NCLEX Blog / Body Systems & Clinical Content / Burns on the NCLEX: Airway First, the Rule of Nines, and the Phases
Burns on the NCLEX: Airway First, the Rule of Nines, and the Phases

Burns on the NCLEX: Airway First, the Rule of Nines, and the Phases

By Ruqia Qatawna, PhD, MSN, RN·6 min read·Updated 2026-10-22
The short answer

Airway comes first in every burn question: singed nasal hairs, soot around the mouth, hoarseness or a fire in an enclosed space all mean the airway may swell shut. Use the Rule of Nines to estimate size. And know the potassium reversal: high in the emergent phase as damaged cells release it, low in the acute phase as it moves back into cells and is lost in urine.

Burns NCLEX Review▶ Watch this lesson
Burns NCLEX Review

Burns: airway first, the Rule of Nines, the three phases of care, fluid resuscitation and the circumferential burn.

From the Intensive NCLEX Course. See the course; the full video library is part of Pro and Ultimate.

Burn stems look like they are about skin. They are about airway, then fluid, then potassium — in that order. Get the reflex right and the questions answer themselves.

Airway first, always

Before the burn size, before the fluids, look for inhalation injury:

  • Burns to the face, neck or chest
  • Singed nasal hairs or eyebrows
  • Soot around the mouth or nose
  • Hoarse voice or a change in voice
  • Coughing up black-tinged sputum
  • Difficulty swallowing
  • Burns from a fire in an enclosed space

Any of these means the airway may swell shut. Assess and secure the airway before anything else — swelling worsens over the first hours.

Estimating burn size — the Rule of Nines (adult)

Body areaPercent
Head and neck9%
Each arm9% (18% for both)
Each leg18% (36% for both)
Front of trunk18%
Back of trunk18%
Perineum1%

Children have different proportions — a larger head and smaller legs — so a modified chart is used.

Adult Rule of Nines, front and back: head 4.5 percent each side, trunk 18 percent each side, each arm 4.5 percent each side, each leg 9 percent each side, perineum 1 percent
The adult Rule of Nines: head 9, each arm 9, each leg 18, front of trunk 18, back of trunk 18, perineum 1. Count only partial- and full-thickness burns.
Burn depth: superficial (epidermis only), superficial partial thickness (upper dermis), deep partial thickness (deeper dermis) and full thickness (entire skin destroyed)
Depth decides pain and healing: a superficial burn is red and painful; a full-thickness burn is white or leathery and painless, because the nerve endings are gone.

The three phases

PhaseWhat is happeningPotassiumNursing focus
Emergent (first 24–48 h)Fluid shifts out of the vessels into the tissues — massive swelling, low blood volume, risk of shock, concentrated bloodHIGH — released from damaged cellsFluid replacement is the priority
AcuteFluid shifts back into the vessels — risk of fluid overload; infection becomes the main dangerLOW — moves back into cells and is lost in urineWound care and nutrition
RehabilitationScarring, contractures, function and emotional recoveryNormalisingMobility, contracture prevention, psychosocial support

The potassium reversal between the first two phases is commonly tested: high in the emergent phase, low in the acute phase.

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The rest of burn care

  • Nutrition: burn clients need very high calories and very high protein to heal — a heavily tested point, with amounts far above normal.
  • Pain: IV route in the early phase. Absorption from muscle and skin is unreliable when circulation is affected.
  • Infection prevention is the main cause of death after the first phase — strict aseptic technique with wound care.
Circumferential burn: rigid eschar around a limb cannot expand, so tissue swelling beneath it compresses the vessels and impairs distal circulation
A burn all the way around a limb or the chest: the stiff eschar cannot stretch as the tissue swells. Check pulses and sensation distal to it; an escharotomy relieves the pressure.

Burns and shock

A large burn causes hypovolaemic shock, because fluid leaves the circulation for the tissues during the emergent phase. The early picture is a fast heart rate, restlessness and a normal blood pressure — not a low one. Hypotension is late.

