HESI Case Study: Burns Questions & Answers latest
update 2024-25
While caring for a client who has burns, which nursing intervention is essential in minimizing
James' potential for infection? - ✔✔Inform James' family members that plants and flowers
are not allowed in James' room. Provide visitors with isolation gowns and instruction in hand
hygiene.
Cleaning the wound and preventing infection are priorities of care. James is scheduled for daily
total immersion hydrotherapy. Which intervention should the nurse implement during James'
hydrotherapy? - ✔✔Active range of motion exercises of his extremities.
Wash burn areas thoroughly and gently with mild soap and water.
The HCP has prescribed mafenide acetate (Sulfamylon) for James' burned areas for application
to the burn wounds twice a day. Topical agents such as mafenide acetate (Sulfamylon) solution
that deeply penetrate tissue are used to cover the wound. To prepare the client for this
treatment, which intervention should the nurse implement? - ✔✔Premedicate with an
opioid analgesic 20 minutes prior to applying this medication.
A burn injury such as James' produces a profound metabolic need. James requires sufficient
nutrients for wound healing and increased metabolic demands. James can take oral nutrients
and requests an evening snack. Which snack is best for the nurse to provide to James? -
✔✔A peanut butter sandwich.
Which action is most important for the nurse to take before the assessment? - ✔✔Ask the
parents to leave the room before obtaining information from James.
According to Erikson, which statement by the client indicates that James is achieving the tasks
of his stage of growth and development? - ✔✔"I really hate it when my mom kisses me in
front of my friends."
, James will be in the hospital for at least 1 month. The multidisciplinary healthcare team
discusses how to best meet James' growth and development needs. Which interventions will
meet James' needs during his hospital stay? - ✔✔Provide James with cds and video games.
Obtain a laptop computer with internet access for James.
How should the nurse respond to James? - ✔✔"If I'm concerned that it will affect your care,
then I will have to tell someone."
Which response by the nurse has the highest priority? - ✔✔"Have you thought about how
you would kill yourself?"
Which intervention has the highest priority? - ✔✔Ensure meticulous hand washing before
and after James' care.
Which action should the nurse implement? - ✔✔Outline the drainage on the dressing and
write the date and time.
How should the nurse respond? - ✔✔"The skin will probably be taken from your son's back."
After the autograft, James is returned to his room. One hour after James returns to his room,
he is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the
pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump.
There is a prescription for morphine 4 mg IV push every 4 to 6 hours PRN for break through
pain.The nurse determines that James could use a PRN dose of morphine for his break through
pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the supervising
nurse administer to James? (Enter the numerical value only. If rounding is required, round to
the nearest tenth.) - ✔✔0.4
update 2024-25
While caring for a client who has burns, which nursing intervention is essential in minimizing
James' potential for infection? - ✔✔Inform James' family members that plants and flowers
are not allowed in James' room. Provide visitors with isolation gowns and instruction in hand
hygiene.
Cleaning the wound and preventing infection are priorities of care. James is scheduled for daily
total immersion hydrotherapy. Which intervention should the nurse implement during James'
hydrotherapy? - ✔✔Active range of motion exercises of his extremities.
Wash burn areas thoroughly and gently with mild soap and water.
The HCP has prescribed mafenide acetate (Sulfamylon) for James' burned areas for application
to the burn wounds twice a day. Topical agents such as mafenide acetate (Sulfamylon) solution
that deeply penetrate tissue are used to cover the wound. To prepare the client for this
treatment, which intervention should the nurse implement? - ✔✔Premedicate with an
opioid analgesic 20 minutes prior to applying this medication.
A burn injury such as James' produces a profound metabolic need. James requires sufficient
nutrients for wound healing and increased metabolic demands. James can take oral nutrients
and requests an evening snack. Which snack is best for the nurse to provide to James? -
✔✔A peanut butter sandwich.
Which action is most important for the nurse to take before the assessment? - ✔✔Ask the
parents to leave the room before obtaining information from James.
According to Erikson, which statement by the client indicates that James is achieving the tasks
of his stage of growth and development? - ✔✔"I really hate it when my mom kisses me in
front of my friends."
, James will be in the hospital for at least 1 month. The multidisciplinary healthcare team
discusses how to best meet James' growth and development needs. Which interventions will
meet James' needs during his hospital stay? - ✔✔Provide James with cds and video games.
Obtain a laptop computer with internet access for James.
How should the nurse respond to James? - ✔✔"If I'm concerned that it will affect your care,
then I will have to tell someone."
Which response by the nurse has the highest priority? - ✔✔"Have you thought about how
you would kill yourself?"
Which intervention has the highest priority? - ✔✔Ensure meticulous hand washing before
and after James' care.
Which action should the nurse implement? - ✔✔Outline the drainage on the dressing and
write the date and time.
How should the nurse respond? - ✔✔"The skin will probably be taken from your son's back."
After the autograft, James is returned to his room. One hour after James returns to his room,
he is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the
pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump.
There is a prescription for morphine 4 mg IV push every 4 to 6 hours PRN for break through
pain.The nurse determines that James could use a PRN dose of morphine for his break through
pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the supervising
nurse administer to James? (Enter the numerical value only. If rounding is required, round to
the nearest tenth.) - ✔✔0.4
