Download HESI RN EXIT CASE STUDY: BURNS and more Exams Medicine in PDF only on Docsity!
HESI RN EXIT CASE STUDY: BURNS
1. Which action is included when a Level I disaster is declared
ANS: All local hospitals prepare to receive casualties.
2. Which action should the nurse implement to help these family members cope with this tragedy
ANS: Designate specific family areas that are staffed with counselors.
3. EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse
implement first ANS: Place a disaster tag securely on each victim.
4. 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 ANS: -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.
5. Which triage category should the nurse assign to James
ANS: Priority 1, Color Red.
6. 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.
7. The nurse should document which percentage of body surface
ANS: 45%
8. James grimaces in pain as the nurse assesses James' red and blistered wounds that are
affecting his epidermis and dermis. Based on this assess- ment, which finding best describes the James' burns ANS: Partial thickness or second degree burns.
9. Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the
time the fluid is given to the client ANS: The nurse admin- isters the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours.
10. Which action should the nurse take
ANS: Inform the officer that he must first speak to James' parents.
11. The police officer then asks to see James' ED medical record. Which action should the nurse take
concerning this request ANS: Allow the police officer access to the requested medical records.
12. Burn clients who surpass 20% Total Body Surface Area (TBSA) have mas- sive 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 ANS: Assess the gastric aspirate for pH and blood the color of coffee grounds.
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.
22. How should the nurse respond to James
ANS: "If I'm concerned that it will affect your care, then I will have to tell someone."
23. Which response by the nurse has the highest priority
ANS: "Have you thought about how you would kill yourself?"
24. Which intervention has the highest priority
ANS: Ensure meticulous hand wash- ing before and after James' care.
25. Which action should the nurse implement
ANS: Outline the drainage on the dressing and write the date and time.
26. How should the nurse respond
ANS: "The skin will probably be taken from your son's back."
27. 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.
28. The nurse assesses both of James' graft sites and notes that the gauze dressing over the donor
site is moist and intact. What action should the nurse implement ANS: Document this assessment in James' chart.
29. How should the nurse explain to James the rationale for wearing these pressure garments
ANS: "The pressure stocking will help prevent scarring that could occur while the burn is healing."
30. Which action should the nurse implement
ANS: Refer James to an adolescent burn support group.
31. Which action should be implemented to address this issue
ANS: Determine if there is a family member who can stay with James during the day.
32. Which discharge preparation has the highest priority
ANS: Provide specific written instructions for James' home care before releasing him to go home.
