MCA1 Exam 1 Questions & Answers
(Grade A+)
The patient has inflammation and reports feeling tired, nausea, and
anorexia. The nurse explains to the patient that these
manifestations are related to inflammation in what way?
Local response
Systemic response
Infectious response
Acute inflammatory response -
correct answer ✅Systemic response
The systemic response to inflammation includes the manifestations
of a shift to the left in the WBC count, malaise, nausea, anorexia,
increased pulse and respiratory rate, and fever. The local response
to inflammation includes redness, heat, pain, swelling, or loss of
function at the site of inflammation. There is not an infectious
response to inflammation, only an inflammatory response to
infection. The acute inflammatory response is a type of
inflammation that heals in 2 to 3 weeks and usually leaves no
residual damage.
,MCA1 Exam 1 Questions & Answers
(Grade A+)
Which intervention should the nurse include in the plan of care for
a patient who is paraplegic with a stage III pressure ulcer?
Keep the pressure ulcer clean and dry.
Maintain protein intake of at least 1.25 g/kg/day.
Use a 10-mL syringe to irrigate the pressure ulcer.
Irrigate the pressure ulcer with hydrogen peroxide. -
correct answer ✅Maintain protein intake of at least 1.25 g/kg/day.
Adequate protein intake (between 1.25 and 1.50 g/kg/day) is
needed to promote healing of pressure ulcers. Hydrogen peroxide
is cytotoxic and should not be used to clean pressure ulcers. A 30-
mL syringe with a 19-gauge needle will provide optimal pressure (4
to 15 psi) without causing tissue trauma or damage. The pressure
ulcer should be kept moist to aid in healing.
,MCA1 Exam 1 Questions & Answers
(Grade A+)
An older adult patient is transferred from the nursing home with a
black wound on her heel. What immediate wound therapy does the
nurse anticipate providing to this patient?
Dress it with an absorbent dressing for exudate.
Handle the wound gently and let it dry out to heal.
Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate
healing. -
correct answer ✅Debride the nonviable, eschar tissue to allow
healing.
With a black wound, the immediate therapy should be
debridement (surgical, mechanical, autolytic, or enzymatic) to
prepare the wound bed for healing. Black wounds may have
purulent drainage, but debridement is done first. The red wound is
handled gently because it is granulating and re-epithelializing, but it
must be kept slightly moist to heal. The negative-pressure wound
(vacuum) therapy is used to remove drainage and is more likely to
be used after debridement.
, MCA1 Exam 1 Questions & Answers
(Grade A+)
A patient arrives in the emergency department reporting fever for
24 hours and lower right quadrant abdominal pain. After laboratory
studies are performed, what does the nurse determine indicates
the patient has a bacterial infection?
Increased platelet count
Increased blood urea nitrogen
Increased number of band neutrophils
Increased number of segmented myelocytes -
correct answer ✅Increased number of band neutrophils
The finding of an increased number of band neutrophils in
circulation is called a shift to the left, which is commonly found in
patients with acute bacterial infections. Platelets increase with
tissue damage through the inflammatory process and for healing
but are not the best indicator of infection. Blood urea nitrogen is
unrelated to infection unless it is in the kidney. Myelocytes increase
(Grade A+)
The patient has inflammation and reports feeling tired, nausea, and
anorexia. The nurse explains to the patient that these
manifestations are related to inflammation in what way?
Local response
Systemic response
Infectious response
Acute inflammatory response -
correct answer ✅Systemic response
The systemic response to inflammation includes the manifestations
of a shift to the left in the WBC count, malaise, nausea, anorexia,
increased pulse and respiratory rate, and fever. The local response
to inflammation includes redness, heat, pain, swelling, or loss of
function at the site of inflammation. There is not an infectious
response to inflammation, only an inflammatory response to
infection. The acute inflammatory response is a type of
inflammation that heals in 2 to 3 weeks and usually leaves no
residual damage.
,MCA1 Exam 1 Questions & Answers
(Grade A+)
Which intervention should the nurse include in the plan of care for
a patient who is paraplegic with a stage III pressure ulcer?
Keep the pressure ulcer clean and dry.
Maintain protein intake of at least 1.25 g/kg/day.
Use a 10-mL syringe to irrigate the pressure ulcer.
Irrigate the pressure ulcer with hydrogen peroxide. -
correct answer ✅Maintain protein intake of at least 1.25 g/kg/day.
Adequate protein intake (between 1.25 and 1.50 g/kg/day) is
needed to promote healing of pressure ulcers. Hydrogen peroxide
is cytotoxic and should not be used to clean pressure ulcers. A 30-
mL syringe with a 19-gauge needle will provide optimal pressure (4
to 15 psi) without causing tissue trauma or damage. The pressure
ulcer should be kept moist to aid in healing.
,MCA1 Exam 1 Questions & Answers
(Grade A+)
An older adult patient is transferred from the nursing home with a
black wound on her heel. What immediate wound therapy does the
nurse anticipate providing to this patient?
Dress it with an absorbent dressing for exudate.
Handle the wound gently and let it dry out to heal.
Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate
healing. -
correct answer ✅Debride the nonviable, eschar tissue to allow
healing.
With a black wound, the immediate therapy should be
debridement (surgical, mechanical, autolytic, or enzymatic) to
prepare the wound bed for healing. Black wounds may have
purulent drainage, but debridement is done first. The red wound is
handled gently because it is granulating and re-epithelializing, but it
must be kept slightly moist to heal. The negative-pressure wound
(vacuum) therapy is used to remove drainage and is more likely to
be used after debridement.
, MCA1 Exam 1 Questions & Answers
(Grade A+)
A patient arrives in the emergency department reporting fever for
24 hours and lower right quadrant abdominal pain. After laboratory
studies are performed, what does the nurse determine indicates
the patient has a bacterial infection?
Increased platelet count
Increased blood urea nitrogen
Increased number of band neutrophils
Increased number of segmented myelocytes -
correct answer ✅Increased number of band neutrophils
The finding of an increased number of band neutrophils in
circulation is called a shift to the left, which is commonly found in
patients with acute bacterial infections. Platelets increase with
tissue damage through the inflammatory process and for healing
but are not the best indicator of infection. Blood urea nitrogen is
unrelated to infection unless it is in the kidney. Myelocytes increase
