90.

The newborn infant of an HIV-positive mother is admitted to the

nursery. Which of the following would the nurse include in the plan of care?
1.
2.
3.
4.

Standard precautions.
Testing for HIV.
Transfer to an acute care nursery facility.
Request AZT from the pharmacy.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) correctprovides immediate protective care for the staff members
(2) might be employed, safety is the priority
(3) might be employed, is not a priority
(4) this medication is not used in infancy
91. A client has received an IV antibiotic every eight hours for four days. It
is mixed in 100 cc D5W. Which of the following would cause the nurse to be
concerned about postinfusion phlebitis?
1.
2.
3.
4.

Tenderness at the IV site.

Increased swelling at the insertion site.
Reddened area or red streaks at the site.
Leaking of fluid around the IV catheter.

Strategy: Determine the significance of each assessment and how it relates

to phlebitis.
(1) tenderness at the IV site is common
(2) increased swelling at the insertion site may indicate infiltration
(3) correctcharacterized by inflammation and reddened areas around site and up
length of vein
(4) not indicative of phlebitis
92. The nurse counsels a 70-year-old woman who comes to the outpatient
clinic for a routine examination. The history indicates the client takes a
laxative tablet twice a day and a laxative suppository once a day. The nurse
should suspect the client
1.
2.
3.
4.

has an anal fixation resulting from recent loss of her husband.

is depressed due to alterations in intestinal absorption and excretion.
is experiencing excessive concern with body function due to physical changes.
has regressed due to a fear of losing the ability to have bowel movements.

Strategy: Think about each answer choice.

(1) makes judgment without information
(2) constipation common finding in elderly, no information about depression
(3) correctphysical changes occur in late adulthood causing changes in body image,
constipation frequent problem of elderly, but reaction by this client is excessive
(4) no information provided about regression