MCA1 Exam 1 – Questions With Accurate Solutions
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Terms in this set (61)
The patient has inflammation and Systemic response
reports feeling tired, nausea, and
anorexia. The nurse explains to the The systemic response to inflammation includes the
patient that these manifestations are manifestations of a shift to the left in the WBC count,
related to inflammation in what way? malaise, nausea, anorexia, increased pulse and
respiratory rate, and fever. The local response to
Local response inflammation includes redness, heat, pain, swelling,
or loss of function at the site of inflammation. There is
Systemic response not an infectious response to inflammation, only an
inflammatory response to infection. The acute
Infectious response inflammatory response is a type of inflammation that
heals in 2 to 3 weeks and usually leaves no residual
Acute inflammatory response damage.
Which intervention should the nurse Maintain protein intake of at least 1.25 g/kg/day.
include in the plan of care for a
patient who is paraplegic with a stage Adequate protein intake (between 1.25 and 1.50
III pressure ulcer? g/kg/day) is needed to promote healing of pressure
ulcers. Hydrogen peroxide is cytotoxic and should
Keep the pressure ulcer clean and dry. not be used to clean pressure ulcers. A 30-mL
syringe with a 19-gauge needle will provide optimal
Maintain protein intake of at least 1.25 pressure (4 to 15 psi) without causing tissue trauma or
g/kg/day. damage. The pressure ulcer should be kept moist to
aid in healing.
Use a 10-mL syringe to irrigate the
pressure ulcer.
Irrigate the pressure ulcer with
hydrogen peroxide.
,An older adult patient is transferred Debride the nonviable, eschar tissue to allow healing.
from the nursing home with a black
wound on her heel. What immediate With a black wound, the immediate therapy should
wound therapy does the nurse be debridement (surgical, mechanical, autolytic, or
anticipate providing to this patient? enzymatic) to prepare the wound bed for healing.
Black wounds may have purulent drainage, but
Dress it with an absorbent dressing for debridement is done first. The red wound is handled
exudate. gently because it is granulating and re-epithelializing,
but it must be kept slightly moist to heal. The
Handle the wound gently and let it dry negative-pressure wound (vacuum) therapy is used to
out to heal. remove drainage and is more likely to be used after
debridement.
Debride the nonviable, eschar tissue
to allow healing.
Use negative-pressure wound
(vacuum) therapy to facilitate healing.
A patient arrives in the emergency Increased number of band neutrophils
department reporting fever for 24
hours and lower right quadrant The finding of an increased number of band
abdominal pain. After laboratory neutrophils in circulation is called a shift to the left,
studies are performed, what does the which is commonly found in patients with acute
nurse determine indicates the patient bacterial infections. Platelets increase with tissue
has a bacterial infection? damage through the inflammatory process and for
healing but are not the best indicator of infection.
Increased platelet count Blood urea nitrogen is unrelated to infection unless it
is in the kidney. Myelocytes increase with infection
Increased blood urea nitrogen and mature to form band neutrophils, but they are
not segmented. The mature neutrophils are
Increased number of band neutrophils segmented.
Increased number of segmented
myelocytes
,A patient had abdominal surgery last Purulent
week and returns to the clinic for
follow-up. The nurse assesses thick, Purulent drainage consists of white blood cells,
white, malodorous drainage. How microorganisms, and other debris that signal an
should the nurse document this infection. Serous drainage is a thin, watery, clear or
drainage? yellowish drainage frequently seen with broken
blisters. Fibrinous drainage occurs with fibrinogen
Serous leakage and is thick and sticky. Catarrhal drainage
occurs when there are cells that produce mucus
Purulent associated with the inflammatory response.
Fibrinous
Catarrhal
The nurse observes a patient Provide a light blanket.
experiencing chills related to an
infection. What is the priority action by Chills often occur in cycles and last for 10 to 30
the nurse? minutes at a time. They usually signal the onset of a
rise in temperature. For this reason, the nurse should
Provide a light blanket. provide a light blanket for comfort but avoid
overheating the patient.
Encourage a hot shower.
Monitor temperature every hour.
Turn up the thermostat in the patient's
room.
, Which patient is most at risk for the An older patient who is septic, bedridden, and
development of a pressure ulcer? incontinent
An older patient who is septic, Individuals at risk for the development of pressure
bedridden, and incontinent ulcers include those who are older, incontinent, bed
or wheelchair bound, or recovering from spinal cord
An obese woman with leukemia who injuries. Other examples of risk factors include
is receiving chemotherapy diabetes mellitus, elevated body temperature,
immobility, and anemia.
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
A nurse is teaching a patient how to Be sure to wash hands after changing the dressing to
promote healing following abdominal avoid infection.
surgery. What should be included in
the teaching (select all that apply.)? Take in more fluid, protein, and vitamins C, B, and A
Select all that apply. to facilitate healing.
Take the antibiotic until the wound Fluid is needed to replace fluid from insensible loss
feels better. and from exudates as well as the increased
metabolic rate. Protein corrects the negative
Take the analgesic every day to nitrogen balance that results from the increased
promote adequate rest for healing. metabolic rate and that needed for synthesis of
immune factors and healing. Vitamin C helps
Be sure to wash hands after changing synthesize capillaries and collagen. Vitamin B
the dressing to avoid infection. complex facilitates metabolism. Vitamin A aids in
epithelialization. The health care provider should be
Take in more fluid, protein, and notified if there are signs of infection. If prophylactic
vitamins C, B, and A to facilitate antibiotics are prescribed, they must be taken until
healing. they are completely gone. Initially analgesics are
taken throughout the day (e.g., every 3 to 4 hours) as
Notify the health care provider of needed. Infection must be avoided with aseptic
redness, swelling, and increased procedures, including washing the hands before
drainage. changing the dressing.
