MCA1 Exam 1 – Study Guide, Practice Questions & Revision
Notes
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 - ✔✔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. - ✔✔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. - ✔✔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 - ✔✔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 - ✔✔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. - ✔✔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
Notes
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 - ✔✔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. - ✔✔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. - ✔✔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 - ✔✔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 - ✔✔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. - ✔✔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
