MCA1 Exam 1 ACTUAL UPDATED
QUESTIONS AND CORRECT 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 ANSWERS✅✅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. - CORRECT ANSWERS✅✅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.
Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate healing. - CORRECT
ANSWERS✅✅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 ANSWERS✅✅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.
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 ANSWERS✅✅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.
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. - CORRECT ANSWERS✅✅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.
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 - CORRECT
ANSWERS✅✅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.
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.
QUESTIONS AND CORRECT 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 ANSWERS✅✅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. - CORRECT ANSWERS✅✅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.
Debride the nonviable, eschar tissue to allow healing.
Use negative-pressure wound (vacuum) therapy to facilitate healing. - CORRECT
ANSWERS✅✅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 ANSWERS✅✅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.
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 ANSWERS✅✅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.
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. - CORRECT ANSWERS✅✅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.
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 - CORRECT
ANSWERS✅✅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.
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.
