H2 GRADE A Q&A
A low income family with children lives in an old, run-down apartment building situated
close to a salvage yard in a poor neighborhood. Which area of assessment would be
most important for the home health nurse?
1. Immunization status
2. School-related problems
3. Lead poisoning
4. Signs of child abuse - (correct answer)3. Correct: Lead may be found in the soil
around rusted cars and can cause lead exposure. Old paint contains lead. Chips of
paint may be consumed by young teething children. Old, run-down apartments may also
have pipes which contain lead. Exposure to and consuming even small amounts of lead
can be harmful. No safe lead level in children has been identified, and lead can affect
nearly every system in the body. Mental and physical development can be negatively
impacted by lead in the body.
1. Incorrect: Although the nurse does need to check immunizations, the hints in the
stem indicate several problems that should direct the focus to lead poisoning, which is
the priority. Immunization should be administered if the child is not on schedule, but
consequences of lead poisoning is much more serious.
2. Incorrect: There was nothing in the stem indicating school problems. This would not
take priority over lead exposure assessment.
4. Incorrect: Although poverty and poor housing conditions have been identified as
environmental factors for potential abuse, the stem of this question does not provide
additional cues that would indicate abuse. Assessment for lead poisoning would be the
priority in this situation based on the environmental issues identified.
A nurse, assigned to take care of a client who is HIV positive, refuses the assignment,
stating fear of personal injury. What action should the charge nurse take first?
1. Re-assign the client to a nurse who does not mind caring for HIV positive clients.
,2. Inform the nurse that refusing client care is not acceptable nursing practice.
3. Have the nurse document rationale and support for refusing the client assignment.
4. Transfer the nurse to a unit where there are no HIV positive clients. - (correct
answer)2. Correct. This action by the charge nurse demonstrates an understanding of
the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care
for a particular type of client faces an ethical dilemma. The reasons given for refusal
range from a conflict of personal values to fear of personal risk of injury. Such instances
have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a
major health problem. The ethical obligation to care for all clients is clearly identified in
the first statement of the Code of Ethics for Nurses. To avoid facing these moral and
ethical situations, a nurse can follow certain strategies. For example, when applying for
a job, one should ask questions regarding the client population. If one is uncomfortable
with a particular situation, then not accepting the position would be an option. Denial of
care, or providing substandard nursing care to some members of our society, is not
acceptable nursing practice. As a professional, the nurse should provide the same level
of care to every client, regardless of diagnosis, skin color, ethnicity or economic status.
1. Incorrect: This is not the best action for the charge nurse to take.The charge nurse
should remind the nurse of the responsibility for the agency to provide nondiscriminatory
care to all clients. The re-assignment of the client to another nurse does not resolve the
ethical dilemma by the nurse refusing to provide care.
3. Incorrect: The nurse can inform the employer of the reluctance to care for a certain
population, but must provide strong rationale and documentation to support the
necessity for refusal of the assignment. Recognition by the organization of an individual
nurse's right to refuse to care for a specific client population sets a major personnel
precedent and will not be made lightly
What information should a nurse include when educating a client regarding buccal
administration of a medication?
1. This route allows the medication to get into the blood stream faster than the oral
route.
2. Stinging may occur after placing the medication in the cheek.
, 3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds. - (correct answer)1., 2., & 3.
Correct: These are correct statements about buccal administration of medication.
Buccal administration involves the medication being placed between the gums and
cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area
has many capillaries that allow the medication to be absorbed quickly without having to
pass through the digestive system. The degree of stinging experienced depends on the
medication being administered. Some effects of certain medications can be lessened by
digestive processes.
4. Incorrect: When given by the buccal route, the medication does not go through the
digestive system. This means that the medication is not metabolized through the liver,
and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get
the dosage and effects desired.
How would the nurse determine the correct size oropharyngeal airway for a client?
1. Select the same size as the little finger of the victim.
2. Measure from the tip of the lips to the epiglottis.
3. Determine the length from the earlobe to the xiphoid process.
4. Measure from the earlobe to the corner of the mouth. - (correct answer)4. Correct:
An airway of proper size will extend from the corner of the client's mouth to the tip of the
earlobe on the same side of the client's face.
1. Incorrect: The size of the client's little finger does not determine the size of the oral
airway that should be used. This would result in an inappropriate size oropharyngeal
airway to be selected.
2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly
measure it. In addition, the measurement would not determine the appropriate size
oropharyngeal airway to use.
A low income family with children lives in an old, run-down apartment building situated
close to a salvage yard in a poor neighborhood. Which area of assessment would be
most important for the home health nurse?
