A nurse is planning care for an adolescent who has sickle cell anemia. Which of the following immunizations should the nurse include in the plan?

Choice A reason:

Oliguria is incorrect. Low potassium levels (hypokalemia) may lead to decreased kidney function and reduced urine output (oliguria) in severe cases. However, at this potassium level, oliguria might not be the immediate or most prominent finding.

Choice B Reason:

Hyperactive bowel sounds are incorrect. Gastroenteritis typically presents with increased bowel sounds due to gastrointestinal irritation or inflammation. Potassium levels might not directly influence bowel sounds, so hyperactive bowel sounds might not be specifically related to the potassium level.

Choice C Reason:

Hyporeflexia is correct. Hypokalemia, indicated by a low potassium level, can affect nerve conduction and muscular function, potentially leading to hyporeflexia (reduced reflexes) as one of its manifestations. This can be a relevant finding associated with low potassium levels.

Choice D Reason:

Hypertension is incorrect. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension (high blood pressure). Therefore, hypertension is less likely to be an expected finding related to low potassium levels.

Correct answer: C

Choice A Reason:

Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.

Choice B Reason:

Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.

Choice C Reason:

Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.

Choice D Reason:

Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.