BURNS HESI RN 2025/2026
EXAMINATION
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 of Curling's ulcer? - ANSWER-Assess the gastric aspirate for pH and
blood the color of coffee grounds.
,Fluid replacement is noted to be ideal if James produces how much output/hour? -
ANSWER-Urine is recorded as hourly output of 30 mL/kg.
James is receiving an escharotomy to treat his burn complications. Which
information is accurate for the nurse provide to James' parents? - ANSWER-"The
HCP will make an incision in James' leg to relieve the pressure."
While caring for a client who has burns, which nursing intervention is essential in
minimizing James' potential for infection? - ANSWER--Inform James' family
members that plants and flowers are not allowed in James' room.
-Provide visitors with isolation gowns and instruction in hand hygiene.
Cleaning the wound and preventing infection are priorities of care. James is
scheduled for daily total immersion hydrotherapy. Which intervention should the
nurse implement during James' hydrotherapy? - ANSWER--Active range of motion
exercises of his extremities.
-Wash burn areas thoroughly and gently with mild soap and water.
The HCP has prescribed mafenide acetate (Sulfamylon) for James' burned areas for
application to the burn wounds twice a day. Topical agents such as mafenide
acetate (Sulfamylon) solution that deeply penetrate tissue are used to cover the
wound. To prepare the client for this treatment, which intervention should the nurse
implement? - ANSWER-Premedicate with an opioid analgesic 20 minutes prior to
applying this medication.
A burn injury such as James' produces a profound metabolic need. James requires
sufficient nutrients for wound healing and increased metabolic demands. James can
take oral nutrients and requests an evening snack. Which snack is best for the nurse
to provide to James? - ANSWER-A peanut butter sandwich.
, Which action is most important for the nurse to take before the assessment? -
ANSWER-Ask the parents to leave the room before obtaining information from
James.
According to Erikson, which statement by the client indicates that James is
achieving the tasks of his stage of growth and development? - ANSWER-"I really
hate it when my mom kisses me in front of my friends."
James will be in the hospital for at least 1 month. The multidisciplinary healthcare
team discusses how to best meet James' growth and development needs. Which
interventions will meet James' needs during his hospital stay? - ANSWER--Provide
James with cds and video games.
-Obtain a laptop computer with internet access for James.
How should the nurse respond to James? - ANSWER-"If I'm concerned that it will
affect your care, then I will have to tell someone."
Which response by the nurse has the highest priority? - ANSWER-"Have you
thought about how you would kill yourself?"
Which intervention has the highest priority? - ANSWER-Ensure meticulous hand
washing before and after James' care.
Which action should the nurse implement? - ANSWER-Outline the drainage on the
dressing and write the date and time.
EXAMINATION
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 of Curling's ulcer? - ANSWER-Assess the gastric aspirate for pH and
blood the color of coffee grounds.
,Fluid replacement is noted to be ideal if James produces how much output/hour? -
ANSWER-Urine is recorded as hourly output of 30 mL/kg.
James is receiving an escharotomy to treat his burn complications. Which
information is accurate for the nurse provide to James' parents? - ANSWER-"The
HCP will make an incision in James' leg to relieve the pressure."
While caring for a client who has burns, which nursing intervention is essential in
minimizing James' potential for infection? - ANSWER--Inform James' family
members that plants and flowers are not allowed in James' room.
-Provide visitors with isolation gowns and instruction in hand hygiene.
Cleaning the wound and preventing infection are priorities of care. James is
scheduled for daily total immersion hydrotherapy. Which intervention should the
nurse implement during James' hydrotherapy? - ANSWER--Active range of motion
exercises of his extremities.
-Wash burn areas thoroughly and gently with mild soap and water.
The HCP has prescribed mafenide acetate (Sulfamylon) for James' burned areas for
application to the burn wounds twice a day. Topical agents such as mafenide
acetate (Sulfamylon) solution that deeply penetrate tissue are used to cover the
wound. To prepare the client for this treatment, which intervention should the nurse
implement? - ANSWER-Premedicate with an opioid analgesic 20 minutes prior to
applying this medication.
A burn injury such as James' produces a profound metabolic need. James requires
sufficient nutrients for wound healing and increased metabolic demands. James can
take oral nutrients and requests an evening snack. Which snack is best for the nurse
to provide to James? - ANSWER-A peanut butter sandwich.
, Which action is most important for the nurse to take before the assessment? -
ANSWER-Ask the parents to leave the room before obtaining information from
James.
According to Erikson, which statement by the client indicates that James is
achieving the tasks of his stage of growth and development? - ANSWER-"I really
hate it when my mom kisses me in front of my friends."
James will be in the hospital for at least 1 month. The multidisciplinary healthcare
team discusses how to best meet James' growth and development needs. Which
interventions will meet James' needs during his hospital stay? - ANSWER--Provide
James with cds and video games.
-Obtain a laptop computer with internet access for James.
How should the nurse respond to James? - ANSWER-"If I'm concerned that it will
affect your care, then I will have to tell someone."
Which response by the nurse has the highest priority? - ANSWER-"Have you
thought about how you would kill yourself?"
Which intervention has the highest priority? - ANSWER-Ensure meticulous hand
washing before and after James' care.
Which action should the nurse implement? - ANSWER-Outline the drainage on the
dressing and write the date and time.
