Changed : New exam content outline; passing score · BCEN
Musculoskeletal and wound care, limb by limb
TCRN · Clinical practice · 13 of 150 scored items
A small domain with a long list. The items reward timing: how fast an open fracture gets antibiotics, when a tight limb becomes an emergency, and what to do with a part that came off.
Extremity fractures and dislocations: open fractures, long bones, joints with vascular risk.
Compartment syndrome: early signs, pressure measurement, fasciotomy.
Amputation: the stump, the amputated part, replantation.
Soft tissue: lacerations, degloving, crush and necrotizing infection, tetanus prophylaxis.
12 limb, spine and wound items
0 of 12 attempted · 0 correct · 0 missed
Clinical Practice: Musculoskeletal and Wound · 13 items
After a direct blow to the upper chest, a patient has difficulty swallowing, stridor, and swelling of the left arm. A depression is palpable beside the sternum at the medial end of the left clavicle. The nurse should suspect:
Answer and why, all 4 options
A posterior sternoclavicular dislocation drives the medial clavicle back into the mediastinum, where it can press on the trachea, esophagus, and great vessels; stridor, dysphagia, and venous congestion of the arm are warning signs. CT confirms it, and urgent reduction is planned with cardiothoracic backup.
Tension causes hypotension, absent breath sounds, and tracheal deviation; a palpable depression at the sternoclavicular joint points to a dislocation.
Midshaft fractures cause deformity and tenderness along the clavicle, not stridor and dysphagia with a medial depression.
An anterior shoulder dislocation squares off the shoulder laterally; it does not cause a depression beside the sternum or compress mediastinal structures.
Item 535563
Clinical Practice: Musculoskeletal and Wound · 13 items
A normotensive patient with a tibial fracture has a compartment pressure of 32 mm Hg. BP is 130/80 mm Hg, and clinical findings are equivocal. The nurse anticipates:
Answer and why, all 4 options
An absolute pressure of 32 mm Hg alone does not mandate fasciotomy in a normotensive patient; the perfusion gradient is still adequate.
A tibial fracture with a borderline compartment pressure needs ongoing monitoring; discharge risks a missed evolving compartment syndrome.
Elevation lowers arterial inflow and can worsen compartment perfusion; the limb is kept at heart level.
The delta pressure (diastolic BP minus compartment pressure) is 80 − 32 = 48 mm Hg; fasciotomy is usually considered when it falls to 30 mm Hg or less. With equivocal findings, the nurse keeps the leg at heart level and repeats the exam and pressure measurement.
Item 535572
Clinical Practice: Musculoskeletal and Wound · 13 items
After massive resuscitation for hemorrhagic shock, a patient develops a tense, painful calf in an UNINJURED leg, with pain on passive toe movement. The nurse recognizes this as:
Answer and why, all 4 options
Dependent edema is soft and diffuse; a tense, painful compartment threatens muscle viability.
Large-volume resuscitation causes capillary leak and tissue edema that can raise compartment pressures in limbs that were never injured, and in the abdomen. Pain on passive stretch and a tense compartment need the same urgent evaluation as in a fractured limb.
DVT causes swelling and calf pain, but not a tense, painful compartment shortly after massive resuscitation; assuming DVT delays fasciotomy.
Transfusion reactions cause urticaria, fever, or hypotension, not a single tense compartment.
Item 535618
Clinical Practice: Musculoskeletal and Wound · 13 items
A patient arrives after an 8-hour evacuation with a tourniquet on the thigh. The limb below is cold and mottled. The nurse should anticipate:
Answer and why, all 4 options
After many hours of ischemia, releasing a tourniquet can flood the circulation with potassium, acid, and myoglobin and cause arrest. A tourniquet on longer than about 6 hours is removed in the operating room with resuscitation ready, and the limb is often not salvageable.
Removal outside a controlled setting risks reperfusion hyperkalemia and rebleeding from injured vessels.
Gradual loosening still releases toxins and allows bleeding; it does not make late removal safe at the bedside.
