MCA1 Exam 1 Will Well Annalised Questions And Answers A+GRADED
1. The patient has inflammation and reports feeling tired, nausea, and anorex-
ia. 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: 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.
2. 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.: 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.
3. 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.: 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.
4. A patient arrives in the emergency department reporting fever for 24 hours
and lower right quadrant abdominal pain. After laboratory studies are per-
formed, 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: 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 with infection and mature to form band neutrophils, but they are not
segmented. The mature neutrophils are segmented.
5. A patient had abdominal surgery last week and returns to the clinic for
follow-up. The nurse assesses thick, white, malodorous drainage. How should
the nurse document this drainage?
Serous
Purulent
Fibrinous
Catarrhal: Purulent
Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous
drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs
with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus
associated with the inflammatory response.
6. The nurse observes a patient experiencing chills related to an infection.
What is the priority action by the nurse?
Provide a light blanket.
Encourage a hot shower.
Monitor temperature every hour.
Turn up the thermostat in the patient's room.: Provide a light blanket.
, Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature.
For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.
7. Which patient is most at risk for the development of a pressure ulcer?
An older patient who is septic, bedridden, and incontinent
An obese woman with leukemia who is receiving chemotherapy
A middle-aged thin man in a halo cast after a motor vehicle accident
An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis: An older
patient who is septic, bedridden, and incontinent
Individuals at risk for the development of pressure ulcers include those who are older, incontinent, bed or wheelchair
bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes mellitus, elevated body
temperature, immobility, and anemia.
8. A nurse is teaching a patient how to promote healing following abdominal
surgery. What should be included in the teaching (select all that apply.)?
Select all that apply.
Take the antibiotic until the wound feels better.
Take the analgesic every day to promote adequate rest for healing.
Be sure to wash hands after changing the dressing to avoid infection.
Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
Notify the health care provider of redness, swelling, and increased drainage.-
: Be sure to wash hands after changing the dressing to avoid infection.
Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
1. The patient has inflammation and reports feeling tired, nausea, and anorex-
ia. 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: 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.
2. 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.: 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.
3. 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.: 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.
4. A patient arrives in the emergency department reporting fever for 24 hours
and lower right quadrant abdominal pain. After laboratory studies are per-
formed, 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: 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 with infection and mature to form band neutrophils, but they are not
segmented. The mature neutrophils are segmented.
5. A patient had abdominal surgery last week and returns to the clinic for
follow-up. The nurse assesses thick, white, malodorous drainage. How should
the nurse document this drainage?
Serous
Purulent
Fibrinous
Catarrhal: Purulent
Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous
drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs
with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus
associated with the inflammatory response.
6. The nurse observes a patient experiencing chills related to an infection.
What is the priority action by the nurse?
Provide a light blanket.
Encourage a hot shower.
Monitor temperature every hour.
Turn up the thermostat in the patient's room.: Provide a light blanket.
, Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature.
For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.
7. Which patient is most at risk for the development of a pressure ulcer?
An older patient who is septic, bedridden, and incontinent
An obese woman with leukemia who is receiving chemotherapy
A middle-aged thin man in a halo cast after a motor vehicle accident
An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis: An older
patient who is septic, bedridden, and incontinent
Individuals at risk for the development of pressure ulcers include those who are older, incontinent, bed or wheelchair
bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes mellitus, elevated body
temperature, immobility, and anemia.
8. A nurse is teaching a patient how to promote healing following abdominal
surgery. What should be included in the teaching (select all that apply.)?
Select all that apply.
Take the antibiotic until the wound feels better.
Take the analgesic every day to promote adequate rest for healing.
Be sure to wash hands after changing the dressing to avoid infection.
Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
Notify the health care provider of redness, swelling, and increased drainage.-
: Be sure to wash hands after changing the dressing to avoid infection.
Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.
