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Quiz Session - Attempts With Random Questions

BCEN CBRN Exam Questions

Page 8 of 20

141.

What is the most common presenting sign of a Curling ulcer in a patient with a burn injury? 

  • Gastrointestinal (GI) bleeding 

  • Abdominal pain 

  • Abdominal distension 

  • Indigestion 

Correct answer: Gastrointestinal (GI) bleeding 

Curling ulcer is a stress-induced ulcer of the stomach or duodenum that occurs in relation to extreme physical stress, such as in massively burned patients. This is because an extensive burn causes more stress on the entire body than any other injury.

This condition is clinically recognized in most cases only by the onset of upper GI bleeding, which may be evidenced by vomiting blood or blood in the stool. Pain is not always a symptom but usually accompanies perforation or bleeding. Other signs and symptoms include nausea or vomiting, dark and loose stools, and fatigue. 

142.

Which clinical finding is not consistent with burn sepsis diagnostic criteria for an adult patient? 

  • Systolic blood pressure 110 mm Hg

  • Temperature 36.4 °C

  • Heart rate 112 beats per minute

  • Respiratory rate 26 breaths per minute

Correct answer: Systolic blood pressure 110 mm Hg

Burn sepsis criteria in adult patients include three of the following plus documented infection:

  • Temperature <36.5 °C or >39 °C
  • Heart rate >110 BPM
  • Respiratory rate >25 per min (non-ventilated)
  • Platelets <100,000 per microliter of blood
  • Hyperglycemia (absent DM) GLC >200 mg/dL
  • Insulin resistance: >7 units/hour or >25% increase in insulin requirements
  • Enteral feeding intolerance: residual equal to two times the feeding rate
  • Uncontrolled diarrhea: >2,500 mL/day

Systolic blood pressure (SBP) ≤100 mm Hg or arterial hypotension (SBP <90 mm Hg) is indicative of sepsis. 

143.

You are providing education to a patient upon discharge who has been prescribed silver sulfadiazine cream for home burn wound management. Education surrounding this topical agent should include which of the following? 

  • It should be discontinued after 2 weeks

  • It is safe for use during pregnancy

  • There may be pain associated with its application

  • It penetrates burn eschar well, so it is useful when an infection is suspected or vascular supply is limited

Correct answer: It should be discontinued after 2 weeks

Silver sulfadiazine is a topical antibiotic agent that is effective against gram-positive and gram-negative organisms and fungi and is one of the most commonly used agents for burn care. The use of silver sulfadiazine should be limited to two weeks. It is not for use in pregnant women, newborns, or sulfa-allergic patients, and there is no pain associated with the application of the cream; many patients report it is comfortable and soothing upon application. It provides broad-spectrum antibacterial properties for up to 24 hours. 

Mafenide acetate (not silver sulfadiazine) has better penetration of eschar, so it is useful when an infection is suspected or vascular supply is minimal. 

144.

For a patient with carbon monoxide (CO) poisoning secondary to smoke exposure, what is the most appropriate laboratory value to assess and monitor? 

  • Carboxyhemoglobin level

  • Arterial blood gas 

  • Fractionated hemoglobin level 

  • Comprehensive metabolic panel 

Correct answer: Carboxyhemoglobin level

A diagnosis of carbon monoxide (CO) poisoning should be based on direct measurement of carboxyhemoglobin (COHb) in arterial or venous blood by co-oximetry, taking into account that venous blood underestimates the arterial COHb content. Levels should be checked upon presentation and throughout treatment to determine progress. Levels are reported as a percentage, with symptoms specific to the value. 

For COHb levels of 5-10%, headaches and dizziness are common. For COHb levels of 10-20%, headache, nausea, vomiting, flushed skin and dyspnea are common. For COHb levels of 20-40%, confusion, lethargy, and visual disturbances may be present. For COHb levels of 40-60%, dysrhythmias, seizures, and coma are common. Finally, for COHb levels above 60%, cherry-red skin is present, and death is imminent.

145.

Which of the following laboratory values best reflects acute changes in the nutritional status of a patient? 

  • Prealbumin

  • Albumin

  • C-reactive protein

  • Transferrin 

Correct answer: Prealbumin

Because of the short half-life of prealbumin (2 days), this protein is decreased quickly when nutrition is inadequate and responds quickly when external nutrients are provided. It is most commonly monitored for acute changes in nutritional status. 

Normal values of prealbumin are 14 mg/dL or greater. If levels fall below 11 mg/dL, the patient should be evaluated further for malnutrition. 

