MCA1 Exam 1 Questions With Complete Solutions|
Samuel Merritt University
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
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
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.
Samuel Merritt University
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
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
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.
