A client is admitted to the emergency department with major burns covering 40% of total body surface area following a house fire. Which are the nurse's priority actions? For each group, select all responses that apply.

Major burns require immediate airway assessment due to inhalation injury risk and fluid resuscitation to prevent hypovolemic shock. Ice packs cause vasoconstriction and worsen tissue damage; oral pain meds may be unsafe if airway compromised. Hourly urine output indicates fluid status; compartment syndrome is a risk with circumferential burns. Blood glucose and abdominal girth are not immediate priorities.

Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label.

Connect the relevant cues to the safest nursing interpretation and action for this exact care setting.

The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented.

Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention.

For major-burn initial priorities, select responses that are both clinically supported and appropriate at this point in care.

• Inhalation injury — Damage to airway from heat or smoke, requiring early intubation if suspected.
• Fluid resuscitation — Large volumes of isotonic crystalloids given to maintain perfusion after major burns.
• Compartment syndrome — Increased pressure within a fascial compartment compromising circulation, may require escharotomy.