NU272 Case Study: Burns (week 3) Questions and
Answers Rated A
Meet the client - ANSWER -A high school these family members cope with this tragedy? -
band is enroute to a Friday night football game. ANSWER -Designate specific family areas
As the bus attempts to pass an 18-wheeler on a that are staffed with counselors.
two lane highway, the bus loses traction and - Family and friends converging on the scene and
lands on its side, sliding 500 feet before coming at local hospitals should be cared for in
to a stop and then catching on fire. Witnesses designated areas by competent personnel to help
immediately dial 911 and Emergency Medical decrease anxiety and provide correct information.
Services personnel (EMS) arrive within 10
minutes of the first phone call. A 14-year-old
male student is trapped by debris and is unable EMS personnel triage clients, with multiple
to get out of the bus. casualties noted. Which action should the triage
nurse implement first? - ANSWER -Place a
disaster tag securely on each victim.
Safety and Infection Control - ANSWER - - Victim tracking is a critical component in
After arriving on the scene, the immediacy of the casualty management. Disaster tags are color-
situation is apparent and paramedics notify the coded and numbered to indicate triage priority.
county hospital emergency department (ED). The They include the client's name, address, and age,
ED personnel initiate the emergency operations as well as a description and location of the
plan (EOP) and a Level I disaster is declared. client's injuries.
Which action is included when a Level I disaster Triage determines in what order a client is seen
is declared? - ANSWER -All local hospitals by a healthcare provider (HCP). Which of the
prepare to receive casualties. following clients would the nurse identify with a
red tag? (Select all that apply.) -
- Classification as a Level I disaster indicates that ANSWER -
local emergency response personnel and - A client whose vital signs include respirations at
organizations can contain and effectively 22 breaths/min, pulse at 120 beats/min, and
manage the disaster and its aftermath. blood pressure at 85/52 mmHg. (This client is
going into shock and should be seen
immediately)
The fire fighters quickly extinguish the flames - A client with a pulsating femur wound. (This
from the bus and it is noted by EMS personnel client has an arterial bleed and can go into shock
that the situation is escalating quickly. The and therefore should be seen immediately.)
parents of some of the band members were - A client with full thickness burns over 50% of
following the bus to the football game and the body. (This client should be attended to
witnessed the accident. While EMS personnel try immediately.)
to care for students, parents are asking
questions and attempting to get to the bus. Some
parents call the EDs in an attempt to learn where A young man is carried to the triage area. He is
their children will be transferred. - alert and screaming in pain. He appears to have
ANSWER -- deep partial-thickness and full-thickness burns on
his lower abdomen and on both of his anterior
and posterior lower legs. He states his name and
Which action should the nurse implement to help he is 14 years old. A disaster tag is placed on his
1/7
, NU272 Case Study: Burns (week 3) Questions and
Answers Rated A
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. - The nurse should document which percentage of
ANSWER -- body surface? - ANSWER -45%.
- According to the Rule of Nines, lower
extremities are 18% each. The front trunk is 18%,
Which triage category should the nurse assign to with the upper torso receiving 9% and the
client? - ANSWER -Priority 1, Color Red. abdomen receiving 9%. Therefore, if the
- A client with deep partial-thickness and full- abdomen (9%) and both legs (36%) are burned,
thickness burns on 15% to 40% of his total body the total percentage is 45%.
surface area is placed in this immediate category
in which injuries are life threatening but
survivable with intervention. Treatment cannot be Client grimaces in pain as the nurse assesses his
delayed. red and blistered wounds that are affecting his
epidermis and dermis. Based on this
assessment, which finding best describes the his
Safety and Infection Control - ANSWER - burns? - ANSWER -Partial thickness or
Client arrives at the county hospital emergency second degree burns.
department (ED) via ambulance from the - Partial thickness wounds are painful, red, and
accident site. He is crying, in severe pain, and moist and are known for their blistering
asking for his mom and dad. appearance.
The client has many physical, emotional, and A client with a burn injury is at significant risk for
psychosocial needs. Which intervention is most hypovolemia from fluid loss and fluid movement
important for the nurse to implement upon from increased capillary permeability and
admission? - ANSWER -Establish and vasodilation. The ED HCP inserts a central
maintain an open airway. venous catheter via the subclavian vein and
- The burns on client's trunk can cause prescribes sodium lactate/Hartmann's solution
constriction leading to a restricted airway. (RL) at 1,000 mL/hr. Fluid volume requirements
Additionally, smoke inhalation is always a are calculated using an accepted formula such as
concern following a fire. Remember Maslow's the Parkland Formula to adequately hydrate
Hierarchy of Needs: ensuring an open airway is client. - ANSWER --
always the highest priority nursing intervention.
Based on the nurse's understanding of the
The ED nurse evaluates client and determines Parkland Formula, which rate correctly describes
the percentage of body surface burned according the time the fluid is given to the client? -
to the Rule of Nines. His burns are noted to be ANSWER -The nurse administers the first
painful, red, moist, and blistered to the areas to half of the fluid from the time the burn occurred
his upper abdomen, and full-thickness burns over 8 hours, and the second half over the
(third degree) on his lower abdomen and on both following 16 hours.
of his anterior and posterior lower legs. - - The first half is given over the first 8 hours from
ANSWER -- the time the burn occurred, and the second half
2/7
Answers Rated A
Meet the client - ANSWER -A high school these family members cope with this tragedy? -
band is enroute to a Friday night football game. ANSWER -Designate specific family areas
As the bus attempts to pass an 18-wheeler on a that are staffed with counselors.
two lane highway, the bus loses traction and - Family and friends converging on the scene and
lands on its side, sliding 500 feet before coming at local hospitals should be cared for in
to a stop and then catching on fire. Witnesses designated areas by competent personnel to help
immediately dial 911 and Emergency Medical decrease anxiety and provide correct information.