146.

Which patient factors should alert you to potential increased complications with a burn injury?

  • The patient sustained partial-thickness burns to the dorsum of the right foot and the right hand

  • The patient's medical history is significant for a burn injury approximately 25 years ago

  • The patient sustained approximately 6% TBSA partial-thickness burns 

  • The patient is a 60-year-old female

Correct answer: The patient sustained partial-thickness burns to the dorsum of the right foot and the right hand

Burns that involve the face, hands, feet, genitalia, perineum, or major joints increase the risk for sepsis. Burns of the hands and feet require special attention to ensure the best functional outcomes. Complications are related to the extension of the burn. 

Burn injuries in patients with pre-existing medical conditions could complicate management, prolong recovery, or affect mortality. A burn injury in the past is not a pre-existing medical condition and does not necessarily increase the patient's risk of complications related to the current burn injury. If the patient sustained a partial-thickness burn to greater than 10% TBSA (not 6%), they are at increased risk of complications. Patients over 50 years old are at an increased risk of complications only if the burn injury is second- or third-degree and greater than 10% TBSA. 

147.

In the emergency department, you are caring for two burn-injured patients with similar acuity. One of the patients is a family friend, while the other patient is not a personal acquaintance. Since you know one patient, you spend more time and care attending to their injuries while leaving the unknown patient unattended. 

Which ethical principle are you disregarding?

  • Justice

  • Paternalism

  • Beneficence

  • Autonomy 

Correct answer: Justice 

Justice is the ethical principle that addresses a patient's right to be treated fairly. In trauma care encounters, need and the likelihood of benefit are the most common considerations in the just distribution of healthcare resources. You are disregarding justice in this scenario by failing to provide the same care to both of patients, as the severity of their injuries is similar.

Paternalism is the ethical principle that requires us to help a patient make decisions when they do not have the needed data or expertise to do so independently. Beneficence is the ethical principle that means we are obligated to only do good, not harm. Autonomy is the ethical principle that requires us to allow a patient to make decisions about their care.

148.

What is the most frequently used crystalloid solution for burn shock resuscitation? 

  • Lactated Ringer's (LR) 

  • 5% albumin in normal saline (NS)

  • Normal saline (NS)

  • 5% dextrose in water 

Correct answer: Lactated Ringer's (LR) 

Crystalloids are the mainstay of burn shock resuscitation, and lactated Ringer's (LR) solution is the common fluid used in the initial resuscitation of burn injury. For resuscitation purposes, the administration of LR compared to normal saline (NS) maintains a higher plasma pH and less pulmonary edema. It also prevents the hyperchloremic acidosis that can be seen with large saline infusions and treats hypovolemia effectively. For pediatric patients under 10 kg, dextrose is often added to LR solution during burn shock resuscitation due to decreased glycogen storage in small children. 

Five percent albumin in NS is the most commonly used colloid (not crystalloid) for burn resuscitation today. 

149.

In acute burn wound healing, which of the following statements is accurate regarding hydrogel dressings?

  • They are used to rehydrate dried-out necrotic eschar 

  • They help promote hemostasis 

  • They have a low absorptive capacity 

  • They provide antimicrobial activity in the wound bed 

Correct answer: They are used to rehydrate dried-out necrotic eschar 

Hydrogels are indicated for exudative burn wounds because they have a high absorptive capacity. They are effective at cleansing and debriding necrotic and sloughy wounds by increasing moisture, aiding in autolytic debridement. Therefore, they are used to rehydrate dried-out necrotic eschar. In addition, they decrease pain at the wound site and do not adhere to the wound. They can be used to cover partial-thickness wounds. 

Alginates release calcium ions, which promote hemostasis. They are applied to surgical wounds for patients with excessive bleeding. Silver-impregnated dressings provide antimicrobial activity in the wound bed. 

150.

You are transitioning a patient from inpatient to outpatient care and are providing education on infection prevention and home wound management. You explain that burn wound cellulitis is a noninvasive infection that could occur in the uninjured skin surrounding the wound. Which pathogen is most often responsible? 

  • Streptococcus pyogenes

  • Staphylococcus aureus

  • Escherichia coli 

  • Pseudomonas aeruginosa 

Correct answer: Streptococcus pyogenes

Burn wound cellulitis refers to a spreading dermal infection in the tissues surrounding the wound  (or donor site), usually secondary to S. pyogenes. While this complication is most commonly seen in the first few days following a burn injury, it is also a postoperative donor site complication. The infection is characterized by erythema, edema, induration, tenderness, and extreme sensitivity to touch. Signs of local infection progress beyond what is expected from burn-related inflammation. 

