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: 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: A

Rationale: Assessing fluid balance is the priority action when caring for a child with severe diarrhea. Diarrhea can lead to significant fluid and electrolyte loss, which can result in dehydration. Early recognition and treatment of dehydration are crucial to prevent further complications. While maintaining fluid therapy is an important part of managing severe diarrhea, the first step should be to assess the child's fluid balance. Rehydration is a key part of the treatment for severe diarrhea, but it should be done after assessing the child's fluid balance. Introducing a regular diet is usually done after the acute phase of diarrhea has resolved and the child's fluid balance has been restored.

Correct Answer: B

Rationale: A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture. Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse's priority as it could lead to long-term damage if not addressed promptly. A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture. A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.

Correct Answer: B

Rationale: Withholding insulin when feeling nauseous is not recommended. Insulin is necessary for the body to use glucose for energy. Without insulin, glucose stays in the bloodstream, leading to high blood sugar levels. Testing the urine for ketones is important in managing type 1 diabetes. When the body does not have enough insulin, it breaks down fat as fuel. This process produces a buildup of acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated. Limiting fluid intake during mealtime is not specifically related to the management of type 1 diabetes. It's important to stay hydrated, but it doesn't directly affect blood glucose levels. Notifying the provider if blood glucose levels are over 350 mg/dL is not the only time medical advice should be sought. Any persistent, unusual, or extreme blood glucose reading should be discussed with a healthcare provider.