Evaluate the effectiveness of pain medication.
Correct Answer: C. Obtain routine vital signs on a stable patient.
Complete Solution
The RN may delegate routine, predictable tasks such as:
 Vital signs on stable patients