HESI Case Study: Burns Q&A
Meet the Client
The Smithville High School band is enroute to a Friday night football game. As the bus
attempts to pass an 18-wheeler on a two lane highway, the bus loses traction and lands
on its side, sliding 500 feet before coming to a stop and then catching on fire. Witnesses
immediately dial 911 and Emergency Medical Services personnel within 10 minutes of
the first phone call. James Watt, a 14-year-old student is trapped by debris and is
unable to get out of the bus.
Which action is included when a Level I disaster is declared?
All local hospitals prepare to receive casualties.
Which action should the nurse implement to help these family members cope
with this tragedy?
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?
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?
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?
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?
Establish and maintain an open airway.
The nurse should document which percentage of body surface?
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?
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?
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?
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?
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
Meet the Client
The Smithville High School band is enroute to a Friday night football game. As the bus
attempts to pass an 18-wheeler on a two lane highway, the bus loses traction and lands
on its side, sliding 500 feet before coming to a stop and then catching on fire. Witnesses
immediately dial 911 and Emergency Medical Services personnel within 10 minutes of
the first phone call. James Watt, a 14-year-old student is trapped by debris and is
unable to get out of the bus.
Which action is included when a Level I disaster is declared?
All local hospitals prepare to receive casualties.
Which action should the nurse implement to help these family members cope
with this tragedy?
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?
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?
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?
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?
Establish and maintain an open airway.
The nurse should document which percentage of body surface?
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?
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?
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?
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?
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
