# 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.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620064&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

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.

Initial Assessment and Interventions

Assess airway and breathing for signs of inhalation injury

Initiate fluid resuscitation with lactated Ringer's

Apply ice packs to burned areas

Administer oral pain medication

Ongoing Monitoring

Monitor urine output hourly

Assess for signs of compartment syndrome in extremities

Check blood glucose every 6 hours

Measure abdominal girth daily

## Explanation

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.

## In-depth explanation

Quick answer
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.
Key cues
Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label.
Clinical reasoning
Connect the relevant cues to the safest nursing interpretation and action for this exact care setting.
Why the alternatives do not fit
The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented.
Priority and safety
Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention.
Takeaway
For major-burn initial priorities, select responses that are both clinically supported and appropriate at this point in care.
**Sources**
- Open RN Nursing Skills 2e

## Clinical scenario

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.

## Key concepts

- **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.

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