HESI Case Studies–Pediatrics-Burns (David Harper) – Flashcards
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1. Which action is included when a level 1 disaster is declared?
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All local hospitals prepare to receive casualties
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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?
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Designate specific family areas that are staffed with counselors
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3. Paramedics are triaging clients at the accident site. Which action is implemented by the triage personnel.
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Place a disaster tag securely on each victim
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4. Which of the following clients would be given a red tag? (Select all)
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-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
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5. Into which triage category should David be placed?
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Priority 1, Color red
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6. What is the priority nursing intervention upon admission?
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Establish and maintain an open airway
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7. The RN should document which percentage of body surface?
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45%
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8. Which intervention will the RN implement?
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Administer the LR solution as prescribed via an infusion pump
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9. Which action should the RN take?
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Inform the officer that he must first speak to David's parents
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10. Which action should the RN take concerning this request?
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Allow the police officer access to the requested medical records
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11. Which nursing diagnosis has the highest priority in the emergent phase?
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Fluid volume deficit related to increased capillary permeability
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12. Which intervention will the RN implement to assess for Curling's ulcer?
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Assess the gastric aspirate for pH and blood the color of coffee grounds
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13. Which action should the nurse implement?
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Notify the HCP immediately
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14. How should the RN respond?
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"The HCP will make an incision in David's leg to relieve the pressure."
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15. Which action should the RN implement? (Select all)
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-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
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16. Which intervention should the nurse implement during David's hydrotherapy? (Select all)
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-Active range of motion exercises of his extremities -Wash burn areas thoroughly and gently with mild soap and water
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17. Which intervention should the RN implement?
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Premedicate with an opioid analgesic 20 minutes prior to applying this medication
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18. Which snack is best for the RN to provide to David?
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A peanut butter sandwich
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19. Which action should the RN take before completing the assessment?
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Ask the parents to leave the room before obtaining information from David
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20. According to Erikson, which statement by the client indicates that he is achieving the tasks of his stage of growth and development?
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"I really hate it when my mom kisses me in front of my friends."
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21. Which interventions will meet David's needs during his hospital stay? (Select all)
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-Provide David with compact discs and video games -Obtain a laptop computer with internet access for David
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22. How should the RN respond to David?
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"If I believe it affects your care, I will have to tell someone."
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23. Which response by the RN has the highest priority?
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"Have you thought about how you would kill yourself?"
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24. Which intervention has the highest priority?
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Ensure meticulous hand washing before and after David's care
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25. Which action should the RN implement?
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Outline the drainage on the dressing and write the date and time
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26. How should the RN respond?
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"The skin will probably be taken from your son's back."
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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?
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0.2
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28. What action should the RN implement?
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Document this assessment in David's chart
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29. How should the RN explain to David the rationale for wearing these pressure garments?
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"The pressure stocking will help prevent scarring that could occur while the burn is healing."
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30. Which action should the RN implement?
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Refer David to an adolescent burn support group
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31. Which action should be implemented to address this issue?
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Determine if there is a family member who can stay with David during the day
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32. Which discharge preparation has the highest priority?
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Provide specific written instructions for David's home care before releasing him to go home