Cellulitic burn wounds benefit from systemic antimicrobials to cover likely causative agents in addition to standard burn treatments (e.g., topical antimicrobials or surgical excision and grafting). 

151.

What is the total resuscitation volume for a 10 kg infant (body surface area 0.5 m2) with 50% total body surface area (TBSA) burns for the first 8 hours? 

  • 1,500 mL

  • 2,000 mL

  • 1,000 mL

  • 3,000 mL

Correct answer: 1,500 mL

Pediatric burn resuscitation is as follows: 

  • Daily basal fluid requirements + 4 mL/kg/% TBSA
  • <30 kg = 2,000 x body surface area 
  • >30 kg = 1,500 x body surface area 

So, for a 10 kg infant, take 2,000 x 0.5 = 1,000 mL/day + (4 x 10 x 50). 1,000 mL + 2,000 mL = 3,000 mL in 24 hours. Give half in the first 8 hours = 1,500 mL/8 hr = 187.5 mL/hr. 

152.

A pediatric burn victim is at an increased risk of developing acute respiratory distress syndrome (ARDS). This condition is characterized by which of the following?

  • Diffuse alveolar injury 

  • Diffuse bronchial injury 

  • Increased lung compliance 

  • Increased levels of surfactant 

Correct answer: Diffuse alveolar injury 

Nurses should monitor a burn-injured child closely for early signs of posttraumatic respiratory insufficiency secondary to smoke inhalation injury. ARDS is a life-threatening syndrome that is characterized by diffuse alveolar injury leading to inflammation. Severe hypoxemia results due to an increase in the permeability of the alveolar-capillary barrier. Hypoxemia is often refractory to high concentrations of oxygen. ARDS is also associated with loss of surfactant, alveolar collapse, and decreased lung compliance.

153.

A 29-year-old male spilled a can of paint stripper while doing home renovations and cleaned it without using gloves. He reports washing his hands shortly after. Approximately 10 minutes after the incident, he experienced painful, blanching erythematous patches on his palms, the back of his hands, and his left cheek. The patient's left eye is painful and sensitive to light. The label on the can shows lye as the primary ingredient. 

All the following are concerns for this patient, except: 

  • Compartment syndrome 

  • Evolution to a greater depth injury over time 

  • Loss of range of motion in the hand 

  • Conjunctival burns 

Correct answer: Compartment syndrome 

Chemical burns may develop a greater depth of injury than what appears on initial assessment. Wounds caused by alkalis (lyes) initially appear superficial but may often become full thickness in 2-3 days. Alkalis are highly corrosive in nature and penetrate deeply. Splash incidents may cause burns to the eyes. Hand burns carry a risk of stiffness unless they are properly splinted and managed with physical therapy exercises. 

Compartment syndrome is more characteristic of electrical burns. 

154.

A 25-year-old female patient is admitted to the emergency department after sustaining a chemical burn on her face and neck due to a workplace accident involving an acidic solution. The affected skin is discolored, and she is in severe pain. 

What is the recommended immediate action for managing this patient's chemical burn?

  • Irrigate the burn area with gently flowing cool water 

  • Apply a neutralizing agent on the burn area

  • Rub the burn area with a dry cloth to remove any residue

  • Open any blisters that may form on the burn area and cover with sterile nonadhesive dressing 

Correct answer: Irrigate the burn area with gently flowing cool water 

Initial care for most chemical burns consists of the immediate removal of clothing, including jewelry and shoes, and dusting off any powders. Emergency personnel should protect themselves with appropriate personal protective equipment (PPE). Immediate copious irrigation (with tap water) will reduce the extent and depth of injury. Irrigation should be a large-volume shower or decontamination station and drained via an appropriate drain. Irrigating the burn area with cool tap water helps remove the chemical(s) and reduce tissue damage. 

Neutralizing agents can react and worsen the burn; they can cause exothermic reactions, producing a thermal component along with a chemical injury. For these reasons, the use of neutralizing agents is generally contraindicated. Rubbing the burn or opening the blisters is not recommended. 

155.

Which of the following factors does not determine the severity of a chemical burn?

  • Skin pH of 4.5-5.5

  • Chemical type 

  • Chemical temperature 

  • Chemical concentration 

Correct answer: Skin pH of 4.5-5.5

When a patient presents with a chemical burn, the triage nurse should find out the type of chemical that caused the burn, as well as the temperature and concentration of the chemical. This information will aid in appropriate management. 

