A nurse is preparing to administer acetaminophen 10mg/kg PO to a preschool child for fever.

The child weighs 22 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? .

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

• Choice A: 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.
• Choice B: 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.
• Choice C: 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.
• Choice D: 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.

Choice A rationale
Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis.
Choice B rationale
Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system.
Choice C rationale
Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia.
Choice D rationale
Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system’s response to hypoglycemia.