A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?

A. Droplet precautions are important for preventing the spread of infections that are transmitted through respiratory droplets. Since epiglottitis can be caused by Haemophilus influenzae type B (Hib), which is a bacterium that can spread via respiratory droplets, initiating droplet precautions is necessary to protect others from infection
B. Initiating intravenous (IV) access is an appropriate action because children with epiglottitis may need urgent and potentially life-saving treatments, such as antibiotics or corticosteroids. IV access allows for the rapid administration of medications and fluids, which is critical for managing severe infections and supporting the child's condition.
C. Inspecting the epiglottis directly, such as by using a tongue depressor or other instruments, can be dangerous in the case of epiglottitis. The inflammation and swelling of the epiglottis can cause airway obstruction, and manipulating the throat area may worsen the child's condition or lead to sudden airway compromise. It is generally safer to avoid direct inspection and rely on imaging studies if needed.

D. Monitoring oxygen saturation is essential in the management of epiglottitis. Children with this condition may experience compromised airway and breathing difficulties, so continuous monitoring of oxygen saturation helps ensure adequate oxygenation and early detection of any respiratory distress or hypoxia.
E. Obtaining a throat culture can be helpful for diagnosing the specific pathogen causing epiglottitis, but it should be done with caution. Invasive procedures like throat cultures should ideally be avoided in acute cases of epiglottitis due to the risk of exacerbating airway obstruction. Diagnostic procedures are typically handled with caution and may be deferred until after initial stabilization and treatment.

A. The halo vest immobilizes the cervical spine completely. Any movement that might disturb the alignment of the spine is contraindicated. Using a turning sheet could potentially cause movement and damage the spine.
B. Tightening the screws without medical direction can be harmful. The screws should be checked regularly by healthcare professionals, and adjustments made as needed.
C. The entire purpose of the halo vest is to immobilize the neck. Any movement of the neck could disrupt the healing process and cause further injury.
D. Pin site care is crucial to prevent infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, drainage, or increased pain.