MCA 1 EXAM
MCA 1 EXAM 1 QUESTIONS AND ANSWERS GRADED 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 ANS >> 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
,MCA 1 EXAM
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. ANS >> 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.
,MCA 1 EXAM
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.
ANS >> 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?
, MCA 1 EXAM
Increased platelet count
Increased blood urea nitrogen
Increased number of band neutrophils
Increased number of segmented myelocytes ANS >> 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
MCA 1 EXAM 1 QUESTIONS AND ANSWERS GRADED 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 ANS >> 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
,MCA 1 EXAM
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. ANS >> 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.
,MCA 1 EXAM
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.
ANS >> 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?
, MCA 1 EXAM
Increased platelet count
Increased blood urea nitrogen
Increased number of band neutrophils
Increased number of segmented myelocytes ANS >> 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
