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HESI RN EXIT CASE STUDY: BURNS 1. Which action is included when a Level I disaster is declared ANS: All local hospitals prepare to receive casualties. 2. Which action should the nurse implement to help these family members cope with this tragedy ANS: Designate specific family areas that are staffed with counselors. 3. EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first ANS: Place a disaster tag securely on each victim. 4. 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 ANS: -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. 5. Which triage category should the nurse assign to James ANS: Priority 1, Color Red. 6. 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. 7. The nurse should document which percentage of body surface ANS: 45% 8. James grimaces in pain as the nurse assesses James' red and blistered wounds that are affecting his epidermis and dermis. Based on this assess- ment, which finding best describes the James' burns ANS: Partial thickness or second degree burns. 9. Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client ANS: The nurse admin- isters the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. 10. Which action should the nurse take ANS: Inform the officer that he must first speak to James' parents.
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