BURNS CS WITH SOLUTIONS
Meet the Client - ✔✔The Smithville High School band is enroute to a Friday night football game. As the
bus attempts to pass an 18-wheeler on a two lane highway, the bus loses traction and lands on its side,
sliding 500 feet before coming to a stop and then catching on fire. Witnesses immediately dial 911 and
Emergency Medical Services personnel within 10 minutes of the first phone call. James Watt, a 14-year-
old student is trapped by debris and is unable to get out of the bus.
Which action is included when a Level I disaster is declared? - ✔✔All local hospitals prepare to receive
casualties.
Classification as a Level I disaster indicates that local emergency response personnel and organizations
can contain and effectively manage the disaster and its aftermath.
Which action should the nurse implement to help these family members cope with this tragedy? -
✔✔Designate specific family areas that are staffed with counselors.
Family and friends converging on the scene and at local hospitals should be cared for in designated areas
by competent personnel to help decrease anxiety and provide correct information.
EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse
implement first? - ✔✔Place a disaster tag securely on each victim.
Victim tracking is a critical component in casualty management. Disaster tags are color-coded and
numbered to indicate triage priority. They include the client's name, address, and age, as well as a
description and location of the client's injuries.
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? - ✔✔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? - ✔✔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 burns on James' trunk can cause constriction leading to a restricted airway. Additionally, smoke
inhalation is always a concern following a fire. Remember Maslow's Hierarchy of Needs: ensuring an
open airway is always the highest priority nursing intervention.
The nurse should document which percentage of body surface? - ✔✔45%
According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with the upper
torso receiving 9% and the abdomen receiving 9%. Therefore, if the abdomen (9%) and both legs (36%)
are burned, the total percentage is 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? -
✔✔Partial thickness or second degree burns.
Partial thickness wounds are painful, red, and moist and are known for their blistering appearance.
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.
The first half is given over the first 8 hours from the time the burn occurred, and the second half over the
following 16 hours.
Which action should the nurse take? - ✔✔Inform the officer that he must first speak to James' parents.
James is a minor, so his parents must be present when he is talking to a representative of the police
department.
The police officer then asks to see James' ED medical record. Which action should the nurse take
concerning this request? - ✔✔Allow the police officer access to the requested medical records.
Meet the Client - ✔✔The Smithville High School band is enroute to a Friday night football game. As the
bus attempts to pass an 18-wheeler on a two lane highway, the bus loses traction and lands on its side,
sliding 500 feet before coming to a stop and then catching on fire. Witnesses immediately dial 911 and
Emergency Medical Services personnel within 10 minutes of the first phone call. James Watt, a 14-year-
old student is trapped by debris and is unable to get out of the bus.
Which action is included when a Level I disaster is declared? - ✔✔All local hospitals prepare to receive
casualties.
Classification as a Level I disaster indicates that local emergency response personnel and organizations
can contain and effectively manage the disaster and its aftermath.
Which action should the nurse implement to help these family members cope with this tragedy? -
✔✔Designate specific family areas that are staffed with counselors.
Family and friends converging on the scene and at local hospitals should be cared for in designated areas
by competent personnel to help decrease anxiety and provide correct information.
EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse
implement first? - ✔✔Place a disaster tag securely on each victim.
Victim tracking is a critical component in casualty management. Disaster tags are color-coded and
numbered to indicate triage priority. They include the client's name, address, and age, as well as a
description and location of the client's injuries.
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? - ✔✔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? - ✔✔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 burns on James' trunk can cause constriction leading to a restricted airway. Additionally, smoke
inhalation is always a concern following a fire. Remember Maslow's Hierarchy of Needs: ensuring an
open airway is always the highest priority nursing intervention.
The nurse should document which percentage of body surface? - ✔✔45%
According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with the upper
torso receiving 9% and the abdomen receiving 9%. Therefore, if the abdomen (9%) and both legs (36%)
are burned, the total percentage is 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? -
✔✔Partial thickness or second degree burns.
Partial thickness wounds are painful, red, and moist and are known for their blistering appearance.
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.
The first half is given over the first 8 hours from the time the burn occurred, and the second half over the
following 16 hours.
Which action should the nurse take? - ✔✔Inform the officer that he must first speak to James' parents.
James is a minor, so his parents must be present when he is talking to a representative of the police
department.
The police officer then asks to see James' ED medical record. Which action should the nurse take
concerning this request? - ✔✔Allow the police officer access to the requested medical records.
