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 rationale:

Assess respiratory status. In a child with a head injury, assessing respiratory status is the top priority. Respiratory distress or compromise could indicate potential brain injury or other serious complications. Ensuring an open airway, adequate breathing, and proper oxygenation is essential for the child's immediate well-being. Any signs of respiratory distress should be promptly addressed to prevent further complications.

Choice B rationale:

Check pupil reactions. Checking pupil reactions is important in assessing neurological function, but it is secondary to assessing respiratory status in this scenario. Respiratory status takes precedence because impaired breathing can lead to hypoxia, which can further compromise neurological function. Once respiratory status is stabilized, assessing neurological signs, including pupil reactions, becomes crucial to evaluate potential brain injury.

Choice C rationale:

Inspect for fluid leaking from the ears. Inspecting for fluid leaking from the ears is important in head injury assessment, specifically for signs of cerebrospinal fluid leakage. However, it is not the first action to take. Assessing respiratory status and ensuring proper oxygenation are immediate

Choice A rationale:

An increase in venous pressure is not an indication that furosemide, a loop diuretic, is effective. In fact, increased venous pressure could suggest worsening heart failure. Loop diuretics like furosemide work by promoting the excretion of excess fluid and sodium from the body, leading to a decrease in blood volume and relieving symptoms of heart failure, such as peripheral edema and pulmonary congestion.

Choice B rationale:

A decrease in cardiac output is not the desired effect of furosemide. Furosemide helps reduce fluid overload and congestion in the heart and lungs, ultimately improving cardiac output. If cardiac output decreases, it indicates that the medication might not be effective or the heart failure is worsening.

Choice C rationale:

An increase in potassium levels is not directly related to the effectiveness of furosemide. Furosemide can cause potassium depletion as it increases the excretion of potassium in the urine. Monitoring potassium levels is essential because severe hypokalemia can lead to cardiac arrhythmias. However, the absence of an increase in potassium levels does not indicate furosemide's effectiveness.

Choice D rationale:

A decrease in peripheral edema is the desired effect of furosemide. By reducing fluid retention, furosemide helps decrease peripheral edema, which is a common symptom of heart failure. The nurse should assess the child for a decrease in peripheral edema to determine the medication's effectiveness. Monitoring daily weights and assessing for reduced edema are key indicators of furosemide's efficacy.