The nurse has taken the blood pressure of a client hospitalized with methicillin-resistant staphylococcus aureus. Which action by the nurse indicates an understanding regarding the care of clients with MRSA?

Correct Answer: A

Rationale: Leaving the stethoscope in the room prevents MRSA spread, adhering to contact precautions alcohol cleaning isn't enough between clients, sharing risks transmission, and water is inadequate. Nurses isolate equipment, ensuring infection control in resistant infections.

Correct Answer: B

Rationale: Weights resting against the bed negate skeletal traction's pull, risking misalignment in a fractured femur warm feet, hip lifts, and clean pins are normal. Nurses adjust this, ensuring countertraction, vital for bone healing in orthopedic care.

Correct Answer: A

Rationale: Vaccines in pregnancy balance maternal-fetal safety. Rubella vaccine (choice A), a live attenuated virus, is contraindicated due to theoretical risks of congenital rubella syndrome if the virus crosses the placenta, though no cases are definitively linked. Diphtheria (choice B) and tetanus (choice C) vaccines, as inactivated toxoids (e.g., Td), are safe and recommended to protect mother and newborn. Hepatitis B vaccine (choice D), an inactivated subunit vaccine, poses no fetal risk and is given if the mother is at risk. A is correct because rubella's live nature excludes it from routine prenatal use. Nurses must counsel pregnant women on vaccine safety, ensuring tetanus protection while avoiding live vaccines like rubella to safeguard fetal development.

Correct Answer: C

Rationale: Developmental milestones flag delays if unmet. Walking at 12 months (choice A) is average; delay to 18 months is still normal. Single words at 12 months (choice B) vary (9-18 months), not an immediate red flag. Social smile by 3 months (choice C, typically 6-8 weeks) is critical; absence by 3 months suggests autism or neurological issues, a major concern. Vocalization at 2 months (choice D, cooing) is expected, but delay isn't as alarming as smile absence. C is correct, as it's a key early red flag. Nurses refer for evaluation, ensuring timely intervention.

Correct Answer: D

Rationale: Wrist drop is inability to extend the wrist. Axillary nerve (choice A) affects shoulder, not wrist. Ulnar nerve (choice B) impacts hand sensation/movement, not extension. Median nerve (choice C) controls forearm flexors. Radial nerve (choice D) innervates wrist extensors; injury (e.g., humeral fracture) causes wrist drop. D is correct, per anatomy. Nurses assess grip, apply splints, and support rehab, aiding recovery.