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Questions 176

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Question 1 of 5

The nurse is collecting data from a client during the first routine prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. The nurse would expect to palpate the uterine fundus

Correct Answer: D

Rationale: At 12 weeks, the uterine fundus is just above the symphysis pubis (
D). It reaches the umbilicus at 20 weeks and higher levels later in pregnancy.

Question 2 of 5

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.

Correct Answer: B, C

Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (
B) and postpartum client (
C). It's contraindicated for infants under 2 (
A), pregnant women (
D), and immunocompromised clients (E).

Question 3 of 5

A client with Addison's disease will most likely exhibit which symptom?

Correct Answer: B

Rationale: A bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.

Question 4 of 5

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

Correct Answer: A

Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

Question 5 of 5

When giving an intramuscular injection to an infant. Which of the following sites is preferred?

Correct Answer: C

Rationale: Vastus lateralis is the ideal choice for infants.

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