HESI RN Case Study: Burns

HESI RN Case Study: Burns

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Teacher 33 terms Wordy_walnut Preview Cleft Li 34 terms Sno Which action is included when a Level I disaster is declared?All local hospitals prepare to receive casualties.Which action should the nurse implement to help these family members cope with this tragedy?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.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 nurse should document which percentage of body surface?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.

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.Which action should the nurse take?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?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?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?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?"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?-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?-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?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?A peanut butter sandwich.Which action is most important for the nurse to take before the assessment?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?"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?-Provide James with cds and video games.-Obtain a laptop computer with internet access for James.How should the nurse respond to James?"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? "Have you thought about how you would kill yourself?" Which intervention has the highest priority?Ensure meticulous hand washing before and after James' care.Which action should the nurse implement?Outline the drainage on the dressing and write the date and time.How should the nurse respond?"The skin will probably be taken from your son's back." After the autograft, James is returned to his room. One hour after James returns to his room, he is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump.There is a prescription for morphine 4 mg IV push every 4 to 6 hours PRN for break through pain.The nurse determines that James could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the supervising nurse administer to James? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 0.4 The nurse assesses both of James' graft sites and notes that the gauze dressing over the donor site is moist and intact. What action should the nurse implement?Document this assessment in James' chart.How should the nurse explain to James the rationale for wearing these pressure garments?"The pressure stocking will help prevent scarring that could occur while the burn is healing." Which action should the nurse implement?Refer James to an adolescent burn support group.Which action should be implemented to address this issue?Determine if there is a family member who can stay with James during the day.Which discharge preparation has the highest priority? Provide specific written instructions for James' home care before releasing him to go home.