The emergency order of priorities

For any emergency, work the ABCDE sequence:

  • Airway
  • Breathing
  • Circulation
  • Disability — neurological status
  • Exposure — look for other injuries, then keep the client warm

In trauma, always look for what you have not found yet. Undress and examine, then cover to prevent heat loss.

NCLEX tip: If a burn stem lists soot, singed hairs or a hoarse voice among the findings, the answer is the airway — every time, regardless of how large the burn is or how stable the blood pressure looks right now.

Educational use only: fluid resuscitation formulas and burn-centre referral criteria vary. Follow current burn-care guidance and facility protocol.

Practice

5 NCLEX practice questions on this topic

The same questions, player and partial-credit scoring students use inside NCLEXPace: answer, submit, read the full rationale, then Next. Your score is waiting at the end. No account needed for these.

Question 1 of 5Score: 0%
Question 1 of 5Multiple Choice

Select the best answer.

A client has a burn with red, wet, blistered skin that is very painful to touch. Which depth of burn does this represent?

Question 2 of 5Multiple Choice

Select the best answer.

Using the adult Rule of Nines, the nurse estimates total body surface area burned for a client with partial-thickness burns covering the entire anterior trunk and one entire arm. What is the estimated percentage?

Question 3 of 5Matrix / Grid (NGN)

For each statement about this casualty, indicate whether it is accurate or inaccurate.

During a mass casualty event with overwhelmed resources, a nurse assesses a casualty with extensive burns, no palpable pulse, and agonal respirations that do not improve with airway repositioning. For each statement about this casualty's triage classification, indicate whether it is accurate or inaccurate.

AccurateInaccurate
The black tag means this casualty receives no further care
This casualty's presentation, given the overwhelmed resources described, meets the criteria for the black (expectant) category
If resources become available, this casualty's triage category could be reassessed
This casualty should receive a red (immediate) tag because of the airway compromise
Note: Each row must have 1 response option selected.
Question 4 of 5Multiple Choice

Select the best answer.

A client arrives with facial burns, singed nasal hair, and soot around the mouth after a house fire. The client is currently speaking clearly with no audible distress. Which action should the nurse take?

Question 5 of 5Multiple Choice

Select the best answer.

A client sustained a major burn injury at 0800 but did not arrive at the emergency department until 1000. When calculating the timing for the first half of the Parkland formula fluid volume, from what time should the nurse count the first 8 hours?

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Frequently asked questions

Common follow-up questions on Body Systems & Clinical Content.

What is the priority in a burn client?

The airway. Signs of inhalation injury (facial burns, singed nasal hairs, soot around the mouth, a hoarse voice, or a fire in an enclosed space) mean the airway may swell shut, and it is assessed and secured before fluid, pain or wound care because swelling worsens over the first hours.

What is the Rule of Nines in an adult?

Head and neck 9%, each arm 9%, each leg 18%, front of trunk 18%, back of trunk 18%, and perineum 1%. Children use a modified chart because they have a proportionally larger head and smaller legs.

Why is potassium high then low in burns?

In the emergent phase, damaged cells release potassium into the blood, so it runs high. In the acute phase, potassium moves back into cells and is lost in the urine, so it runs low. This reversal between the two phases is a frequently tested point.

What are the three phases of burn care?

The emergent phase over the first 24–48 hours, when fluid shifts out of the vessels and replacement is the priority; the acute phase, when fluid shifts back and infection and nutrition dominate; and the rehabilitation phase, focused on scarring, contractures, function and emotional recovery.

What kind of shock do large burns cause?

Hypovolaemic shock, because fluid leaves the circulation for the tissues during the emergent phase. The early picture is tachycardia and restlessness with a normal blood pressure; hypotension is a late sign.

Sources and references

  1. Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Burns.
  2. American Burn Association. Advanced Burn Life Support (ABLS) Provider Manual. 2018 update. Chicago, IL: American Burn Association.

Reviewed by the NCLEXPace team, October 2026.

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