MCA1 Exam 1 2026 Exam
Questions and Correct
Answers | New Update
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 - 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.
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. - 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.
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.
3
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STATEMENT. ALL RIGHTS RESERVED
, Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate healing. -
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.
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
Questions and Correct
Answers | New Update
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 - 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.
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. - 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.
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.
3
COPYRIGHT©JOSHCLAY 2025/2026. YEAR PUBLISHED 2026. COMPANY REGISTRATION NUMBER: 619652435. TERMS OF USE. PRIVACY
STATEMENT. ALL RIGHTS RESERVED
, Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate healing. -
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.
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