Conversion is considered within about 2 hours of placement; after 8 hours of ischemia, conversion is a surgical decision.
Item 535619
Clinical Practice: Musculoskeletal and Wound · 13 items
A patient has a 3-cm laceration through the eyebrow that will be sutured. While preparing the wound, the nurse should:
Answer and why, all 4 options
Eyebrow hair marks the alignment of the wound edges and may grow back slowly or abnormally if shaved. The wound is cleaned and irrigated with the brow intact.
Depilatory chemicals irritate an open wound and remove the alignment landmark.
Trimming flush has the same effect as shaving, hiding the line of the brow needed for alignment.
Shaving removes the landmark needed for precise alignment, and regrowth can be incomplete.
Item 535777
Clinical Practice: Musculoskeletal and Wound · 13 items
After a fall onto the buttocks, a patient with an L2 burst fracture has perineal and inner-thigh numbness, weak legs with absent ankle reflexes, and urinary retention. These findings are consistent with:
Answer and why, all 4 options
The injury here is lumbar, below the cord; spinal shock is a temporary loss of cord function after a cord injury.
Brown-Séquard results from cord hemisection, with same-side weakness and opposite-side pain and temperature loss, not saddle anesthesia with lost reflexes.
Compression of the lumbosacral nerve roots below the conus causes saddle anesthesia, lower motor neuron leg weakness with lost reflexes, and urinary retention. It needs urgent decompression to save bladder and leg function.
Central cord syndrome follows cervical hyperextension and weakens the arms more than the legs; it does not cause saddle anesthesia.
Item 535871
Clinical Practice: Musculoskeletal and Wound · 13 items
A worker has been trapped under a collapsed wall with both legs crushed for 5 hours. Rescuers are about to lift the wall. Which intervention is MOST important?
Answer and why, all 4 options
Waiting for hospital arrival misses the window before release, and potassium-containing fluids are avoided in crush injury.
Starting isotonic saline before the weight is lifted expands the circulation so the potassium, acid, and myoglobin released on reperfusion are diluted, lowering the risk of arrest and kidney failure. Fluid continues after extrication toward a high urine output.
A diuretic before volume loading deepens hypovolemia and does nothing to blunt the potassium surge on release.
Bicarbonate may be added once fluids are running, but it is not the first step and cannot replace volume expansion.
Item 1883066
Clinical Practice: Musculoskeletal and Wound · 13 items
A patient has a clean, guillotine-type amputation of the forearm. A tourniquet has controlled the bleeding for 30 minutes; BP is 124/78 mm Hg, HR 96 beats/min, and there are no other injuries. The amputated part is properly packaged. A replantation center is 45 minutes away by air and a Level III trauma center 10 minutes away. Which destination is MOST appropriate?
Answer and why, all 4 options
A two-stage plan makes sense for an unstable patient; this patient is stable, so an extra stop only lengthens ischemia time.
A stable patient with an isolated forearm amputation and controlled bleeding goes directly to the center that can replant the part, minimizing ischemia time. A stop at a hospital that cannot replant only adds delay.
A hospital without surgical services cannot manage the injury or the part.
A closer center that cannot replant does not help a stable patient whose main need is replantation.
Item 1883070
Clinical Practice: Musculoskeletal and Wound · 13 items
A 52-year-old has a grossly contaminated open femoral shaft fracture with absent distal pulses after a crush injury. IV antibiotics were given in the ED. Which operative sequence BEST addresses the limb ischemia?
Answer and why, all 4 options
A graft placed before the fracture is reduced can be stretched or torn when the bone is pulled out to length.
Nailing first adds an hour or more of ischemia, and internal hardware in a grossly contaminated wound raises the risk of deep infection.
Fasciotomy may be needed after reperfusion, but a 24-hour delay far exceeds the roughly 6-hour window for muscle survival.
Restoring flow comes first, so a temporary intraluminal shunt reperfuses the limb within minutes. External fixation then restores length without implanting hardware in a contaminated wound, and the definitive vascular repair is done on a stable skeleton so later manipulation cannot disrupt it.
