Burns, wound care, and skin integrity are heavily tested on the NCLEX. Work through these 10 practice questions — airway priority in inhalation injury, the Parkland formula, the rule of nines, burn depth, pressure injury staging, and melanoma warning signs — each with a full rationale that explains why every option is right or wrong.
Burns, Wounds & Skin Integrity: High-Yield Review
The single most important concept in burn care is airway. Facial and neck burns, singed nasal hair, soot around the nares, hoarseness, stridor, and carbonaceous (sooty) sputum all signal inhalation injury. Airway edema can develop and occlude the airway within hours, so the priority is anticipating EARLY endotracheal intubation before swelling makes it impossible. After the airway is secured, fluid resuscitation drives the emergent phase. The Parkland formula (the classic exam formula; 2024 American Burn Association guidance recommends starting adults with large burns lower, at 2 mL/kg/%TBSA) uses 4 mL x weight (kg) x %TBSA of lactated Ringer over 24 hours, with HALF given in the first 8 hours calculated from the TIME OF INJURY (not the time of admission) and the remaining half over the next 16 hours. Titrate to an adult urine output of about 0.5-1.0 mL/kg/hr. Estimate %TBSA with the rule of nines: head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, and perineum 1%.
Burn depth guides prognosis. Superficial (first-degree) burns are red, painful, and blanch with no blisters. Partial-thickness (second-degree) burns blister, are moist, and are very painful. Full-thickness (third-degree) burns are dry, white/tan/leathery or charred, and PAINLESS because nerve endings are destroyed. Know the phases: the emergent/resuscitative phase (first ~24-48 hours) shifts fluid OUT of the vessels, producing hypovolemia and HYPERkalemia from cell destruction; the acute phase shifts fluid back with diuresis and HYPOkalemia. Watch for Curling (stress) ulcers and circumferential burns that may need escharotomy.
Pressure injuries are staged: Stage 1 is intact skin with non-blanchable erythema; Stage 2 is partial-thickness loss (shallow open ulcer or intact/ruptured blister); Stage 3 is full-thickness with possible visible subcutaneous fat; Stage 4 exposes bone, muscle, or tendon; plus unstageable and deep tissue injury. Prevent injury by repositioning at least every 2 hours, keeping skin clean and dry, offloading bony prominences, and NEVER massaging reddened areas. Because burns and wounds are hypermetabolic, patients need a HIGH-calorie, HIGH-protein diet with vitamin C and zinc for healing. Finally, teach the melanoma ABCDE rule: Asymmetry, Border irregularity, Color variation, Diameter over 6 mm, and Evolving change—plus daily sun protection.
Integumentary & Burns NCLEX Practice Questions
Question 1 · Inhalation/Airway Injury (Priority)
A client arrives after a house fire with burns to the face and neck, singed nasal hair, hoarseness, and carbonaceous (sooty) sputum. Which action should the nurse anticipate as the PRIORITY?
- A Administer IV morphine for pain control
- B Prepare for early endotracheal intubation
- C Apply a high-humidity oxygen face tent
- D Begin fluid resuscitation using the Parkland formula
Show answer & rationale
Correct answer: B
Burns to the face and neck, singed nasal hair, hoarseness, and carbonaceous sputum are classic signs of inhalation and upper-airway injury. Airway edema can develop rapidly and occlude the airway within hours, so the priority is preparing for early endotracheal intubation while the airway can still be visualized and secured. The teaching pearl is intubate early, before the swelling closes the airway. Administering IV morphine addresses pain but does nothing for the threatened airway and can further depress respiratory drive. Applying a high-humidity oxygen face tent delivers oxygen but will not maintain patency once the airway swells, and it delays definitive airway management. Beginning Parkland fluid resuscitation is essential and follows immediately after, but airway always precedes circulation in the ABC hierarchy; large fluid volumes can even worsen airway edema, making early intubation more urgent. Memory aid: singed nasal hair + hoarseness + sooty sputum = secure the airway now. Current standards prioritize proactive airway management for suspected inhalation injury rather than waiting for overt respiratory distress.
Question 2 · Burn Fluid Resuscitation (Parkland)
A 70 kg adult sustains burns to 40% of total body surface area (TBSA) at 0800, the moment of injury. Using the Parkland formula (4 mL x kg x %TBSA of lactated Ringer over 24 hours, half in the first 8 hours), how much fluid should be infused during the first 8 hours?
