A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.
The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Rationale for Choice A:

Serum Helicobacter pylori (H. pylori) antibody results are not directly relevant to the diagnosis or management of acute pancreatitis. While H. pylori infection can cause gastritis and peptic ulcers, it is not a common cause of pancreatitis.

Urine output amounts are important to monitor in patients with pancreatitis to assess for dehydration and kidney function. However, they are not as specific to the diagnosis of pancreatitis as other findings.

Rationale for Choice B:

Reports of chronic constipation are not typically associated with acute pancreatitis.

Serum gastrin levels are used to diagnose conditions such as Zollinger-Ellison syndrome, which is characterized by excessive acid production in the stomach. They are not relevant to the diagnosis of pancreatitis.

Rationale for Choice C:

Severity of nausea and vomiting are key symptoms of pancreatitis. The severity of these symptoms can help to gauge the severity of the pancreatitis and guide treatment decisions.

Serum amylase results are a highly sensitive and specific marker for pancreatitis. Elevated levels of amylase in the blood strongly suggest the presence of pancreatitis.

Rationale for Choice D:

Presence of bowel sounds can be variable in patients with pancreatitis and are not always reliable indicators of the severity of the condition.

Degree of abdominal pain is a subjective symptom that can be difficult to assess accurately. While it is an important symptom of pancreatitis, it is not as objective as other findings such as serum amylase levels.

Therefore, the most valuable information to report to the healthcare provider in this case is the severity of nausea and vomiting and serum amylase results.

Choice A rationale:

While ABGs can provide valuable information about a patient's respiratory status, they are not routinely required prior to postural drainage in patients with COPD.

ABGs might be considered if the patient is experiencing acute respiratory distress or if there are concerns about their oxygenation or ventilation status.

However, in the absence of such concerns, obtaining ABGs would not be necessary and could potentially cause discomfort or anxiety for the patient.

Choice C rationale:

Performing postural drainage immediately after meals is not recommended for patients with COPD.

This is because eating can cause a feeling of fullness in the stomach, which can make it difficult for the patient to breathe deeply and effectively during the procedure.

Additionally, there is a risk of aspiration if the patient were to vomit during or after postural drainage.

It is generally recommended to perform postural drainage at least 1-2 hours after meals to reduce these risks.

Choice D rationale:

Instructing the patient to breathe shallow and fast is not appropriate for postural drainage.

The goal of postural drainage is to help the patient mobilize and expectorate secretions from the lungs.

This is best achieved by encouraging the patient to breathe deeply and slowly, which helps to open up the airways and promote mucus clearance.

Shallow, rapid breathing can actually make it more difficult to clear secretions and can lead to increased shortness of breath.

Choice B rationale:

Explaining that the patient may be placed in five positions is the most appropriate approach for postural drainage in a patient with COPD.

This is because different positions help to drain different areas of the lungs. The five positions typically used for postural drainage are:

Head down position (to drain the lower lobes)

Prone position (to drain the posterior segments of the lungs)

Right lateral position (to drain the right middle lobe and right lower lobe) Left lateral position (to drain the left lower lobe)

Sitting upright position (to drain the upper lobes)

By placing the patient in these different positions, the nurse can help to ensure that all areas of the lungs are drained effectively.