A nurse is collecting data from a client diagnosed with laryngeal cancer who is postoperative following a laryngectomy. Which of the following is a clinical manifestation of a hemorrhage?
Increased pain
Continuous swallowing
Poor fluid intake
Drooling
The Correct Answer is B
Choice A Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.
Choice B Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.
Choice C Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.
Choice D Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Atropine sulfate is the medication that the nurse should ensure is available to treat cholinergic crisis, as it blocks the effects of acetylcholine and reverses the symptoms of excessive parasympathetic stimulation.
Choice B Reason: Pyridostigmine bromide (Mestinon) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat myasthenia gravis by increasing acetylcholine levels and improving muscle strength.
Choice C Reason: Protamine sulfate is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to reverse the effects of heparin and prevent bleeding.
Choice D Reason: Acetylcysteine (Mucomyst) is not the medication that the nurse should ensure is available to treat cholinergic crisis, but it is used to treat acetaminophen overdose and prevent liver damage.
Correct Answer is D
Explanation
Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.
Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.
Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.
Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.
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