Hesi Case Study Pediatric Burns

1. Which action is included when a Level I disaster is declared?
All local hospitals prepare to receive casualties.
2. Which action should be implemented to help these family members?
Designate specific family areas that are staffed with counselors.
3. Which action is implemented first by the triage personnel?
Place a disaster tag securely on each victim.
4.
Burn
leg
5. Into which triage category should David be placed?
Priority 1, Color Red.

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6. What is the priority nursing intervention upon admission?
Establish and maintain an open airway.
The nurse should document which percentage of body surface?
45%

According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with 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%.

Which intervention will the nurse implement?
Administer the Lactated Ringer’s solution as prescribed via an infusion pum
Which action should the nurse take?
Inform the officer that he must first speak to David’s parents.
9. Which action should the nurse take concerning this request?
Allow the police officer access to the requested medical records.
10. Which nursing diagnosis has the highest priority in the emergent phase?
Fluid volume deficit related to increased capillary permeability.
Which intervention will the nurse implement to assess for Curling’s ulcer?
Assess the gastric aspirate for pH and blood the color of coffee grounds.
Which action should the nurse implement?
Notify the healthcare provider immediately.
How should the nurse respond?
“The healthcare provider will make an incision in David’s leg to relieve the pressure.”
14. Which action should the nurse implement?
Provide visitors with isolation gowns and instruction in hand hygiene.
15. Which intervention should the nurse implement during David’s hydrotherapy?.
Active range of motion exercises of his extremities.
16. Which intervention should the nurse implement?
Premedicate with an opioid analgesic 20 minutes prior to applying this medication.
Which snack is best for the nurse to provide David?
Peanut butter sandwich
Which action should the nurse take before completing the assessment?
Ask the parents to leave the room before obtaining information from David.
20. Which intervention will meet David’s needs during his hospital stay?
Provide David with compact discs and video games.
21. How should the nurse respond to David?
“If I believe it affects your care, I will have to tell someone.”
22. Which response by the nurse has the highest priority?
“Have you thought about how you would kill yourself?”
23. Which intervention has the highest priority?
Ensure meticulous hand washing before and after David’s care.
24. Which action should the nurse implement?
Outline the drainage on the dressing and write the date and time.
25. How should the nurse respond?
“The skin will probably be taken from your son’s back.”
How much morphine should the nurse give?
0.2 ml
What action should the nurse implement?
Document this assessment in David’s chart.
How should the nurse 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.”
Which action should the nurse implement?
Refer David to an adolescent burn support group.
Which action should be implemented to address this issue?
Determine if there is any family member that can stay with David during the day.
Which discharge preparation has the highest priority?
Provide specific written instructions for David’s home care before releasing him to go home.
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