HESI RN CASE STUDY PEDI #1 BURNS
1. Safety and Infection Control
2. 3.ID: 17498029214
EMS personnel triage clients, with multiple casualties noted. Which action should the
triage nurse implement first?
A. Place a disaster tag securely on each victim. Correct
Victim tracking is a critical component in casualty management. Disaster tags are
color-coded and numbered to indicate triage priority. They include the client's
name, address, and age, as well as a description and location of the client's
injuries.
B. Communicate with the county emergency room.
Communication is a key component of disaster management, but it is not the
initial priority for triage personnel.
C. Determine which ambulance will transport which client.
Arranging transportation for clients is important, but it is not the initial priority for
triage personnel.
D. Identify a site for the casualties to be taken until identified.
This is an important intervention for addressing the deaths, but it is not the initial
priority for triage personnel.
Awarded 1.0 points out of 1.0 possible points.
3. 4.ID: 17498029209
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? (Select all that
apply.)
A. A client whose vital signs include respirations at 22 breaths/min , pulse
at 120 beats/min, and blood pressure at 85/52 mmHg. Correct
This client is going into shock and should be seen immediately.
B. A client with a pulsating femur wound. Correct
This client has an arterial bleed and can go into shock and therefore should be
seen immediately.
C. A client with full thickness burns over 50% of the body. Correct
This client should be attended to immediately.
D. A client with a crushing head injury.
This client would probably not survive under the best of circumstances.
E. A client who is alert and oriented with a minor laceration to her
forehead.
This client would be considered a green tag because the client is alert, oriented,
and can wait to be seen.
Awarded 1.0 points out of 1.0 possible points.
4. A young man is carried to the triage area. He is alert and screaming in pain.
He appears to have deep partial-thickness and full-thickness burns on his lower
abdomen and on both of his anterior and posterior lower legs. He states that his
name is James Watt and he is 14 years old. A disaster tag is placed on his left wrist. A
large bore IV is started in his right antecubital area, and a sterile drape is placed over
the lower part of his body.
5. 5.ID: 17498029212
, Which triage category should the nurse assign to James?
A. Priority 1, Color Red. Correct
A client with deep partial-thickness and full-thickness burns on 15% to 40% of his
total body surface area is placed in this immediate category in which injuries are
life threatening but survivable with intervention. Treatment cannot be
delayed.
B. Priority 2, Color Yellow.
This is a delayed category where injuries are significant and require medical care,
but treatment can be delayed 30 to 60 minutes. James does not meet the
guidelines for this category.
C. Priority 3, Color Green.
This is a minimal category where injuries are minor, and treatment can be
delayed several hours. James does not meet the guidelines for this category.
D. Priority 4, Color Black.
This is an expectant category where injuries are extensive and chances of
survival are unlikely, even with definitive care. No treatment is given. James does
not meet the guidelines for this category.
1. Safety and Infection Control
James arrives at the county hospital emergency department via ambulance from the
accident site. He is crying, in severe pain, and asking for his mom and dad.
2. 6.ID: 17498029261
The client has many physical, emotional, and psychosocial needs. Which intervention
is most important for the nurse to implement upon admission?
A. Attempt to locate James' parents.
James needs to have his parents with him, but this is not the priority nursing
intervention at this time.
B. Determine the depth and extent of James' burns.
This intervention is indicated to help determine fluid resuscitation needs,
but it is not the priority intervention at this time.
C. Administer IV pain medication.
Although the administration of pain medication is indicated, it is not the
priority nursing intervention at this time.
D. Establish and maintain an open airway. Correct
The burns on James' trunk can cause constriction leading to a restricted
airway. Additionally, smoke inhalation is always a concern following a fire.
Remember Maslow's Hierarchy of Needs: ensuring an open airway is always
the highest priority nursing intervention.
Awarded 1.0 points out of 1.0 possible points.
3. The ED nurse evaluates James and determines the percentage of body surface
burned according to the Rule of Nines. James’ burns are noted to be painful,
red, moist, and blistered to the areas to his upper abdomen, and full-thickness
burns (third degree) on his lower abdomen and on both of his anterior and
posterior lower legs.