The severity of a chemical burn injury is determined by several factors:

  • Concentration of chemical in contact or ingested
  • Quantity of chemical agent
  • Manner and duration of contact (skin or ingestion)
  • Extent of penetration
  • Mechanism of action 
  • Physical state of agent (liquid, solid, gas)

A pH of 4.5 to 5.5 is normal for the skin.

156.

During the acute phase of nursing care, you apply gentamicin sulfate (a topical antibiotic) to your patient's burn before dressing the wound. This agent has broad-spectrum bactericidal activity against aerobes and is often deployed against which of the following?

  • Pseudomonas aeruginosa

  • Clostridium 

  • Candida albicans

  • Klebsiella pneumoniae

Correct answer: Pseudomonas aeruginosa

Gentamicin sulfate (Gentamicin) is an aminoglycoside available as a 0.1% water-soluble cream or solution. It is most often deployed against P. aeruginosa. However, resistance can develop, and sensitivities should be monitored. 

157.

You are discharging a 32-year-old female who sustained a deep partial-thickness scald burn to her upper thigh (4% TBSA) and are reviewing outpatient management for her burn wound. When should a follow-up visit be scheduled? 

  • Within 24 hours of discharge

  • Within 48 hours of discharge 

  • Within 72 hours of discharge 

  • Within 1 week of discharge 

Correct answer: Within 24 hours of discharge 

Before discharge from inpatient care, a follow-up visit should be scheduled for the following day (within 24 hours) to ensure close monitoring of the burn wound is continued on an outpatient basis. Wound healing, early detection of infection, and adequate pain management are all important aspects of outpatient management. Immediate follow-up (within 24 hours) will help assess whether the patient's pain is being well managed and evaluate the patient's or caretaker's competence with dressing changes. 

Depending on these early outpatient assessment findings, the plan of care might need updating to include daily home health visits, particularly during the first week after discharge. 

158.

What is the recommended urinary output (UO) in adult burn resuscitation management? 

  • 30-50 mL/hr

  • >50 mL/hr

  • 0.5 to 1.0 mL/kg/hr

  • 1.0 to 2.0 mL/kg/hr

Correct answer: 30-50 mL/hr

The primary index of adequacy of resuscitation is most often the urinary output. The amount of fluid administered depends on how much intravenous (IV) fluid per hour is required to maintain a urinary output of 30 to 50 mL/hr. UO is usually recorded hourly. 

For children weighing less than 30 kg, the recommended UO is 0.5 to 1.0 mL/kg/hr. For infants, the recommended UO is 1.0 to 2.0 mL/kg/hr. 

159.

What surgical procedure is used to relieve compartment syndrome and resulting nerve damage secondary to tissue edema? 

  • Fasciotomy 

  • Escharotomy 

  • Grafting 

  • Incision and drainage 

Correct answer: Fasciotomy 

Compartments are defined as closed spaces containing nerves, muscles, and vascular structures that are enclosed by fascia. Compartment syndrome may result when either the internal contents or external sources cause an increase in compartment pressure. 

Internal etiologies of increased compartment pressures include conditions that cause blood accumulation, tissue edema, or fluid infiltration within the closed space. External causes, such as constricting dressings, decrease the size of the compartment. When compartment pressures exceed 30 mm Hg, surgical decompression by open fasciotomy becomes necessary to prevent ischemic muscle injury. 

A fasciotomy is a surgical incision into a compartment to relieve pressure on neurovascular structures and restore effective perfusion.

160.

In terms of wound depth, a full-thickness burn injury is characterized by which of the following? 

  • Loss of epidermis and dermis

  • Loss of epidermis only 

  • Loss of all tissue and extends into muscle and/or bone

  • May extend into the superficial subcutaneous tissue and may or may not require excision and grafting 

Correct answer: Loss of epidermis and dermis

Full-thickness burns (third-degree burns) involve the entire cutaneous layer (epidermis and dermis) and may extend into the superficial subcutaneous tissue. They may appear charred, leathery, dry, firm, and depressed when compared to adjoining normal skin. These wounds are insensate to light touch and pinprick. Most full-thickness burns should undergo early excision and grafting to minimize infection and hypertrophic scarring and to expedite patient recovery. 

Deeper burns that involve adipose tissue (fourth-degree burns), muscle (fifth-degree burns), and bone (sixth-degree burns) also require surgical management. 

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