1. Immunization status
2. School-related problems
3. Lead poisoning
4. Signs of child abuse - (correct answer)3. Correct: Lead may be found in the soil
around rusted cars and can cause lead exposure. Old paint contains lead. Chips of
paint may be consumed by young teething children. Old, run-down apartments may also
have pipes which contain lead. Exposure to and consuming even small amounts of lead
can be harmful. No safe lead level in children has been identified, and lead can affect
nearly every system in the body. Mental and physical development can be negatively
impacted by lead in the body.
1. Incorrect: Although the nurse does need to check immunizations, the hints in the
stem indicate several problems that should direct the focus to lead poisoning, which is
the priority. Immunization should be administered if the child is not on schedule, but
consequences of lead poisoning is much more serious.
2. Incorrect: There was nothing in the stem indicating school problems. This would not
take priority over lead exposure assessment.
4. Incorrect: Although poverty and poor housing conditions have been identified as
environmental factors for potential abuse, the stem of this question does not provide
additional cues that would indicate abuse. Assessment for lead poisoning would be the
priority in this situation based on the environmental issues identified.
A nurse, assigned to take care of a client who is HIV positive, refuses the assignment,
stating fear of personal injury. What action should the charge nurse take first?
1. Re-assign the client to a nurse who does not mind caring for HIV positive clients.
,2. Inform the nurse that refusing client care is not acceptable nursing practice.
3. Have the nurse document rationale and support for refusing the client assignment.
4. Transfer the nurse to a unit where there are no HIV positive clients. - (correct
answer)2. Correct. This action by the charge nurse demonstrates an understanding of
the code of ethics for nurses. Any nurse who feels compelled to refuse to provide care
for a particular type of client faces an ethical dilemma. The reasons given for refusal
range from a conflict of personal values to fear of personal risk of injury. Such instances
have increased since the advent of acquired immunodeficiency syndrome (AIDS) as a
major health problem. The ethical obligation to care for all clients is clearly identified in
the first statement of the Code of Ethics for Nurses. To avoid facing these moral and
ethical situations, a nurse can follow certain strategies. For example, when applying for
a job, one should ask questions regarding the client population. If one is uncomfortable
with a particular situation, then not accepting the position would be an option. Denial of
care, or providing substandard nursing care to some members of our society, is not
acceptable nursing practice. As a professional, the nurse should provide the same level
of care to every client, regardless of diagnosis, skin color, ethnicity or economic status.
1. Incorrect: This is not the best action for the charge nurse to take.The charge nurse
should remind the nurse of the responsibility for the agency to provide nondiscriminatory
care to all clients. The re-assignment of the client to another nurse does not resolve the
ethical dilemma by the nurse refusing to provide care.
3. Incorrect: The nurse can inform the employer of the reluctance to care for a certain
population, but must provide strong rationale and documentation to support the
necessity for refusal of the assignment. Recognition by the organization of an individual
nurse's right to refuse to care for a specific client population sets a major personnel
precedent and will not be made lightly
What information should a nurse include when educating a client regarding buccal
administration of a medication?
1. This route allows the medication to get into the blood stream faster than the oral
route.
2. Stinging may occur after placing the medication in the cheek.
, 3. If swallowed, the medication may be inactivated by gastric secretions.
4. The buccal dose of medication will need to be increased from the oral dose.
5. Remove the tablet from buccal area after 15 seconds. - (correct answer)1., 2., & 3.
Correct: These are correct statements about buccal administration of medication.
Buccal administration involves the medication being placed between the gums and
cheek, where it dissolves and becomes absorbed into the bloodstream. The cheek area
has many capillaries that allow the medication to be absorbed quickly without having to
pass through the digestive system. The degree of stinging experienced depends on the
medication being administered. Some effects of certain medications can be lessened by
digestive processes.
4. Incorrect: When given by the buccal route, the medication does not go through the
digestive system. This means that the medication is not metabolized through the liver,
and thus a lower dose can be used.
5. Incorrect: Placement should be maintained until the tablet is dissolved in order to get
the dosage and effects desired.
How would the nurse determine the correct size oropharyngeal airway for a client?
1. Select the same size as the little finger of the victim.
2. Measure from the tip of the lips to the epiglottis.
3. Determine the length from the earlobe to the xiphoid process.
4. Measure from the earlobe to the corner of the mouth. - (correct answer)4. Correct:
An airway of proper size will extend from the corner of the client's mouth to the tip of the
earlobe on the same side of the client's face.
1. Incorrect: The size of the client's little finger does not determine the size of the oral
airway that should be used. This would result in an inappropriate size oropharyngeal
airway to be selected.
2. Incorrect: The epiglottis is an internal body part thus making it impossible to correctly
measure it. In addition, the measurement would not determine the appropriate size
oropharyngeal airway to use.
