HESI RN CASE
STUDY PEDI #1
BURNS1. Safety and Infection Control
2. 3.ID: 17498029214
EMS personnel triage clients, with multiple casualties noted.
... [Show More] Which action should the triage nurse implement first?
A. Place a disaster tag securely on each victim. Correct
B. Communicate with the county emergency room.
C. Determine which ambulance will transport which client.
D. Identify a site for the casualties to be taken until identified.
Awarded 1.0 points out of 1.0 possible points.
3. 4.ID: 17498029209
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. A client whose vital signs include respirations at 22 breaths/min , pulse at 120 beats/min, and blood pressure at 85/52 mmHg. Correct
This client is going into shock and should be seen immediately.
B. A client with a pulsating femur wound. Correct
C. A client with full thickness burns over 50% of the body. Correct
This client should be attended to immediately.
D. A client with a crushing head injury.
This client would probably not survive under the best of circumstances.
E. A client who is alert and oriented with a minor laceration to her forehead.
Awarded 1.0 points out of 1.0 possible points.
4. A young man is carried to the triage area. He is alert and screaming in pain. He appears to have deep partial-thickness and full-thickness burns on his lower abdomen and on both of his anterior and posterior lower legs. He states that his name is James Watt and he is 14 years old. A disaster tag is placed on his left wrist. A large bore IV is started in his right antecubital area, and a sterile drape is placed over the lower part of his body.
5. 5.ID: 17498029212
Which triage category should the nurse assign to James?
A. Priority 1, Color Red. Correct
B. Priority 2, Color Yellow.
C. Priority 3, Color Green.
D. Priority 4, Color Black.
1. Safety and Infection Control
James arrives at the county hospital emergency department via ambulance from the accident site. He is crying, in severe pain, and asking for his mom and dad.
2. 6.ID: 17498029261
The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission?
A. Attempt to locate James' parents.
B. Determine the depth and extent of James' burns.
C. Administer IV pain medication.
D. Establish and maintain an open airway. Correct
Awarded 1.0 points out of 1.0 possible points.
3. The ED nurse evaluates James and determines the percentage of body surface burned according to the Rule of Nines. James’ 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. [Show Less]