Save
Terms in this set (61)
The patient has inflammation and Systemic response
reports feeling tired, nausea, and
anorexia. The nurse explains to the The systemic response to inflammation includes the
patient that these manifestations are manifestations of a shift to the left in the WBC count,
related to inflammation in what way? malaise, nausea, anorexia, increased pulse and
respiratory rate, and fever. The local response to
Local response inflammation includes redness, heat, pain, swelling,
or loss of function at the site of inflammation. There is
Systemic response not an infectious response to inflammation, only an
inflammatory response to infection. The acute
Infectious response inflammatory response is a type of inflammation that
heals in 2 to 3 weeks and usually leaves no residual
Acute inflammatory response damage.
Which intervention should the nurse Maintain protein intake of at least 1.25 g/kg/day.
include in the plan of care for a
patient who is paraplegic with a stage Adequate protein intake (between 1.25 and 1.50
III pressure ulcer? g/kg/day) is needed to promote healing of pressure
ulcers. Hydrogen peroxide is cytotoxic and should
Keep the pressure ulcer clean and dry. not be used to clean pressure ulcers. A 30-mL
syringe with a 19-gauge needle will provide optimal
Maintain protein intake of at least 1.25 pressure (4 to 15 psi) without causing tissue trauma or
g/kg/day. damage. The pressure ulcer should be kept moist to
aid in healing.
Use a 10-mL syringe to irrigate the
pressure ulcer.
Irrigate the pressure ulcer with
hydrogen peroxide.
,An older adult patient is transferred Debride the nonviable, eschar tissue to allow healing.
from the nursing home with a black
wound on her heel. What immediate With a black wound, the immediate therapy should
wound therapy does the nurse be debridement (surgical, mechanical, autolytic, or
anticipate providing to this patient? enzymatic) to prepare the wound bed for healing.
Black wounds may have purulent drainage, but
Dress it with an absorbent dressing for debridement is done first. The red wound is handled
exudate. gently because it is granulating and re-epithelializing,
but it must be kept slightly moist to heal. The
Handle the wound gently and let it dry negative-pressure wound (vacuum) therapy is used to
out to heal. remove drainage and is more likely to be used after
debridement.
Debride the nonviable, eschar tissue
to allow healing.
Use negative-pressure wound
(vacuum) therapy to facilitate healing.
A patient arrives in the emergency Increased number of band neutrophils
department reporting fever for 24
hours and lower right quadrant The finding of an increased number of band
abdominal pain. After laboratory neutrophils in circulation is called a shift to the left,
studies are performed, what does the which is commonly found in patients with acute
nurse determine indicates the patient bacterial infections. Platelets increase with tissue
has a bacterial infection? damage through the inflammatory process and for
healing but are not the best indicator of infection.
Increased platelet count Blood urea nitrogen is unrelated to infection unless it
is in the kidney. Myelocytes increase with infection
Increased blood urea nitrogen and mature to form band neutrophils, but they are
not segmented. The mature neutrophils are
Increased number of band neutrophils segmented.
Increased number of segmented
myelocytes
,A patient had abdominal surgery last Purulent
week and returns to the clinic for
follow-up. The nurse assesses thick, Purulent drainage consists of white blood cells,
white, malodorous drainage. How microorganisms, and other debris that signal an
should the nurse document this infection. Serous drainage is a thin, watery, clear or
drainage? yellowish drainage frequently seen with broken
blisters. Fibrinous drainage occurs with fibrinogen
Serous leakage and is thick and sticky. Catarrhal drainage
occurs when there are cells that produce mucus
Purulent associated with the inflammatory response.
Fibrinous
Catarrhal
The nurse observes a patient Provide a light blanket.
experiencing chills related to an
infection. What is the priority action by Chills often occur in cycles and last for 10 to 30
the nurse? minutes at a time. They usually signal the onset of a
rise in temperature. For this reason, the nurse should
Provide a light blanket. provide a light blanket for comfort but avoid
overheating the patient.
Encourage a hot shower.
Monitor temperature every hour.
Turn up the thermostat in the patient's
room.
, Which patient is most at risk for the An older patient who is septic, bedridden, and
development of a pressure ulcer? incontinent
An older patient who is septic, Individuals at risk for the development of pressure
bedridden, and incontinent ulcers include those who are older, incontinent, bed
or wheelchair bound, or recovering from spinal cord
An obese woman with leukemia who injuries. Other examples of risk factors include
is receiving chemotherapy diabetes mellitus, elevated body temperature,
immobility, and anemia.
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
A nurse is teaching a patient how to Be sure to wash hands after changing the dressing to
promote healing following abdominal avoid infection.
surgery. What should be included in
the teaching (select all that apply.)? Take in more fluid, protein, and vitamins C, B, and A
Select all that apply. to facilitate healing.
Take the antibiotic until the wound Fluid is needed to replace fluid from insensible loss
feels better. and from exudates as well as the increased
metabolic rate. Protein corrects the negative
Take the analgesic every day to nitrogen balance that results from the increased
promote adequate rest for healing. metabolic rate and that needed for synthesis of
immune factors and healing. Vitamin C helps
Be sure to wash hands after changing synthesize capillaries and collagen. Vitamin B
the dressing to avoid infection. complex facilitates metabolism. Vitamin A aids in
epithelialization. The health care provider should be
Take in more fluid, protein, and notified if there are signs of infection. If prophylactic
vitamins C, B, and A to facilitate antibiotics are prescribed, they must be taken until
healing. they are completely gone. Initially analgesics are
taken throughout the day (e.g., every 3 to 4 hours) as
Notify the health care provider of needed. Infection must be avoided with aseptic
redness, swelling, and increased procedures, including washing the hands before
drainage. changing the dressing.
