# A 25-year-old construction worker presents to the emergency department after a loud explosion at the worksite, reporting severe ear pain, hearing loss, and bloody drainage from the right ear, diagnosed with traumatic tympanic membrane rupture. Which nursing intervention should be implemented first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541722  
> language: ko  
> subject: Adult Health

## 문제

A 25-year-old construction worker presents to the emergency department after a loud explosion at the worksite, reporting severe ear pain, hearing loss, and bloody drainage from the right ear, diagnosed with traumatic tympanic membrane rupture. Which nursing intervention should be implemented first?

## 보기

1. Keep the affected ear dry and avoid inserting anything into the ear canal **✔ 정답**
2. Irrigate the ear canal with normal saline to remove debris
3. Apply a warm compress to the affected ear for comfort
4. Instill antibiotic ear drops to prevent infection

**정답: 1**

## 해설

For traumatic tympanic membrane rupture, priority is to keep the ear dry and avoid inserting anything to prevent infection and further damage. Irrigation, warm compress, or ear drops can worsen the condition.

## 심화 해설

Clinical Reasoning and Priority Setting for Traumatic Tympanic Membrane Rupture

The correct answer is 1. The first nursing intervention for a patient with a traumatic tympanic membrane rupture is to keep the affected ear dry and avoid inserting anything into the ear canal. This is a critical safety and infection prevention measure. The tympanic membrane serves as a protective barrier between the external auditory canal and the sterile middle ear space. When this barrier is disrupted by a blast injury, a direct pathway for pathogens, water, and debris to enter the middle ear is created, significantly increasing the risk of infection [4].

The rationale for this priority intervention is rooted in the pathophysiology of secondary injury and infection prevention. The primary blast wave causes the mechanical rupture, but the subsequent risk of otitis media from introduced contaminants represents a preventable secondary complication. The middle ear mucosa, now exposed, is a warm, moist environment susceptible to bacterial colonization. Introducing water, even clean water, can carry pathogens like Pseudomonas aeruginosa or Staphylococcus aureus, which are common culprits in suppurative otitis media [4]. The principle of maintaining a dry, undisturbed environment to allow natural healing is paramount. The body's inflammatory response will initiate repair, but this process is easily disrupted by mechanical trauma from cotton swabs or irrigation fluid pressure, which could push debris and bacteria deeper into the middle ear, potentially causing chronic suppurative otitis media (CSOM) [4].

The other options are incorrect and potentially harmful as a first-line intervention. Irrigating the ear canal (Option 2) is contraindicated because the fluid can introduce bacteria from the external canal into the sterile middle ear, directly causing infection. Applying a warm compress (Option 3) may provide comfort but is not the priority; it does not address the immediate risk of infection and could introduce moisture if the compress is damp. Instilling antibiotic ear drops (Option 4) is not an evidence-based first step without a specific order following a thorough examination. Many otic preparations are ototoxic and are contraindicated in the presence of a tympanic membrane perforation unless specifically formulated for middle ear use. The priority is to protect the site from further harm, not to introduce a substance that could cause sensorineural hearing loss or carry its own risk of local irritation and infection [4]. The foundational nursing action is to secure the site from external contamination, a principle that aligns with managing any open wound communicating with a sterile body cavity.References (research sources)

- [4]Systemic antibiotics for chronic suppurative otitis media.Research articleChong LY, Head K, Webster KE, Daw J, Strobel NA, Richmond PC, Snelling T, Bhutta MF, Schilder AG, Brennan-Jones CG. (2025) · DOI: 10.1002/14651858.cd013052.pub3

## 임상 시나리오

Traumatic TM Rupture: Initial CarePriority is keeping the ear dry and undisturbed
The first and most critical step is to keep the affected ear completely dry. The ruptured tympanic membrane eliminates the barrier to the sterile middle ear, so any water entry can introduce pathogens like Pseudomonas aeruginosa.

Instruct the patient to avoid inserting anything into the ear canal, including cotton swabs. Mechanical trauma can disrupt the healing process and push debris deeper.

CautionNever irrigate the ear or instill any drops without a specific provider order. Irrigation pressure can cause further injury and force contaminants into the middle ear space.

## 핵심 개념

- **Tympanic Membrane Rupture** — A tear in the eardrum, creating a direct pathway between the external ear canal and the sterile middle ear.
- **Blast Injury** — Trauma caused by the pressure wave from an explosion, commonly causing tympanic membrane rupture.
- **Otitis Media** — Infection of the middle ear, a primary complication of tympanic membrane rupture due to pathogen entry.

## 같은 주제 문제

- [A 25-year-old construction worker presents to the emergency department after a piece of me…](https://mymerci.kr/pages/nclex_q.php?qn_id=541718)
- [A nurse is assessing a 45-year-old client who sustained a blunt trauma to the left ear aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=541719)
- [A nurse is assessing a client who sustained a blunt trauma to the right ear during a motor…](https://mymerci.kr/pages/nclex_q.php?qn_id=541720)
- [A client presents to the emergency department with a penetrating ear injury from a metal o…](https://mymerci.kr/pages/nclex_q.php?qn_id=541721)
- [A nurse is caring for a client who sustained a traumatic injury to the right ear from a mo…](https://mymerci.kr/pages/nclex_q.php?qn_id=541723)
- [A 32-year-old client presents to the emergency department with a penetrating ear injury fr…](https://mymerci.kr/pages/nclex_q.php?qn_id=541724)
- [A client arrives at the emergency department with a penetrating ear injury from a metal ob…](https://mymerci.kr/pages/nclex_q.php?qn_id=541725)
- [A 5-year-old child is brought to the emergency department by parents after inserting a bea…](https://mymerci.kr/pages/nclex_q.php?qn_id=541726)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._