- A 5,600 mL
- B 11,200 mL
- C 2,800 mL
- D 1,400 mL
Show answer & rationale
Correct answer: A
Calculate the 24-hour total first: 4 mL x 70 kg x 40 %TBSA = 11,200 mL of lactated Ringer over 24 hours. Half of that total is delivered in the first 8 hours, timed FROM THE MOMENT OF INJURY (0800), not from arrival: 11,200 / 2 = 5,600 mL. That makes 5,600 mL the correct amount for the first 8 hours; the remaining 5,600 mL infuses over the next 16 hours. The 11,200 mL option is the full 24-hour volume, not the first-8-hour portion. The 2,800 mL option is only one quarter of the total and would under-resuscitate the client, risking hypovolemic (burn) shock and acute kidney injury. The 1,400 mL option is one eighth of the total and is far too small. Note the timing detail: because the clock starts at the time of the burn, any delay reaching care shortens the remaining time, so the first-8-hour volume must be given faster over the hours that are left. Parkland provides only an estimated starting rate; titrate to response, using adult urine output of 0.5-1.0 mL/kg/hr as the best bedside indicator of adequate resuscitation, along with mean arterial pressure and lactate clearance. Avoid both under- and over-resuscitation ("fluid creep"), which causes compartment syndromes and pulmonary edema. Pearl: Parkland = 4 x weight (kg) x %TBSA, half in the first 8 hours from the burn; adjust the drip to keep urine output at 0.5-1.0 mL/kg/hr.
Question 3 · Rule of Nines (%TBSA)
Using the rule of nines for an adult, the nurse estimates %TBSA for a client with full-thickness burns covering the entire anterior trunk and one entire leg (front and back). What is the estimated %TBSA?
Show answer & rationale
Correct answer: B
In the adult rule of nines, the anterior trunk is 18% and each entire leg (anterior plus posterior) is 18%. Adding them: 18% (anterior trunk) + 18% (one whole leg) = 36%. That makes 36% correct. The 18% choice accounts for only one of the two burned areas. The 27% choice would fit an anterior trunk (18%) plus one arm (9%), which is not the scenario described. The 45% choice overestimates the burned surface. Review the full adult map: head 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, and perineum 1%, totaling 100%. Accurate %TBSA is essential because it drives the Parkland fluid calculation and triage decisions. Pearl: the body is divided into multiples of 9 (with the perineum getting the single 1%). Note that the rule of nines differs in children, who have proportionally larger heads and smaller legs, so a modified Lund-Browder chart is more precise for pediatric burns.
Question 4 · Burn Depth Classification
The nurse assesses a burn wound that is dry, white and leathery in appearance, and the client reports NO pain when the area is touched. How should the nurse classify this burn?
- A Superficial (first-degree) burn
- B Superficial partial-thickness burn
- C Deep partial-thickness burn
- D Full-thickness burn
Show answer & rationale
Correct answer: D
A burn that is dry, white/tan/leathery or charred, and notably PAINLESS is a full-thickness (third-degree) burn. It is painless because the nerve endings in the dermis have been destroyed, so classifying it correctly is critical clinical reasoning. A superficial (first-degree) burn is red, painful, and blanches with no blisters, which does not match a dry, leathery, painless wound. Superficial partial-thickness burns are moist, blistered, pink or red, and very painful. Deep partial-thickness burns are also blistered and painful (though sometimes less so than superficial partial-thickness) and remain moist rather than dry and leathery. The key discriminator here is the combination of a dry, leathery (eschar) surface and the ABSENCE of pain. Pearl: full-thickness = full loss of nerves = no pain, and the tough leathery eschar may require escharotomy if it is circumferential and compromises circulation or chest expansion. Do not be reassured by a client's lack of pain in a burn; painlessness can signal deeper, more serious injury, and surrounding areas of partial-thickness burn are often intensely painful.
Question 5 · Burn Phases & Electrolytes
During the emergent/resuscitative phase (first 24-48 hours) after a major burn, which electrolyte imbalance should the nurse anticipate?
- A Hypokalemia
- B Hypercalcemia
- C Hypomagnesemia
- D Hyperkalemia
Show answer & rationale
Correct answer: D
In the emergent/resuscitative phase (the first ~24-48 hours), massive cell destruction releases intracellular potassium into the bloodstream, and fluid shifts OUT of the vessels into the interstitium, producing hypovolemia. The result is HYPERkalemia, so the nurse should monitor for peaked T waves, dysrhythmias, and other signs of high potassium. Hypokalemia is the opposite and characterizes the later acute phase, when capillary integrity is restored, fluid shifts back into the vessels, and diuresis (along with potassium moving back into cells and being excreted) lowers serum potassium. Hypercalcemia is not typical; if anything, calcium can be lost into burn wound exudate. Hypomagnesemia is also not the hallmark disturbance of the emergent phase. Pearl: think emergent phase = fluids shift OUT + cells rupture = high potassium (hyperkalemia); acute phase = fluids shift BACK + diuresis = low potassium (hypokalemia). Sodium is typically lost into the interstitium and wound during the emergent phase (hyponatremia risk), reinforcing the picture of fluid leaving the vascular space. Understanding this shift explains why aggressive lactated Ringer resuscitation and cardiac monitoring are priorities early on.