4. 7.ID: 17498029264
1. Safety and Infection Control
2. 3.ID: 17498029214
EMS personnel triage clients, with multiple casualties noted. Which action should the
triage nurse implement first?
A. Place a disaster tag securely on each victim. Correct
Victim tracking is a critical component in casualty management. Disaster tags are
color-coded and numbered to indicate triage priority. They include the client's
name, address, and age, as well as a description and location of the client's
injuries.
B. Communicate with the county emergency room.
Communication is a key component of disaster management, but it is not the
initial priority for triage personnel.
C. Determine which ambulance will transport which client.
Arranging transportation for clients is important, but it is not the initial priority for
triage personnel.
D. Identify a site for the casualties to be taken until identified.
This is an important intervention for addressing the deaths, but it is not the initial
priority for triage personnel.
Awarded 1.0 points out of 1.0 possible points.
3. 4.ID: 17498029209
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? (Select all that
apply.)
A. A client whose vital signs include respirations at 22 breaths/min , pulse
at 120 beats/min, and blood pressure at 85/52 mmHg. Correct
This client is going into shock and should be seen immediately.
B. A client with a pulsating femur wound. Correct
This client has an arterial bleed and can go into shock and therefore should be
seen immediately.
C. A client with full thickness burns over 50% of the body. Correct
This client should be attended to immediately.
D. A client with a crushing head injury.
This client would probably not survive under the best of circumstances.
E. A client who is alert and oriented with a minor laceration to her
forehead.
This client would be considered a green tag because the client is alert, oriented,
and can wait to be seen.
Awarded 1.0 points out of 1.0 possible points.
4. A young man is carried to the triage area. He is alert and screaming in pain.
He appears to have deep partial-thickness and full-thickness burns on his lower
abdomen and on both of his anterior and posterior lower legs. He states that his
name is James Watt and he is 14 years old. A disaster tag is placed on his left wrist. A
large bore IV is started in his right antecubital area, and a sterile drape is placed over
the lower part of his body.
5. 5.ID: 17498029212
, Which triage category should the nurse assign to James?
A. Priority 1, Color Red. Correct
A client with deep partial-thickness and full-thickness burns on 15% to 40% of his
total body surface area is placed in this immediate category in which injuries are
life threatening but survivable with intervention. Treatment cannot be
delayed.
B. Priority 2, Color Yellow.
This is a delayed category where injuries are significant and require medical care,
but treatment can be delayed 30 to 60 minutes. James does not meet the
guidelines for this category.
C. Priority 3, Color Green.
This is a minimal category where injuries are minor, and treatment can be
delayed several hours. James does not meet the guidelines for this category.
D. Priority 4, Color Black.
This is an expectant category where injuries are extensive and chances of
survival are unlikely, even with definitive care. No treatment is given. James does
not meet the guidelines for this category.
1. Safety and Infection Control
James arrives at the county hospital emergency department via ambulance from the
accident site. He is crying, in severe pain, and asking for his mom and dad.
2. 6.ID: 17498029261
The client has many physical, emotional, and psychosocial needs. Which intervention
is most important for the nurse to implement upon admission?
A. Attempt to locate James' parents.
James needs to have his parents with him, but this is not the priority nursing
intervention at this time.
B. Determine the depth and extent of James' burns.
This intervention is indicated to help determine fluid resuscitation needs,
but it is not the priority intervention at this time.
C. Administer IV pain medication.
Although the administration of pain medication is indicated, it is not the
priority nursing intervention at this time.
D. Establish and maintain an open airway. Correct
The burns on James' trunk can cause constriction leading to a restricted
airway. Additionally, smoke inhalation is always a concern following a fire.
Remember Maslow's Hierarchy of Needs: ensuring an open airway is always
the highest priority nursing intervention.
Awarded 1.0 points out of 1.0 possible points.
3. The ED nurse evaluates James and determines the percentage of body surface
burned according to the Rule of Nines. James’ burns are noted to be painful,
red, moist, and blistered to the areas to his upper abdomen, and full-thickness
burns (third degree) on his lower abdomen and on both of his anterior and
posterior lower legs.
4. 7.ID: 17498029264
