HESI Case Studies–Pediatrics-Burns (David Harper)
1. Which action is included when a level 1 disaster is declared?
All local hospitals prepare to receive casualties
2. Some parents call the local emergency rooms in an attempt to learn where their children will be transferred. Which action should be implemented to help these family members?
Designate specific family areas that are staffed with counselors
3. Paramedics are triaging clients at the accident site. Which action is implemented by the triage personnel.
Place a disaster tag securely on each victim
4. Which of the following clients would be given a red tag? (Select all)
-A client whose vitals signs are as follows: RR 22, HR 120, BP 85/52
-A client with a pulsating femur wound
-A client with full-thickness burns over 50% of the body
5. Into which triage category should David be placed?
Priority 1, Color red
6. What is the priority nursing intervention upon admission?
Establish and maintain an open airway
7. The RN should document which percentage of body surface?
8. Which intervention will the RN implement?
Administer the LR solution as prescribed via an infusion pump
9. Which action should the RN take?
Inform the officer that he must first speak to David’s parents
10. Which action should the RN take concerning this request?
Allow the police officer access to the requested medical records
11. Which nursing diagnosis has the highest priority in the emergent phase?
Fluid volume deficit related to increased capillary permeability
12. Which intervention will the RN implement to assess for Curling’s ulcer?
Assess the gastric aspirate for pH and blood the color of coffee grounds
13. Which action should the nurse implement?
Notify the HCP immediately
14. How should the RN respond?
“The HCP will make an incision in David’s leg to relieve the pressure.”
15. Which action should the RN implement? (Select all)
-Inform David’s family members that plants and flowers are not allowed in David’s room
-Provide visitors with isolation gowns and instruction in hand hygiene
16. Which intervention should the nurse implement during David’s hydrotherapy? (Select all)
-Active range of motion exercises of his extremities
-Wash burn areas thoroughly and gently with mild soap and water
17. Which intervention should the RN implement?
Premedicate with an opioid analgesic 20 minutes prior to applying this medication
18. Which snack is best for the RN to provide to David?
A peanut butter sandwich
19. Which action should the RN take before completing the assessment?
Ask the parents to leave the room before obtaining information from David
20. According to Erikson, which statement by the client indicates that he 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.”
21. Which interventions will meet David’s needs during his hospital stay? (Select all)
-Provide David with compact discs and video games
-Obtain a laptop computer with internet access for David
22. How should the RN respond to David?
“If I believe it affects your care, I will have to tell someone.”
23. Which response by the RN has the highest priority?
“Have you thought about how you would kill yourself?”
24. Which intervention has the highest priority?
Ensure meticulous hand washing before and after David’s care
25. Which action should the RN implement?
Outline the drainage on the dressing and write the date and time
26. How should the RN respond?
“The skin will probably be taken from your son’s back.”
27. There is a prescription for morphine 2mg IV push every 4-6 hours PRN. The RN determines that David could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10mg/mL. How much morphine will the supervising RN administer to David?
28. What action should the RN implement?
Document this assessment in David’s chart
29. How should the RN explain to David the rationale for wearing these pressure garments?
“The pressure stocking will help prevent scarring that could occur while the burn is healing.”
30. Which action should the RN implement?
Refer David to an adolescent burn support group
31. Which action should be implemented to address this issue?
Determine if there is a family member who can stay with David during the day
32. Which discharge preparation has the highest priority?
Provide specific written instructions for David’s home care before releasing him to go home