Item 1923056
Clinical Practice: Musculoskeletal and Wound · 13 items
A patient has a lip laceration that crosses the vermilion border. The nurse anticipates that during repair the provider will FIRST:
Answer and why, all 4 options
Starting at the commissure and working toward the border leaves any mismatch at the most visible point; the border is set first and the remaining skin closed from it.
A laceration across the vermilion border left open heals with notching and a visible step.
Trimming removes tissue that cannot be replaced and distorts the lip line; debridement is minimal.
Even a 1-mm step in the vermilion border is visible at conversational distance, so the first suture aligns the border exactly, often after marking it before local anesthetic distorts the tissue. The rest of the repair follows from that point.
Item 2100483
Clinical Practice: Musculoskeletal and Wound · 13 items
A hemodynamically stable adult has an isolated closed femoral shaft fracture held in a traction splint. To reduce pulmonary complications such as fat embolism syndrome, the nurse anticipates definitive fracture fixation:
Answer and why, all 4 options
Waiting for callus is nonoperative fracture care, which for a femoral shaft fracture means months of immobility and high complication rates.
Prolonged traction keeps the fracture mobile, releasing more marrow fat and keeping the patient bedbound.
Early stabilization of a femoral shaft fracture in a stable patient reduces fat embolism syndrome, ARDS, pneumonia, and length of stay, and allows early mobilization. Unstable patients may get damage-control external fixation instead.
Waiting a week extends the period of risk for fat embolism and pulmonary complications; swelling is not a reason to delay femoral fixation.
Item 2100556
Clinical Practice: Musculoskeletal and Wound · 13 items
A patient has a first-time anterior shoulder dislocation from a high-energy fall. Neurovascular status is intact. Before reduction, the nurse anticipates:
Answer and why, all 4 options
Reducing blind risks displacing an occult fracture; skipping films is reserved for some recurrent, low-energy dislocations.
With intact neurovascular status, vascular imaging is not indicated before reduction.
A first-time dislocation from a high-energy mechanism can come with a humeral head, neck, or greater tuberosity fracture, and reducing over an unseen neck fracture can displace it. Prereduction films are standard in this setting.
Cuff injury is assessed later if weakness persists; MRI is not needed before reduction.
Item 535541
Your score: – fills in as you answer; nothing is saved.Doubt a key? Note the item number — how corrections work →
Fracture and wound traps
Elevating a limb with a developing compartment syndrome. Keep it at heart level and remove anything circumferential; elevation lowers perfusion pressure further.
Waiting for a lost pulse. Early warning is pain that outruns the injury and spikes when the compartment's muscles are passively stretched; pulselessness comes late, often after the muscle is lost.
Antibiotics "when the OR is ready." The ACS TQIP guideline on orthopedic trauma asks for IV antibiotics inside the first hour after arrival for an open fracture.
Tetanus by habit. For a dirty or major wound, CDC advises a tetanus booster if the last dose was 5 or more years ago, and tetanus immune globulin as well when the patient has had fewer than three doses or does not know.
An amputated part on ice. Wrap it in gauze moistened with saline, seal it in a plastic bag, and set the bag in ice water: no direct contact with ice and no immersion of the part itself.
The long board as transport. The 2018 joint statement from ACS-COT, ACEP and NAEMSP limits backboards to extrication and calls for removing them early. Isolated penetrating trauma without a neurologic deficit does not need spinal motion restriction.
A palpable pulse after a knee dislocation. The popliteal artery can be injured with a pulse present; an ankle-brachial index below 0.9 calls for vascular imaging.
Related limb and spine topics
Cord injury, as opposed to the fractured vertebra:head and neck.
No. BCEN lists thermal, chemical and electrical burns and inhalation injury under special populations; this domain covers mechanical wounds and soft-tissue injury.
Why is the spine split across two TCRN domains?
The outline puts vertebral injuries here and spinal cord injuries in head and neck. A question about a fracture and its handling belongs here; one about cord function belongs there.