Correct Answer: B

Rationale: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child's symptoms suggest a possible Wilms' tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action. Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms' tumor, pressing on the abdominal area could potentially cause the cancer to spread.
Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed. Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child's symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care. Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient's health, it is not the immediate priority in this situation. The child's symptoms suggest a possible Wilms' tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.

Correct Answer: 1170 mL

Rationale:
Step 1 is to convert all fluid intake to mL. Using the conversion factor 1 oz = 30 mL and 1 cup = 240 mL, we get: 1 cup of coffee = 240 mL, 4 oz of orange juice = 4 × 30 mL = 120 mL, 3 oz of water = 3 × 30 mL = 90 mL, 1 cup of flavored gelatin = 240 mL, 1 cup of tea = 240 mL, 5 oz of broth = 5 × 30 mL = 150 mL, 3 oz of water = 3 × 30 mL = 90 mL.
Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL. So, the nurse should record a fluid intake of 1170 mL.

Correct Answer: D

Rationale: Methylphenidate (Ritalin) is a medication used to treat attention-deficit hyperactivity disorder (ADH
D). It is not necessary to give the medication after meals. The medication can be taken with or without food. However, some people find that taking it with food can help prevent stomach upset. Regular blood glucose level checks are not typically required when a child is taking methylphenidate. This medication does not have a significant impact on blood sugar levels. It is not generally recommended to skip doses of methylphenidate on weekends. Consistent medication administration is important for managing ADHD symptoms. However, the prescribing doctor may sometimes recommend a 'drug holiday' or break from the medication. This should only be done under the guidance of a healthcare professional. This is the correct answer. Methylphenidate is a stimulant, and taking it later in the day can cause insomnia or trouble sleeping.
Therefore, it is often recommended that the last dose of the medication be given before 6 o'clock in the evening to minimize sleep disturbances.

Correct Answer: A

Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.

Correct Answer: C

Rationale: While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. This is the correct answer. Checking the child's weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions. Educating the parents about potential complications is important, but it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications.