NUR 104 EXAM 3 HIGH-YIELD
CARDIOVASCULAR, RESPIRATORY, AND NEURO
NURSING CARE SUMMARY 2026
◉ Braden Scare.
Answer: predicts pressure sore risk by using categories; sensory
perception, moisture, activity, mobility, nutrition, friction, and shear
◉ Norton Scale.
Answer: measures pressure ulcers by using categories; physical
condition, mental state, activity, mobility, continence.
◉ Prioritizing greatest risk.
Answer: identify age, any infection, medical devices, diabetes?
◉ Stage 1 pressure injury.
Answer: nonblanchable erythema of intact skin, temp different than
surrounding skin
◉ Stage 2 pressure injury.
Answer: shallow/superficial, partial thickness skin loss, exposed
dermis, intact/ruptured blisters
,◉ Stage 3 pressure injury.
Answer: full-thickness skin loss reaching subcutaneous tissue,
potential undermining (tissue loss under intact skin, "lip"), and
tunneling
◉ Stage 4 pressure injury.
Answer: Full-thickness skin and tissue loss, osteomyelitis, exposure
to muscle, bone, or connective tissue
◉ Unstageable pressure injury.
Answer: full-thickness skin & tissue loss, unable to assess depth
until eschar is removed
◉ Deep tissue pressure injury.
Answer: intact persistent, nonblanchable, deep red, maroon, purple
discoloration
◉ Ture or False
as healing takes place, a pressure injury will not be able to return to
a normal state prior to injury.
Answer: True
,◉ Serous Drainage.
Answer: contains clear/yellow watery fluid from plasma
◉ Serosanguineous Draingage.
Answer: pink - pale red, mix of serous fluid and red/bloody fluid
◉ Sanguineous.
Answer: indicates bleeding, bright red.
◉ Purulent.
Answer: thick, yellow-greenish-beige, indicates infection
◉ Dehiscence.
Answer: PARTIAL/COMPLETE separation of tissue layers during the
healing process
◉ Evisceration.
Answer: -TOTAL separation of tissue layers, causing protrusion of
visceral organs
"popping" sensation
◉ caring for dehiscence or evisceration.
, Answer: -cover wound with sterile saline-moistened gauze
- notify provider
◉ How to identify an infected wound.
Answer: visible redness, warmth, increased drainage, MAY or MAY
NOT be purulent
◉ Primary intention healing.
Answer: ACUTE WOUND= heals quickly, minimal scar formation
ex: surgical incisions, traumatic wounds
◉ Secondary intention healing.
Answer: CHRONIC WOUND= stay open for period of time to allow
for drainage and observation, once infection lowers it is closed, new
tissue growth begins from BOTTOM-TOP
◉ Tertiary intention healing.
Answer: CHRONIC WOUND= delay occurs between injury and
closure
ex: G.I tract surgery
◉ Vitamins aiding in healing of pressure wounds.
Answer: A.C.E
CARDIOVASCULAR, RESPIRATORY, AND NEURO
NURSING CARE SUMMARY 2026
◉ Braden Scare.
Answer: predicts pressure sore risk by using categories; sensory
perception, moisture, activity, mobility, nutrition, friction, and shear
◉ Norton Scale.
Answer: measures pressure ulcers by using categories; physical
condition, mental state, activity, mobility, continence.
◉ Prioritizing greatest risk.
Answer: identify age, any infection, medical devices, diabetes?
◉ Stage 1 pressure injury.
Answer: nonblanchable erythema of intact skin, temp different than
surrounding skin
◉ Stage 2 pressure injury.
Answer: shallow/superficial, partial thickness skin loss, exposed
dermis, intact/ruptured blisters
,◉ Stage 3 pressure injury.
Answer: full-thickness skin loss reaching subcutaneous tissue,
potential undermining (tissue loss under intact skin, "lip"), and
tunneling
◉ Stage 4 pressure injury.
Answer: Full-thickness skin and tissue loss, osteomyelitis, exposure
to muscle, bone, or connective tissue
◉ Unstageable pressure injury.
Answer: full-thickness skin & tissue loss, unable to assess depth
until eschar is removed
◉ Deep tissue pressure injury.
Answer: intact persistent, nonblanchable, deep red, maroon, purple
discoloration
◉ Ture or False
as healing takes place, a pressure injury will not be able to return to
a normal state prior to injury.
Answer: True
,◉ Serous Drainage.
Answer: contains clear/yellow watery fluid from plasma
◉ Serosanguineous Draingage.
Answer: pink - pale red, mix of serous fluid and red/bloody fluid
◉ Sanguineous.
Answer: indicates bleeding, bright red.
◉ Purulent.
Answer: thick, yellow-greenish-beige, indicates infection
◉ Dehiscence.
Answer: PARTIAL/COMPLETE separation of tissue layers during the
healing process
◉ Evisceration.
Answer: -TOTAL separation of tissue layers, causing protrusion of
visceral organs
"popping" sensation
◉ caring for dehiscence or evisceration.
, Answer: -cover wound with sterile saline-moistened gauze
- notify provider
◉ How to identify an infected wound.
Answer: visible redness, warmth, increased drainage, MAY or MAY
NOT be purulent
◉ Primary intention healing.
Answer: ACUTE WOUND= heals quickly, minimal scar formation
ex: surgical incisions, traumatic wounds
◉ Secondary intention healing.
Answer: CHRONIC WOUND= stay open for period of time to allow
for drainage and observation, once infection lowers it is closed, new
tissue growth begins from BOTTOM-TOP
◉ Tertiary intention healing.
Answer: CHRONIC WOUND= delay occurs between injury and
closure
ex: G.I tract surgery
◉ Vitamins aiding in healing of pressure wounds.
Answer: A.C.E
