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