A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Rationale for correct choices:

• Nephrotic syndrome: The child exhibits classic features, including periorbital edema, hypoalbuminemia, hypercholesterolemia, proteinuria, and foamy urine. These findings indicate significant protein loss and fluid retention, which are hallmark signs of nephrotic syndrome.
• Administer oral corticosteroids: Corticosteroids reduce kidney inflammation and proteinuria in nephrotic syndrome, helping to achieve remission. Timely administration is essential to control edema, restore albumin levels, and improve the child’s overall nutritional status and well-being.
• Encourage a low sodium diet: A low-sodium diet helps minimize fluid retention and edema, which are major complications of nephrotic syndrome. Reducing sodium intake also supports blood pressure control and prevents additional strain on the kidneys while the child is being treated.
• Abdominal girth: Measuring abdominal girth tracks the accumulation of fluid in the abdomen and the progression of edema. It provides a noninvasive, simple way to monitor the effectiveness of treatment and to detect early signs of worsening fluid retention.
• Urine specific gravity: Monitoring urine specific gravity helps evaluate kidney function and the concentration of solutes, including protein. Changes in this parameter reflect the child’s response to therapy and assist the nurse in assessing disease progression.

Rationale for incorrect choices:

• Chronic kidney disease: Chronic kidney disease develops gradually and usually shows slow, progressive renal impairment over time. The rapid onset of periorbital edema, hypoalbuminemia, hypercholesterolemia, and proteinuria in this child is more consistent with nephrotic syndrome rather than CKD.
• Hemolytic uremic syndrome: HUS typically presents after a diarrheal illness and is characterized by anemia, thrombocytopenia, and acute kidney injury. This child’s lab results show elevated platelets and normal hemoglobin levels, which are inconsistent with HUS.
• Acute glomerulonephritis: Acute glomerulonephritis presents with hematuria, mild edema, and hypertension. In contrast, this child has significant proteinuria, hypoalbuminemia, and hypercholesterolemia, which are hallmark features of nephrotic syndrome.
• Administer IV antibiotics: There is no clinical or laboratory evidence of infection in this child. Antibiotics would not address the underlying kidney pathology or the protein loss associated with nephrotic syndrome, so they are not indicated at this time.
• Initiate peritoneal dialysis: Dialysis is indicated only for severe renal failure or life-threatening complications. This child maintains adequate urine output and does not show signs of renal failure, making dialysis unnecessary.
• Initiate contact precautions: Nephrotic syndrome is not a contagious condition. Implementing contact precautions would not provide any benefit for this child and is not part of standard management.
• Bilirubin: Bilirubin monitoring is relevant for liver disease or hemolysis but is not related to nephrotic syndrome unless there is comorbid hepatic dysfunction, which is not present in this case.
• Head circumference: Head circumference monitoring is primarily used in infants to assess brain growth and development. It does not provide useful information about nephrotic syndrome progression in a school-age child.
• HbA1c: HbA1c measures long-term blood glucose control for diabetes management. It has no relevance in assessing nephrotic syndrome, its complications, or the child’s response to treatment.

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.