A nurse is providing teaching to a client who has otitis media and is 1 hr postoperative following a myringotomy. Which of the following statements should the nurse include in the teaching?
"You should not drink through a straw for 2 weeks.
"You should expect excessive ear drainage for about 48 hours
"You can wash your hair 3 days after the procedure."
"You should blow your nose with your mouth closed."
The Correct Answer is A
Rationale:
A. "You should not drink through a straw for 2 weeks.": Drinking through a straw can create pressure in the middle ear, which may dislodge the tympanic membrane graft or interfere with healing after a myringotomy. Avoiding straws is an important precaution to protect the surgical site and promote proper recovery.
B. "You should expect excessive ear drainage for about 48 hours": Some drainage may occur, but excessive drainage is not expected and could indicate infection or complications. Clients should be instructed to report any abnormal or persistent drainage to the provider rather than expecting it as normal.
C. "You can wash your hair 3 days after the procedure.": Hair washing is typically delayed until the provider confirms it is safe, usually after avoiding water in the ear for a few days. Premature washing could allow water to enter the middle ear, increasing the risk of infection.
D. "You should blow your nose with your mouth closed": Blowing the nose increases pressure in the middle ear and can compromise the healing of the tympanic membrane. Clients should be taught to avoid nose-blowing entirely or do so gently with the mouth open if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A newborn who has forceful vomiting with feedings: Forceful vomiting in a newborn may indicate pyloric stenosis, gastrointestinal obstruction, or other serious conditions that can quickly lead to dehydration and electrolyte imbalance. This is an urgent finding requiring immediate assessment to prevent rapid deterioration.
B. A newborn who has a heart rate of 160/min while crying: A heart rate of 160/min is within the expected range for a newborn (120–160/min) during activity or crying. While monitoring is necessary, this finding is not immediately concerning and does not require urgent intervention.
C. A newborn who is 24 hr of age and has blood-tinged vaginal discharge: A small amount of blood-tinged vaginal discharge (pseudomenstruation) is a normal hormonal response in female newborns due to maternal estrogen withdrawal. This is an expected finding and does not require urgent assessment.
D. A newborn who is 12 hr of age and has not voided: While monitoring urinary output is important, a newborn may normally not void within the first 12 hours of life. Assessment is needed, but it is not as urgent as forceful vomiting, which can quickly cause serious complications.
Correct Answer is B
Explanation
Rationale:
A. A client who is 4 hr postpartum and has a heart rate of 90/min: A heart rate of 90/min is within normal postpartum limits. This client is stable and does not require immediate assessment, making them a lower priority compared to clients showing signs of possible infection or complications.
B. A client who is 4 days postpartum and has a WBC count of 18,000/mm³ (5,000 to 10,000/mm³): An elevated WBC count 4 days postpartum can indicate a serious infection, such as endometritis or another postpartum infection. This client is at risk for rapid deterioration and requires immediate assessment and intervention.
C. A client who is 12 hr postpartum and has an oral temperature of 37.8° C (100° F): A mild temperature elevation shortly after birth can be expected due to normal postpartum physiologic changes. While it should be monitored, it is not as urgent as the markedly elevated WBC count indicating potential infection.
D. A client who is 2 days postpartum and reports dysuria: Dysuria may indicate a urinary tract infection, which requires evaluation, but this is less immediately threatening than a client with signs of systemic infection. This client should be assessed after clients with potential severe infection or hemodynamic instability.
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