A nurse is providing discharge planning for a young adult client who is postoperative following a myringotomy. Which of the following information should the nurse include in the discharge planning?

Irrigate the affected ear with hydrogen peroxide.

Drink liquids through a straw.

Swimming is permitted after 1 week.

Air travel is allowed after 3 weeks.

Answer and Explanation

The Correct Answer is D

A) Irrigate the affected ear with hydrogen peroxide: Irrigating the ear with hydrogen peroxide is not recommended post-myringotomy. This can cause irritation or infection at the surgical site, which could impede healing and potentially worsen the condition.

B) Drink liquids through a straw: Drinking liquids through a straw can create pressure changes in the ear, which is not advisable post-myringotomy. These pressure changes might affect the healing process of the ear.

C) Swimming is permitted after 1 week: Swimming is typically restricted for a longer period post-myringotomy to prevent water from entering the ear, which can lead to infection or interfere with the healing process.

D) Air travel is allowed after 3 weeks: Air travel restrictions are generally recommended for a few weeks post-myringotomy due to pressure changes that occur during flight, which can affect the ear's healing process. Waiting for 3 weeks allows the surgical site to heal sufficiently, reducing the risk of complications from pressure changes.

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Correct Answer is C

Explanation

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

A. Hematocrit 37% B. Iron 160 mcg/dL C. Prealbumin 9 mg/dL. D. C-reactive protein 15 mg/L

Correct Answer is C

Explanation

A) Hematocrit 37% is within the normal range for adults, indicating that the client’s red blood cell volume is adequate. While anemia can be a concern in clients with Crohn's disease, this value does not specifically indicate malnutrition.

B) Iron 160 mcg/dL is above the normal range (typically 50-170 mcg/dL). Elevated iron levels can result from supplementation or other factors, but it does not directly indicate malnutrition. Iron status alone is not a reliable marker for overall nutritional status.

C) Prealbumin 9 mg/dL is significantly below the normal range (15-36 mg/dL). Low prealbumin levels are a strong indicator of malnutrition because prealbumin has a short half-life and reflects recent changes in protein status and dietary intake. This result suggests the client has been experiencing inadequate nutritional intake or absorption.

D) C-reactive protein (CRP) 15 mg/L indicates inflammation, which is common during an exacerbation of Crohn's disease. While elevated CRP levels signal active inflammation, they do not specifically indicate malnutrition. CRP is more commonly used as a marker of inflammatory activity rather than nutritional status.

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A nurse is providing discharge planning for a young adult client who is postoperative following a myringotomy. Which of the following information should the nurse include in the discharge planning?

Nursing Test Bank

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