A client presents to the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis. The client reports nausea and vomiting from laboratory studies. Which information is most valuable in reporting the client’s status to the healthcare provider?
Reports of chronic constipation and serum gastrin levels
Serum Helicobacter pylori antibody results and urine output amounts
Presence of bowel sounds and degree of abdominal pain
Severity of nausea and vomiting and serum amylase results
The Correct Answer is D
Choice A reason: Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis. Constipation may indicate gastrointestinal issues, but gastrin primarily relates to gastric acid secretion. These do not confirm pancreatitis or guide acute management, unlike amylase levels, which are diagnostic for pancreatic inflammation.
Choice B reason: Helicobacter pylori antibodies indicate gastric infection, unrelated to pancreatitis, which involves pancreatic inflammation. Urine output is a general vital sign but not specific to pancreatitis diagnosis. Amylase and symptom severity are more critical for confirming and managing acute pancreatitis, making this less valuable.
Choice C reason: Bowel sounds and abdominal pain degree provide general information but are nonspecific. Pain is expected in pancreatitis, and bowel sounds may vary. Serum amylase and nausea/vomiting severity are more diagnostic, directly reflecting pancreatic inflammation and its systemic effects, making them more critical to report.
Choice D reason: Serum amylase levels are a key diagnostic marker for acute pancreatitis, as pancreatic inflammation releases amylase into the blood. Severity of nausea and vomiting reflects disease impact and fluid loss, guiding treatment. These are the most valuable data for reporting, as they confirm diagnosis and inform management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring oxygen saturation is critical in COPD, as oxygen therapy aims to maintain saturation (88–92%) to prevent hypoxia. Pulse oximetry ensures adequate oxygenation, guiding therapy adjustments, making it the priority assessment to prevent respiratory failure and optimize lung function.
Choice B reason: Checking skin color assesses cyanosis but is less precise than oxygen saturation. Pulse oximetry provides objective data on oxygenation in COPD, guiding oxygen therapy, making it the priority over subjective visual assessments, which are secondary to quantitative measures.
Choice C reason: Assessing chest pain is relevant for cardiac issues but not the primary concern in COPD oxygen therapy. Oxygen saturation directly evaluates therapy effectiveness, preventing hypoxia, making it the priority assessment to ensure respiratory stability in chronic lung disease.
Choice D reason: Measuring blood pressure monitors cardiovascular status but is secondary to oxygenation in COPD. Oxygen saturation is critical, as hypoxia exacerbates respiratory distress, requiring immediate assessment to adjust oxygen therapy, making it the priority over hemodynamic evaluations.
Correct Answer is D
Explanation
Choice A reason: Obtaining an arterial blood gas assesses oxygenation and acid-base status, useful in COPD management, but is not required before postural drainage. This invasive procedure is unnecessary for routine drainage, which mobilizes secretions. Explaining positions prepares the client, enhancing cooperation and effectiveness.
Choice B reason: Performing drainage after meals risks aspiration or vomiting, as a full stomach increases intra-abdominal pressure in COPD patients. Postural drainage is most effective when performed on an empty stomach, making this approach incorrect. Patient education on positioning is the priority.
Choice C reason: Shallow, fast breathing is counterproductive in COPD, as it reduces tidal volume and worsens hypercapnia. Postural drainage requires slow, deep breaths to mobilize secretions and improve ventilation. Explaining positions ensures proper technique, making this breathing instruction incorrect.
Choice D reason: Explaining that the client may be placed in five positions (e.g., prone, supine, lateral) prepares them for postural drainage, which uses gravity to mobilize lung secretions in COPD. This education enhances compliance and effectiveness, as proper positioning is critical for therapeutic success, making it the correct approach.
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