Question 6 · Pressure Injury Staging
The nurse assesses a sacral pressure injury with full-thickness skin loss in which subcutaneous fat is visible. There is no exposed bone, muscle, or tendon, and no slough or eschar obscuring the wound bed. How should the nurse stage this injury?
- A Stage 1 pressure injury
- B Stage 2 pressure injury
- C Stage 3 pressure injury
- D Stage 4 pressure injury
Show answer & rationale
Correct answer: C
Full-thickness skin loss with visible subcutaneous fat, but WITHOUT exposed bone, muscle, or tendon, defines a Stage 3 pressure injury. A Stage 1 injury is intact skin with non-blanchable erythema (no open wound), which does not fit a full-thickness wound with visible fat. A Stage 2 injury is partial-thickness loss presenting as a shallow open ulcer or an intact/ruptured serum-filled blister; it does not extend deep enough to expose fat. A Stage 4 injury exposes bone, muscle, or tendon, which the scenario specifically rules out. Because the wound bed is fully visible (no slough or eschar hiding the depth), it cannot be classified as unstageable. Pearl: fat = Stage 3; bone, muscle, or tendon = Stage 4; blister or shallow open = Stage 2; intact red skin = Stage 1. If slough or eschar obscures the base so depth cannot be determined, it is unstageable, and a persistent maroon or purple intact area of discoloration suggests a deep tissue injury. Accurate staging drives the treatment plan and reimbursement documentation, so assess the deepest visible tissue.
Question 7 · Skin Cancer (Melanoma ABCDE)
A nurse performs skin assessments at a community screening. Which lesion is MOST concerning for melanoma and warrants prompt referral?
- A A 9 mm asymmetric mole with notched borders and mixed brown-black color that changed in 3 months
- B A 4 mm round, uniformly tan macule with smooth, even borders that has looked the same for years
- C A symmetric, evenly bordered 3 mm brown nevus on the forearm that has been present since childhood
- D A soft, flesh-colored, dome-shaped 2 mm papule on the neck that blanches with light pressure
Show answer & rationale
Correct answer: A
The melanoma ABCDE rule flags Asymmetry, Border irregularity, Color variation, Diameter over 6 mm, and Evolving change. The mole that is asymmetric, has irregular notched borders, shows mixed brown and black color, measures 9 mm (greater than 6 mm), and has changed in 3 months meets every ABCDE criterion and is the most concerning; it warrants prompt dermatology referral and likely biopsy. The 4 mm round, uniformly tan macule with smooth borders that has been stable for years is symmetric, evenly bordered, uniform in color, small, and non-evolving, making it reassuring. The symmetric, evenly bordered 3 mm childhood nevus is a typical benign mole. The soft, flesh-colored, dome-shaped papule that blanches with pressure is not pigmented or irregular and does not fit melanoma criteria. Pearl: memorize ABCDE and treat any Evolving lesion as suspicious until proven otherwise. Also teach sun protection: apply broad-spectrum SPF 30 or higher, reapply every 2 hours and after swimming, avoid peak midday sun and tanning beds, and wear protective clothing and hats. Early detection dramatically improves melanoma survival, so encourage regular self-examination and professional skin checks.
Question 8 · Pressure Injury Prevention (SATA)
A nurse is developing a pressure injury prevention plan for an immobile client. Which interventions should the nurse include? Select all that apply.
- A Vigorously massage reddened areas over bony prominences
- B Reposition the client at least every 2 hours
- C Keep the skin clean and dry
- D Maintain the head of bed at 90 degrees continuously
- E Use pillows or foam wedges to offload the heels
- F Encourage a high-protein diet
Show answer & rationale
Correct answer: B, C, E, F
Effective prevention includes repositioning at least every 2 hours to relieve sustained pressure, keeping skin clean and dry to prevent maceration and breakdown, offloading the heels with pillows or foam wedges to eliminate pressure over a high-risk bony prominence, and encouraging a high-protein diet to supply the building blocks for tissue integrity and repair. Massaging reddened areas over bony prominences is NOT recommended; massage over compromised tissue can cause deeper damage and worsen an early pressure injury, so it should be avoided. Maintaining the head of bed at 90 degrees continuously is harmful because it increases shear and pressure over the sacrum and coccyx; the head of bed should generally be kept at or below 30 degrees when possible to reduce shear. Pearl: turn every 2 hours, keep skin clean and dry, offload bony points, feed protein, and never rub a red spot. Also inspect skin at least once per shift, use pressure-redistributing surfaces, manage moisture from incontinence promptly, and reassess risk with a validated tool such as the Braden scale.
Question 9 · Wound Healing & Nutrition (SATA)
A client recovering from extensive burns is hypermetabolic. Which dietary recommendations support wound healing? Select all that apply.
