Client Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Maternity/PostpartumReference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
(2nd ed.). St. Louis: Elsevier, p. 1115.203. The mother of a child that had a myringotomy with insertion of tympanostomytubes calls the nurse and tells the nurse that the “tubes” fell out. The nurse makes whichresponse to the mother?1. “Replace the tubes immediately so that the created opening does not close.”2. “This is an emergency and requires immediate intervention. Bring the child to theemergency room.”3. “This is not an emergency. I will speak to the physician and call you right back.”4. “Soak the tubes in alcohol for 1 hour before replacing them in the child’s ears.”Answer: 3Rationale: The size and appearance of the tympanostomy tubes should be described tothe parents following surgery. They should be reassured that if the tubes fall out, it is notan emergency but that the physician should be notified. Options 1, 2, and 4 are incorrect.Test-Taking Strategy: Use the process of elimination. Option 2 should be eliminated first because this will cause concern in the parent. Next, eliminate options 1 and 4 becausethey are similar and relate to replacing the tubes. Review home care instructionsfollowing this procedure if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Child HealthReference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
(2nd ed.). St. Louis: Elsevier, p. 1119.204. A child is scheduled for a tonsillectomy in the “day stay” surgical unit. On the dayfollowing surgery, the mother calls the surgical unit and expresses concern because thechild has very bad mouth odor. The nurse makes which response to the mother?1. “The child probably has an infection.”2. “You need to contact the physician immediately.”3. “Bad mouth odor is normal and may be relieved by drinking more liquids.”4. “Have the child gargle with mouthwash.”Answer: 3Rationale: Bad mouth odor is normal following a tonsillectomy and may be relieved bydrinking more liquids. Options 1, 2, and 4 are incorrect. Additionally, mouthwashgargles will irritate the throat.Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first knowingthat mouthwash gargles will irritate the surgical site. Options 1 and 2 are similar and can be eliminated; these responses will cause additional concern in the mother. Review postoperative expectations following a tonsillectomy if you had difficulty with thisquestion.Level of Cognitive Ability: Application