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 D
Explanation
Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.
Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.
Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.
Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.
Correct Answer is A
Explanation
Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.
Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.
Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.
Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.
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