NUR 185 EXAM 2 2026 HEALTH ASSESSMENT
AND VITAL SIGNS WORKBOOK SOLVED
QUESTIONS COMPILATION
◉ Pros of Heterograft.
Answer: Protect wound, reduced fluid/protein loss, decreases
infection risk.
◉ Cons of Heterograft.
Answer: Rejected quickly (within days).
◉ Nursing Care for Heterograft.
Answer: Treat as a short-term dressing; Replace when body rejects
or sloughs it off.
◉ Priorities in Emergent Phase.
Answer: Airway: swelling, inhalation injury, intubation if needed;
Breathing: oxygen, monitor ABGs, CO poisoning→100% O2;
Circulation: IV fluids → Parkland formula, prevent shock; Control
bleeding, stop burning process (remove clothing/jewelry).
◉ Complications in Emergent Phase.
,Answer: Hyperkalemia; Hypovolemic shock.
◉ Nursing Considerations in Emergent Phase.
Answer: Total respiratory assessment; Cardiac monitor; Untreated
fluid shifts→ shock.
◉ Priorities in Acute Phase.
Answer: Monitor urine output (kidneys start excreting fluid→ watch
for electrolyte changes); Electrolyte monitoring; Prevent & treat
infection (wound care, topical antimicrobials, aseptic technique);
Pain management & nutrition (high protein, high calorie);
Psychosocial support (body image, anxiety, depression).
◉ Superficial (1st degree).
Answer: Layers involved: epidermis only; Appearance: red, dry,
painful, blanchable; Blisters: no; Healing: 3-6 days, no scarring;
Example: sunburn.
◉ Partial thickness (2nd degree).
Answer: Layers involved: epidermis & part of dermis; Appearance:
red, blistered, moist, very painful; Blisters: yes; Healing: ~2-3 weeks
minimal scarring.
◉ Deep partial thickness (2nd degree).
, Answer: Layers: epidermis & deep dermis; Appearance: red/white,
dry to moist, less blanching, ↓ sensation (less pain); Healing: >3
weeks, may need grafting, scarring likely.
◉ Full thickness (3rd degree).
Answer: Layers: epidermis & entire dermis (may extend into fat);
Appearance: white, brown, black, leathery, dry, no blanching;
Blisters: no; Pain: little to none (nerves destroyed); Healing: cannot
heal on its own→ requires grafting, significant scarring.
◉ Deep full thickness (4th degree).
Answer: Layers: all skin & underlying tissue (muscle, bone);
Appearance: black, charred, eschar present; Pain: none (nerves
destroyed); Healing: requires grafting, possible amputation.
◉ Baux Score.
Answer: Age + % TBSA burned + 17 (inhalation injury)= mortality
risk; If there is no inhalation injury, no need to add the inhalation
injury.
◉ Extremely poor prognosis.
Answer: 140 → extremely poor prognosis (very high risk of death)
◉ Airway edema.
AND VITAL SIGNS WORKBOOK SOLVED
QUESTIONS COMPILATION
◉ Pros of Heterograft.
Answer: Protect wound, reduced fluid/protein loss, decreases
infection risk.
◉ Cons of Heterograft.
Answer: Rejected quickly (within days).
◉ Nursing Care for Heterograft.
Answer: Treat as a short-term dressing; Replace when body rejects
or sloughs it off.
◉ Priorities in Emergent Phase.
Answer: Airway: swelling, inhalation injury, intubation if needed;
Breathing: oxygen, monitor ABGs, CO poisoning→100% O2;
Circulation: IV fluids → Parkland formula, prevent shock; Control
bleeding, stop burning process (remove clothing/jewelry).
◉ Complications in Emergent Phase.
,Answer: Hyperkalemia; Hypovolemic shock.
◉ Nursing Considerations in Emergent Phase.
Answer: Total respiratory assessment; Cardiac monitor; Untreated
fluid shifts→ shock.
◉ Priorities in Acute Phase.
Answer: Monitor urine output (kidneys start excreting fluid→ watch
for electrolyte changes); Electrolyte monitoring; Prevent & treat
infection (wound care, topical antimicrobials, aseptic technique);
Pain management & nutrition (high protein, high calorie);
Psychosocial support (body image, anxiety, depression).
◉ Superficial (1st degree).
Answer: Layers involved: epidermis only; Appearance: red, dry,
painful, blanchable; Blisters: no; Healing: 3-6 days, no scarring;
Example: sunburn.
◉ Partial thickness (2nd degree).
Answer: Layers involved: epidermis & part of dermis; Appearance:
red, blistered, moist, very painful; Blisters: yes; Healing: ~2-3 weeks
minimal scarring.
◉ Deep partial thickness (2nd degree).
, Answer: Layers: epidermis & deep dermis; Appearance: red/white,
dry to moist, less blanching, ↓ sensation (less pain); Healing: >3
weeks, may need grafting, scarring likely.
◉ Full thickness (3rd degree).
Answer: Layers: epidermis & entire dermis (may extend into fat);
Appearance: white, brown, black, leathery, dry, no blanching;
Blisters: no; Pain: little to none (nerves destroyed); Healing: cannot
heal on its own→ requires grafting, significant scarring.
◉ Deep full thickness (4th degree).
Answer: Layers: all skin & underlying tissue (muscle, bone);
Appearance: black, charred, eschar present; Pain: none (nerves
destroyed); Healing: requires grafting, possible amputation.
◉ Baux Score.
Answer: Age + % TBSA burned + 17 (inhalation injury)= mortality
risk; If there is no inhalation injury, no need to add the inhalation
injury.
◉ Extremely poor prognosis.
Answer: 140 → extremely poor prognosis (very high risk of death)
◉ Airway edema.
