A nurse is preparing to administer an IM injection for an infant. Which of the following actions should the nurse take?

Rationale:

A. Administer pancreatic enzymes with meals: Pancreatic enzymes are used to aid digestion in clients with pancreatic insufficiency, not for epiglottitis. This intervention is unrelated to the acute respiratory management required for this condition.

B. Carefully suction the child's oropharynx to remove secretions: Suctioning the oropharynx in a child with epiglottitis can trigger laryngospasm and complete airway obstruction. Suctioning should be avoided unless absolutely necessary and performed only by experienced personnel with emergency airway equipment ready.

C. Continuously monitor the child's respiratory status: Epiglottitis can rapidly progress to airway obstruction. Continuous assessment of respiratory rate, effort, oxygen saturation, and signs of distress is critical to detect deterioration early and initiate emergency interventions, making this a priority nursing action.

D. Instill normal saline drops to nares before meals: Nasal saline drops are used to relieve mild nasal congestion and facilitate feeding in children but do not address the life-threatening airway risk in epiglottitis. This is a supportive measure, not a priority intervention.

Rationale:

A. Calcium: While calcium is important for many bodily functions, it is not a primary indicator for monitoring hepatic encephalopathy. Calcium imbalances do not directly correlate with the severity or management of this condition.

B. Potassium: Potassium levels are important for overall electrolyte balance, but they are not specific to hepatic encephalopathy. Monitoring potassium is part of routine care but does not indicate the progression or severity of encephalopathy.

C. Ammonia: Elevated ammonia levels are a key contributor to hepatic encephalopathy. The liver normally converts ammonia to urea, and when liver function is impaired, ammonia accumulates, affecting neurological function. Monitoring ammonia helps assess severity and guide treatment interventions.

D. Glucose: While glucose monitoring is important in general care, it is not specific to hepatic encephalopathy. Hyper- or hypoglycemia may occur with liver disease but does not directly reflect the presence or progression of encephalopathy.