BURNS CASE STUDY WITH SOLUTIONS
Which action is included when a Level I disaster is declared? - ✔✔All local hospitals prepare to receive
casualties.
Which action should the nurse implement to help these family members cope with this tragedy? -
✔✔Designate specific family areas that are staffed with counselors.
EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse
implement first? - ✔✔Place a disaster tag securely on each victim.
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? (Select all that apply.) - ✔✔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.
Which triage category should the nurse assign to client? - ✔✔Priority 1, Color Red.
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.
The nurse should document which percentage of body surface? - ✔✔45%.
Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his
epidermis and dermis. Based on this assessment, which finding best describes his burns? - ✔✔Partial
thickness or second degree burns.
Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the
fluid is given to the client? - ✔✔The nurse administers the first half of the fluid from the time the burn
occurred over 8 hours, and the second half over the following 16 hours.
A police officer comes to the ED nursing station and asks to speak to the client concerning the bus
accident because he was sitting at the front of the bus and may have witnessed the accident.
Question 10 of 32
Which action should the nurse take? - ✔✔Inform the officer that he must first speak to the client's
parents.
, The police officer then asks to see client's ED medical record. Which action should the nurse take
concerning this request? - ✔✔Allow the police officer access to the requested medical records.
Burn clients who surpass 20% Total Body Surface Area (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? - ✔✔Assess the gastric aspirate for pH and blood
the color of coffee grounds.
Curling's ulcer is a duodenal ulcer that develops in clients who have severe body surface burns. Coffee
ground vomitus, or aspirate, is a term to describe hemoglobin that is darker because it has been
denatured by acid in the stomach. Gastric ulceration does not occur at a pH above 7.
Fluid replacement is noted to be ideal if client produces how much output/hour? - ✔✔Urine is recorded
as hourly output of 30 mL/kg (30 mL/2.2 lbs).
A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50
mL/2.2 lbs) per hour.
The client is receiving an escharotomy to treat his burn complications. Which information is accurate for
the nurse provide to his parents? - ✔✔"The HCP will make an incision in his leg to relieve the pressure."
An escharotomy is a surgical incision into the eschar to relieve the constricting effect of the burned
tissue. It is appropriate for the nurse to give a client's mother accurate information.
While caring for a client who has burns, which nursing intervention is essential in minimizing client's
potential for infection? (Select all that apply.) - ✔✔-Inform the client's family members that plants and
flowers are not allowed in his room.
Plants and flowers are not allowed because stagnant water is a potential source of bacterial growth.
-Provide visitors with isolation gowns and instruction in hand hygiene.
A major responsibility of the nurse is detecting infection and protecting client from infection. This must
be balanced with the need for 14-year-old client to be able to visit with family and friends.
Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total
immersion hydrotherapy. Which intervention should the nurse implement during his hydrotherapy?
(Select all that apply.) - ✔✔-Active range of motion exercises of his extremities.
Which action is included when a Level I disaster is declared? - ✔✔All local hospitals prepare to receive
casualties.
Which action should the nurse implement to help these family members cope with this tragedy? -
✔✔Designate specific family areas that are staffed with counselors.
EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse
implement first? - ✔✔Place a disaster tag securely on each victim.
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? (Select all that apply.) - ✔✔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.
Which triage category should the nurse assign to client? - ✔✔Priority 1, Color Red.
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.
The nurse should document which percentage of body surface? - ✔✔45%.
Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his
epidermis and dermis. Based on this assessment, which finding best describes his burns? - ✔✔Partial
thickness or second degree burns.
Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the
fluid is given to the client? - ✔✔The nurse administers the first half of the fluid from the time the burn
occurred over 8 hours, and the second half over the following 16 hours.
A police officer comes to the ED nursing station and asks to speak to the client concerning the bus
accident because he was sitting at the front of the bus and may have witnessed the accident.
Question 10 of 32
Which action should the nurse take? - ✔✔Inform the officer that he must first speak to the client's
parents.
, The police officer then asks to see client's ED medical record. Which action should the nurse take
concerning this request? - ✔✔Allow the police officer access to the requested medical records.
Burn clients who surpass 20% Total Body Surface Area (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? - ✔✔Assess the gastric aspirate for pH and blood
the color of coffee grounds.
Curling's ulcer is a duodenal ulcer that develops in clients who have severe body surface burns. Coffee
ground vomitus, or aspirate, is a term to describe hemoglobin that is darker because it has been
denatured by acid in the stomach. Gastric ulceration does not occur at a pH above 7.
Fluid replacement is noted to be ideal if client produces how much output/hour? - ✔✔Urine is recorded
as hourly output of 30 mL/kg (30 mL/2.2 lbs).
A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50
mL/2.2 lbs) per hour.
The client is receiving an escharotomy to treat his burn complications. Which information is accurate for
the nurse provide to his parents? - ✔✔"The HCP will make an incision in his leg to relieve the pressure."
An escharotomy is a surgical incision into the eschar to relieve the constricting effect of the burned
tissue. It is appropriate for the nurse to give a client's mother accurate information.
While caring for a client who has burns, which nursing intervention is essential in minimizing client's
potential for infection? (Select all that apply.) - ✔✔-Inform the client's family members that plants and
flowers are not allowed in his room.
Plants and flowers are not allowed because stagnant water is a potential source of bacterial growth.
-Provide visitors with isolation gowns and instruction in hand hygiene.
A major responsibility of the nurse is detecting infection and protecting client from infection. This must
be balanced with the need for 14-year-old client to be able to visit with family and friends.
Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total
immersion hydrotherapy. Which intervention should the nurse implement during his hydrotherapy?
(Select all that apply.) - ✔✔-Active range of motion exercises of his extremities.