Services personnel (EMS) arrive within 10
minutes of the first phone call. A 14-year-old
male student is trapped by debris and is unable EMS personnel triage clients, with multiple
to get out of the bus. casualties noted. Which action should the triage
nurse implement first? - ANSWER -Place a
disaster tag securely on each victim.
Safety and Infection Control - ANSWER - - Victim tracking is a critical component in
After arriving on the scene, the immediacy of the casualty management. Disaster tags are color-
situation is apparent and paramedics notify the coded and numbered to indicate triage priority.
county hospital emergency department (ED). The They include the client's name, address, and age,
ED personnel initiate the emergency operations as well as a description and location of the
plan (EOP) and a Level I disaster is declared. client's injuries.
Which action is included when a Level I disaster Triage determines in what order a client is seen
is declared? - ANSWER -All local hospitals by a healthcare provider (HCP). Which of the
prepare to receive casualties. following clients would the nurse identify with a
red tag? (Select all that apply.) -
- Classification as a Level I disaster indicates that ANSWER -
local emergency response personnel and - A client whose vital signs include respirations at
organizations can contain and effectively 22 breaths/min, pulse at 120 beats/min, and
manage the disaster and its aftermath. blood pressure at 85/52 mmHg. (This client is
going into shock and should be seen
immediately)
The fire fighters quickly extinguish the flames - A client with a pulsating femur wound. (This
from the bus and it is noted by EMS personnel client has an arterial bleed and can go into shock
that the situation is escalating quickly. The and therefore should be seen immediately.)
parents of some of the band members were - A client with full thickness burns over 50% of
following the bus to the football game and the body. (This client should be attended to
witnessed the accident. While EMS personnel try immediately.)
to care for students, parents are asking
questions and attempting to get to the bus. Some
parents call the EDs in an attempt to learn where A young man is carried to the triage area. He is
their children will be transferred. - alert and screaming in pain. He appears to have
ANSWER -- deep partial-thickness and full-thickness burns on
his lower abdomen and on both of his anterior
and posterior lower legs. He states his name and
Which action should the nurse implement to help he is 14 years old. A disaster tag is placed on his
1/7
, NU272 Case Study: Burns (week 3) Questions and
Answers Rated A
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. - The nurse should document which percentage of
ANSWER -- body surface? - ANSWER -45%.
- According to the Rule of Nines, lower
extremities are 18% each. The front trunk is 18%,
Which triage category should the nurse assign to with the upper torso receiving 9% and the
client? - ANSWER -Priority 1, Color Red. abdomen receiving 9%. Therefore, if the
- A client with deep partial-thickness and full- abdomen (9%) and both legs (36%) are burned,
thickness burns on 15% to 40% of his total body the total percentage is 45%.
surface area is placed in this immediate category
in which injuries are life threatening but
survivable with intervention. Treatment cannot be Client grimaces in pain as the nurse assesses his
delayed. red and blistered wounds that are affecting his
epidermis and dermis. Based on this
assessment, which finding best describes the his
Safety and Infection Control - ANSWER - burns? - ANSWER -Partial thickness or
Client arrives at the county hospital emergency second degree burns.
department (ED) via ambulance from the - Partial thickness wounds are painful, red, and
accident site. He is crying, in severe pain, and moist and are known for their blistering
asking for his mom and dad. appearance.
The client has many physical, emotional, and A client with a burn injury is at significant risk for
psychosocial needs. Which intervention is most hypovolemia from fluid loss and fluid movement
important for the nurse to implement upon from increased capillary permeability and
admission? - ANSWER -Establish and vasodilation. The ED HCP inserts a central
maintain an open airway. venous catheter via the subclavian vein and
- The burns on client's trunk can cause prescribes sodium lactate/Hartmann's solution
constriction leading to a restricted airway. (RL) at 1,000 mL/hr. Fluid volume requirements
Additionally, smoke inhalation is always a are calculated using an accepted formula such as
concern following a fire. Remember Maslow's the Parkland Formula to adequately hydrate
Hierarchy of Needs: ensuring an open airway is client. - ANSWER --
always the highest priority nursing intervention.
Based on the nurse's understanding of the
The ED nurse evaluates client and determines Parkland Formula, which rate correctly describes
the percentage of body surface burned according the time the fluid is given to the client? -
to the Rule of Nines. His burns are noted to be ANSWER -The nurse administers the first
painful, red, moist, and blistered to the areas to half of the fluid from the time the burn occurred
his upper abdomen, and full-thickness burns over 8 hours, and the second half over the
(third degree) on his lower abdomen and on both following 16 hours.
of his anterior and posterior lower legs. - - The first half is given over the first 8 hours from
ANSWER -- the time the burn occurred, and the second half
2/7
