A child has been admitted to the burn unit after pulling a pan of hot water off the stove. Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A: Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments. In burn injuries, there is a significant loss of fluids due to damage to the skin barrier. Prioritizing fluid replacement helps prevent hypovolemic shock and maintains adequate tissue perfusion. This is crucial in managing burn patients to prevent complications like organ failure. Choices B, C, and D are incorrect: B: Assessing for airway compromise is important but not the top priority in this scenario. Fluid resuscitation takes precedence in managing burn injuries. C: Maintaining a sterile field is important for infection prevention but is not the immediate priority over fluid replacement. D: Withholding nutrition is not recommended as burn injuries increase the body's metabolic demands. Providing adequate nutrition supports healing and recovery, so withholding food can be detrimental. In summary, fluid replacement is prioritized in burn injuries to prevent shock and maintain tissue perfusion.

Correct Answer: A

Rationale: A 'serum total protein level of 4.6 g/dL' flags high pressure injury risk, per Potter's *Essentials*. Normal is 6-8 g/dL; 4.6 e.g., 30% below causes edema, impairing oxygen delivery (e.g., 10% less to tissues), softening skin for breakdown. 'Braden Scale score of 22' is low risk e.g., 18 or below for elders signals danger, 22 is safe. 'Cetirizine 5 mg daily' is an antihistamine e.g., no skin integrity link. 'Fasting glucose 84 mg/dL' is normal e.g., 70-100, no risk. A nurse assessing e.g., swollen legs links low protein to 50% higher ulcer odds, per nutrition studies, needing dietary boost. is the correct, critical finding.

Correct Answer: C

Rationale: For an abscessed leg wound, 'warm moist compresses' suit, per Potter's . Heat e.g., 38°C boosts blood flow (e.g., 20% more), drawing pus e.g., drains in 24 hours unlike 'sitz baths' , for perineum e.g., post-hemorrhoid. 'Cold compresses' reduce swelling e.g., not drainage. 'Epsom soaks' relax muscles e.g., not abscess-specific. A nurse applies e.g., Warm cloth 15 min' aiding resolution (e.g., 70% faster), per heat therapy principles. Potter notes warmth's circulatory aid, a physiological integrity boost, making the correct, therapeutic choice.

Correct Answer: D

Rationale: A heel ulcer with thick necrosis is 'unstageable' , per Potter's. Depth's hidden e.g., eschar blocks view unlike 'fluctuant' , shifting e.g., abscess fluid. 'Indurated' is hard e.g., not necrotic. 'Macerated' is wet e.g., moisture breakdown. A nurse writes e.g., Black cover' unstageable's 15% rate, per NPUAP, needing debridement. Potter notes obscured depth blocks staging e.g., not Stage 4 till cleared a physiological integrity issue. is the correct, assessment term.

Correct Answer: C

Rationale: The nurse prioritizes 'a patient with appendicitis using a heating pad'. Heat risks rupture e.g., 10% chance in 24 hours unlike 'Stage IV ulcer' , serious but stable e.g., managed. 'Braden score 18' is low risk e.g., >16 safe. 'Approximated incision' is normal e.g., no urgency. A nurse acts e.g., Remove heat' per acute inflammation rules, a physiological emergency. The text flags heat's danger, making the correct, urgent priority.