HESI Case Study Burns Exam Questions with Complete Solutions
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Course
Burns
Institution
Burns
Which action is included when a Level I disaster is declared?
Radio stations interrupt broadcasting to declare a state of emergency.
A statewide emergency response team is deployed to the accident site.
Hospital staff from the county hospital report to the disaster site for triage.
All local ...
HESI Case Study Burns Exam Questions
with Complete Solutions
Which action is included when a Level I disaster is declared?
Radio stations interrupt broadcasting to declare a state of emergency.
A statewide emergency response team is deployed to the accident site.
Hospital staff from the county hospital report to the disaster site for triage.
All local hospitals prepare to receive casualties. - Answer-All local hospitals prepare to
receive casualties.
Which action should the nurse implement to help these family members cope with this
tragedy?
Direct all family members to the local EDs immediately.
Designate specific family areas that are staffed with counselors.
Contact the American Red Cross to begin notifying immediate family members.
Refer all family members to the police, who will provide essential information. - 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?
Place a disaster tag securely on each victim.
Communicate with the county emergency room.
Determine which ambulance will transport which client.
Identify a site for the casualties to be taken until identified. - 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? (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.
A client with a crushing head injury.
A client who is alert and oriented with a minor laceration to her forehead. - 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 client?
Priority 1, Color Red.
Priority 2, Color Yellow.
Priority 3, Color Green.
Priority 4, Color Black. - 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?
Attempt to locate his parents.
Determine the depth and extent of his burns.
Administer IV pain medication.
Establish and maintain an open airway. - Answer-Establish and maintain an open
airway.
The ED nurse evaluates client and determines the percentage of body surface burned
according to the Rule of Nines. His burns are noted to be painful, red, moist, and
blistered to the areas to his upper abdomen, and full-thickness burns (third degree) on
his lower abdomen and on both of his anterior and posterior lower legs.
The nurse should document which percentage of body surface?
20%.
45%.
60%.
85%. - Answer-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%.
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 the his burns?
Fourth degree burns.
First degree burns.
Partial thickness or second degree burns.
Full thickness or third degree burns. - Answer-Partial thickness or second degree burns.
Partial thickness wounds are painful, red, and moist and are known for their blistering
appearance.
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