- A High-calorie intake
- B Protein restriction to reduce metabolic demand
- C High-protein intake
- D Foods rich in vitamin C
- E A low-calorie diet to prevent weight gain
- F Zinc supplementation as prescribed
Show answer & rationale
Correct answer: A, C, D, F
Burns and large wounds create a profoundly hypermetabolic, catabolic state, so nutrition must supply extra fuel and building blocks. A high-calorie intake meets the elevated energy demand and spares protein from being burned for energy. A high-protein intake provides amino acids for collagen synthesis, tissue rebuilding, and immune function. Vitamin C supports collagen formation and wound repair, and zinc (given as prescribed) is a cofactor for the enzymes involved in tissue growth and healing. Protein restriction is incorrect and harmful; restricting protein would worsen the catabolic state, delay healing, and promote muscle wasting. A low-calorie diet is also wrong because inadequate calories force the body to break down its own protein stores, impairing healing and immunity. Pearl: think high-calorie, high-protein, plus vitamin C and zinc to heal a burn. Adequate hydration, and often iron and vitamin A, further support recovery, and many burn clients need enteral supplementation or tube feeding to meet caloric goals. Recognize wound infection signs (increasing pain, purulent or foul drainage, spreading erythema, warmth, fever, and a rising white blood cell count) that can derail healing despite good nutrition.
Question 10 · Inhalation Injury Assessment (SATA)
A nurse assesses a client pulled from an enclosed burning building. Which findings indicate possible inhalation/airway injury and require close monitoring? Select all that apply.
- A Pink, moist oral mucosa with no cough
- B Hoarseness and stridor
- C Burns to the face and neck
- D Singed nasal hair and soot around the nares
- E Clear breath sounds with an unlabored respiratory rate of 16
- F Carbonaceous (sooty) sputum
Show answer & rationale
Correct answer: B, C, D, F
Signs pointing to inhalation and upper-airway injury include singed nasal hair with soot around the nares, hoarseness and stridor (indicating laryngeal edema and airflow obstruction), carbonaceous (sooty) sputum reflecting inhaled combustion products, and burns to the face and neck, which raise the risk of rapidly progressing airway edema. All of these should prompt close monitoring and readiness for early intubation. Clear breath sounds with an unlabored respiratory rate of 16 is a normal, reassuring finding and does not indicate airway injury. Pink, moist oral mucosa with no cough is likewise a normal finding, not a warning sign. The key concept is that airway compromise after a burn can worsen quickly, so any of the warning signs warrants proactive airway management before edema closes the airway. Pearl: enclosed-space fire + facial burns + hoarseness + sooty sputum = suspect inhalation injury and secure the airway early. Remember that carbon monoxide poisoning can coexist and may present with headache, confusion, or cherry-red skin, with a falsely normal pulse oximeter reading, so obtain carboxyhemoglobin levels and give 100% oxygen.
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Integumentary & Burns FAQ
How do I calculate burn fluid resuscitation with the Parkland formula?
Use 4 mL x body weight in kg x %TBSA of lactated Ringer over 24 hours. Give half in the first 8 hours calculated from the TIME OF INJURY (not admission) and the remaining half over the next 16 hours. Titrate to an adult urine output of about 0.5 mL/kg/hr (target range 0.5-1.0 mL/kg/hr), with 0.5 mL/kg/hr as the minimum adequate output. Example: a 70 kg adult with 40% TBSA = 4 x 70 x 40 = 11,200 mL total, so 5,600 mL in the first 8 hours.
Why is a full-thickness (third-degree) burn painless?
Full-thickness burns destroy the nerve endings in the dermis, so the client feels no pain in that area. The wound appears dry, white, tan, leathery, or charred. Do not be falsely reassured by a lack of pain; painlessness signals deeper, more serious injury. Surrounding areas of partial-thickness burn (which blister and are moist) are often intensely painful because their nerve endings remain intact.
What is the priority when a burn client has facial burns and hoarseness?
Airway is always the top priority. Facial and neck burns, singed nasal hair, soot around the nares, hoarseness, stridor, and carbonaceous (sooty) sputum all suggest inhalation injury. Airway edema can close the airway within hours, so anticipate EARLY endotracheal intubation while the airway can still be secured. Airway comes before fluid resuscitation and pain control in the ABC hierarchy.
How are pressure injuries staged?
Stage 1 is intact skin with non-blanchable erythema. Stage 2 is partial-thickness loss with a shallow open ulcer or intact/ruptured blister. Stage 3 is full-thickness loss with possible visible subcutaneous fat. Stage 4 exposes bone, muscle, or tendon. If slough or eschar hides the wound base, it is unstageable, and a persistent maroon or purple intact area suggests deep tissue injury. Prevent injury by repositioning at least every 2 hours, keeping skin clean and dry, offloading bony areas, and never massaging reddened skin.