Hesi Case Study Pediatric Burns – Flashcards
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1. Which action is included when a Level I disaster is declared?
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All local hospitals prepare to receive casualties.
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2. 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. Which action is implemented first by the triage personnel?
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Place a disaster tag securely on each victim.
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4.
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Burn leg
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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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The nurse should document which percentage of body surface?
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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%.
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Which intervention will the nurse implement?
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Administer the Lactated Ringer's solution as prescribed via an infusion pum
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Which action should the nurse take?
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Inform the officer that he must first speak to David's parents.
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9. Which action should the nurse take concerning this request?
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Allow the police officer access to the requested medical records.
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10. 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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Which intervention will the nurse 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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Which action should the nurse implement?
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Notify the healthcare provider immediately.
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How should the nurse respond?
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"The healthcare provider will make an incision in David's leg to relieve the pressure."
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14. Which action should the nurse implement?
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Provide visitors with isolation gowns and instruction in hand hygiene.
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15. Which intervention should the nurse implement during David's hydrotherapy?.
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Active range of motion exercises of his extremities.
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16. Which intervention should the nurse implement?
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Premedicate with an opioid analgesic 20 minutes prior to applying this medication.
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Which snack is best for the nurse to provide David?
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Peanut butter sandwich
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Which action should the nurse 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. Which intervention will meet David's needs during his hospital stay?
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Provide David with compact discs and video games.
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21. How should the nurse respond to David?
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"If I believe it affects your care, I will have to tell someone."
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22. Which response by the nurse has the highest priority?
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"Have you thought about how you would kill yourself?"
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23. Which intervention has the highest priority?
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Ensure meticulous hand washing before and after David's care.
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24. Which action should the nurse implement?
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Outline the drainage on the dressing and write the date and time.
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25. How should the nurse respond?
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"The skin will probably be taken from your son's back."
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How much morphine should the nurse give?
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0.2 ml
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What action should the nurse implement?
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Document this assessment in David's chart.
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How should the nurse 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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Which action should the nurse implement?
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Refer David to an adolescent burn support group.
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Which action should be implemented to address this issue?
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Determine if there is any family member that can stay with David during the day.
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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.
