HESI RN Case Study: Burns | Questions and Answers
Terms in this set (32)
Which action is included when All local hospitals prepare to receive casualties.
a Level I disaster is
declared?
Which action should the nurse Designate specific family areas that are staffed with counselors.
implement to help these
family members cope with
this tragedy?
EMS personnel triage clients, Place a disaster tag securely on each victim.
with multiple casualties noted.
Which action should the
triage nurse implement
first?
Triage determines in what -A client whose vital signs include respirations at 22
order a client is seen by a breaths/min , pulse at 120 beats/min, and blood pressure at
healthcare provider (HCP). 85/52 mmHg.
Which of the following clients -A client with a pulsating femur wound.
would the nurse identify -A client with full thickness burns over 50% of the body.
with a red tag?
Which triage category should Priority 1, Color Red.
the nurse assign to James?
The client has many Establish and maintain an open airway.
physical, emotional, and
psychosocial needs. Which
intervention is most important
for the nurse to implement
upon admission?
The nurse should document 45%
which percentage of body
surface?
, James grimaces in pain as Partial thickness or second degree burns.
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?
Based on the nurse's The nurse administers the first half of the fluid from the time
understanding of the the burn occurred over 8 hours, and the second half over
Parkland Formula, which the following 16 hours.
rate correctly describes the
time the fluid is given to the
client?
Which action should the nurse Inform the officer that he must first speak to James' parents.
take?
The police officer then asks to Allow the police officer access to the requested medical records.
see James' ED medical
record. Which action should
the nurse take concerning
this request?
Burn clients who surpass Assess the gastric aspirate for pH and blood the color of coffee
20% Total Body Surface Area grounds.
(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
diagnosis of
Curling's ulcer?
Fluid replacement is noted Urine is recorded as hourly output of 30 mL/kg.
to be ideal if James produces
how much output/hour?
James is receiving an "The HCP will make an incision in James' leg to relieve the pressure."
escharotomy to treat his burn
complications. Which
information is accurate for the
nurse provide to James'
Terms in this set (32)
Which action is included when All local hospitals prepare to receive casualties.
a Level I disaster is
declared?
Which action should the nurse Designate specific family areas that are staffed with counselors.
implement to help these
family members cope with
this tragedy?
EMS personnel triage clients, Place a disaster tag securely on each victim.
with multiple casualties noted.
Which action should the
triage nurse implement
first?
Triage determines in what -A client whose vital signs include respirations at 22
order a client is seen by a breaths/min , pulse at 120 beats/min, and blood pressure at
healthcare provider (HCP). 85/52 mmHg.
Which of the following clients -A client with a pulsating femur wound.
would the nurse identify -A client with full thickness burns over 50% of the body.
with a red tag?
Which triage category should Priority 1, Color Red.
the nurse assign to James?
The client has many Establish and maintain an open airway.
physical, emotional, and
psychosocial needs. Which
intervention is most important
for the nurse to implement
upon admission?
The nurse should document 45%
which percentage of body
surface?
, James grimaces in pain as Partial thickness or second degree burns.
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?
Based on the nurse's The nurse administers the first half of the fluid from the time
understanding of the the burn occurred over 8 hours, and the second half over
Parkland Formula, which the following 16 hours.
rate correctly describes the
time the fluid is given to the
client?
Which action should the nurse Inform the officer that he must first speak to James' parents.
take?
The police officer then asks to Allow the police officer access to the requested medical records.
see James' ED medical
record. Which action should
the nurse take concerning
this request?
Burn clients who surpass Assess the gastric aspirate for pH and blood the color of coffee
20% Total Body Surface Area grounds.
(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
diagnosis of
Curling's ulcer?
Fluid replacement is noted Urine is recorded as hourly output of 30 mL/kg.
to be ideal if James produces
how much output/hour?
James is receiving an "The HCP will make an incision in James' leg to relieve the pressure."
escharotomy to treat his burn
complications. Which
information is accurate for the
nurse provide to James'
