HESI RN Case Study Burns Exam Questions With
Correct Answers
Which action is included when a Level I disaster is declared? - CORRECT
| | | | | | | | | | | | |
ANSWER✔✔-All local hospitals prepare to receive casualties. | | | | | |
Which action should the nurse implement to help these family members cope
| | | | | | | | | | | |
with this tragedy? - CORRECT ANSWER✔✔-Designate specific family areas that
| | | | | | | | | |
are staffed with counselors.
| | |
EMS personnel triage clients, with multiple casualties noted. Which action should
| | | | | | | | | | |
the triage nurse implement first? - CORRECT ANSWER✔✔-Place a disaster tag
| | | | | | | | | | |
securely on each victim.| | |
Triage determines in what order a client is seen by a healthcare provider (HCP).
| | | | | | | | | | | | | |
Which of the following clients would the nurse identify with a red tag? - CORRECT
| | | | | | | | | | | | | |
ANSWER✔✔--A client whose vital signs include respirations at 22 breaths/min ,
| | | | | | | | | | | |
pulse at 120 beats/min, and blood pressure at 85/52 mmHg.
| | | | | | | | |
-A client with a pulsating femur wound.
| | | | | |
-A client with full thickness burns over 50% of the body.
| | | | | | | | | |
Which triage category should the nurse assign to James? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-Priority 1, Color Red. | | |
, The client has many physical, emotional, and psychosocial needs. Which
| | | | | | | | | |
intervention is most important for the nurse to implement upon admission? -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-Establish and maintain an open airway.
| | | | | |
The nurse should document which percentage of body surface? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-45%
James grimaces in pain as the nurse assesses James' red and blistered wounds
| | | | | | | | | | | | |
that are affecting his epidermis and dermis. Based on this assessment, which
| | | | | | | | | | | |
finding best describes the James' burns? - CORRECT ANSWER✔✔-Partial
| | | | | | | | |
thickness or second degree burns. | | | |
Based on the nurse's understanding of the Parkland Formula, which rate correctly
| | | | | | | | | | |
describes the time the fluid is given to the client? - CORRECT ANSWER✔✔-The
| | | | | | | | | | | | | |
nurse administers the first half of the fluid from the time the burn occurred over
| | | | | | | | | | | | | | |
8 hours, and the second half over the following 16 hours.
| | | | | | | | | |
Which action should the nurse take? - CORRECT ANSWER✔✔-Inform the officer
| | | | | | | | | | |
that he must first speak to James' parents.
| | | | | | |
The police officer then asks to see James' ED medical record. Which action should
| | | | | | | | | | | | |
the nurse take concerning this request? - CORRECT ANSWER✔✔-Allow the police
| | | | | | | | | | |
officer access to the requested medical records.
| | | | | | |
Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts
| | | | | | | | | | | | |
of fluid and electrolytes from intravascular to extravascular spaces, which can
| | | | | | | | | | |
lead to cardiovascular collapse. Which assessment relates most directly to a
| | | | | | | | | | |
Correct Answers
Which action is included when a Level I disaster is declared? - CORRECT
| | | | | | | | | | | | |
ANSWER✔✔-All local hospitals prepare to receive casualties. | | | | | |
Which action should the nurse implement to help these family members cope
| | | | | | | | | | | |
with this tragedy? - CORRECT ANSWER✔✔-Designate specific family areas that
| | | | | | | | | |
are staffed with counselors.
| | |
EMS personnel triage clients, with multiple casualties noted. Which action should
| | | | | | | | | | |
the triage nurse implement first? - CORRECT ANSWER✔✔-Place a disaster tag
| | | | | | | | | | |
securely on each victim.| | |
Triage determines in what order a client is seen by a healthcare provider (HCP).
| | | | | | | | | | | | | |
Which of the following clients would the nurse identify with a red tag? - CORRECT
| | | | | | | | | | | | | |
ANSWER✔✔--A client whose vital signs include respirations at 22 breaths/min ,
| | | | | | | | | | | |
pulse at 120 beats/min, and blood pressure at 85/52 mmHg.
| | | | | | | | |
-A client with a pulsating femur wound.
| | | | | |
-A client with full thickness burns over 50% of the body.
| | | | | | | | | |
Which triage category should the nurse assign to James? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-Priority 1, Color Red. | | |
, The client has many physical, emotional, and psychosocial needs. Which
| | | | | | | | | |
intervention is most important for the nurse to implement upon admission? -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-Establish and maintain an open airway.
| | | | | |
The nurse should document which percentage of body surface? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-45%
James grimaces in pain as the nurse assesses James' red and blistered wounds
| | | | | | | | | | | | |
that are affecting his epidermis and dermis. Based on this assessment, which
| | | | | | | | | | | |
finding best describes the James' burns? - CORRECT ANSWER✔✔-Partial
| | | | | | | | |
thickness or second degree burns. | | | |
Based on the nurse's understanding of the Parkland Formula, which rate correctly
| | | | | | | | | | |
describes the time the fluid is given to the client? - CORRECT ANSWER✔✔-The
| | | | | | | | | | | | | |
nurse administers the first half of the fluid from the time the burn occurred over
| | | | | | | | | | | | | | |
8 hours, and the second half over the following 16 hours.
| | | | | | | | | |
Which action should the nurse take? - CORRECT ANSWER✔✔-Inform the officer
| | | | | | | | | | |
that he must first speak to James' parents.
| | | | | | |
The police officer then asks to see James' ED medical record. Which action should
| | | | | | | | | | | | |
the nurse take concerning this request? - CORRECT ANSWER✔✔-Allow the police
| | | | | | | | | | |
officer access to the requested medical records.
| | | | | | |
Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts
| | | | | | | | | | | | |
of fluid and electrolytes from intravascular to extravascular spaces, which can
| | | | | | | | | | |
lead to cardiovascular collapse. Which assessment relates most directly to a
| | | | | | | | | | |
