HESI RN EXIT CASE STUDY: BURNS UPDATED AND
REVISED IN 2024-2025 DECEMBER
Which action is included when a Level I disaster is declared? -
ANSWER->All local hospitals prepare to receive casualties.
Which action should the nurse implement to help these family
members cope with this tragedy? - ANSWER->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? -
ANSWER->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? - ANSWER->-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 James? -
ANSWER->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? - ANSWER->Establish and maintain
an open airway.
, The nurse should document which percentage of body surface?
- ANSWER->45%
James grimaces in pain as 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? - ANSWER->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? - ANSWER->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.
Which action should the nurse take? - ANSWER->Inform the
officer that he must first speak to James' parents.
The police officer then asks to see James' ED medical record.
Which action should the nurse take concerning this request? -
ANSWER->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
REVISED IN 2024-2025 DECEMBER
Which action is included when a Level I disaster is declared? -
ANSWER->All local hospitals prepare to receive casualties.
Which action should the nurse implement to help these family
members cope with this tragedy? - ANSWER->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? -
ANSWER->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? - ANSWER->-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 James? -
ANSWER->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? - ANSWER->Establish and maintain
an open airway.
, The nurse should document which percentage of body surface?
- ANSWER->45%
James grimaces in pain as 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? - ANSWER->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? - ANSWER->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.
Which action should the nurse take? - ANSWER->Inform the
officer that he must first speak to James' parents.
The police officer then asks to see James' ED medical record.
Which action should the nurse take concerning this request? -
ANSWER->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
