2
MCA1 Exam 1 Questions With || || || || ||
Answers ||
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(S)✔✔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. - CORRECT
|| || || || || || || || ||
ANSWER(S)✔✔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.
|| || || || || || || || || ||
, 2
Debride the nonviable, eschar tissue to allow healing.
|| || || || || || ||
Use negative-pressure wound (vacuum) therapy to facilitate healing. -
|| || || || || || || || ||
CORRECT ANSWER(S)✔✔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 || ||
Increased blood urea nitrogen || || ||
Increased number of band neutrophils || || || ||
Increased number of segmented myelocytes - CORRECT
|| || || || || || ||
ANSWER(S)✔✔Increased number of band neutrophils || || || ||
, 2
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.
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 - CORRECT ANSWER(S)✔✔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
|| || || || || || || || || || ||
MCA1 Exam 1 Questions With || || || || ||
Answers ||
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(S)✔✔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. - CORRECT
|| || || || || || || || ||
ANSWER(S)✔✔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.
|| || || || || || || || || ||
, 2
Debride the nonviable, eschar tissue to allow healing.
|| || || || || || ||
Use negative-pressure wound (vacuum) therapy to facilitate healing. -
|| || || || || || || || ||
CORRECT ANSWER(S)✔✔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 || ||
Increased blood urea nitrogen || || ||
Increased number of band neutrophils || || || ||
Increased number of segmented myelocytes - CORRECT
|| || || || || || ||
ANSWER(S)✔✔Increased number of band neutrophils || || || ||
, 2
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.
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 - CORRECT ANSWER(S)✔✔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
|| || || || || || || || || || ||
