ABSN February 2025-2026 Assessment 2

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Free ABSN February 2025-2026 Assessment 2 Questions

1.

The nurse is performing an assessment on a child with varicella and notices the child scratching the lesions. Which nursing intervention will the nurse perform to provide comfort at this time?

  • A Give aspirin or acetaminophen as needed.
  • B Encourage frequent warm bubble baths
  • C Give a pediatric dose of an antihistamine.
  • D Apply baby lotion over the open lesions.

Explanation

Explanation
Pruritus is a common and distressing symptom of varicella, and antihistamines are effective in reducing itching by blocking histamine release. Administering a pediatric-appropriate antihistamine helps relieve discomfort, decreases scratching, and reduces the risk of secondary skin infections caused by excoriation of the lesions. This intervention directly addresses the child’s immediate comfort needs while supporting skin integrity during the active phase of the infection.
2.

The nurse is caring for a pregnant client who has just been diagnosed with cholecystitis. When considering anticipatory guidance, what should the nurse include in education regarding nutrition?

  • A Choose low-fat foods and avoid fried foods.
  • B Include a diet high in cholesterol and salt.
  • C Include healthy servings of eggs and cheese.
  • D Include a diet high in calories and low protein.

Explanation

Explanation
Cholecystitis is inflammation of the gallbladder, often triggered by gallstones, and symptoms are commonly worsened by high-fat foods. A low-fat diet reduces gallbladder stimulation and bile release, helping decrease pain, nausea, and inflammation. Avoiding fried and greasy foods is especially important during pregnancy, when gallbladder motility is already reduced, to help manage symptoms and prevent exacerbations.
3.

The nurse is caring for a newly admitted client suspected of having bacterial gastroenteritis with frequent watery diarrhea for several days and has been unable to hold down fluids. All of the following are ordered for the client. What is the priority intervention?

  • A Apply zinc ointment to perianal area for excoriation
  • B Administer probiotics one capsule by mouth three times a day
  • C Obtain a stool specimen for culture
  • D Administer intravenous fluids at 125 mL per hour

Explanation

Explanation
The priority intervention for a client with prolonged watery diarrhea and inability to tolerate oral fluids is restoration of fluid volume. This client is at high risk for dehydration, electrolyte imbalance, and hypovolemic shock. Intravenous fluids immediately address circulatory volume, tissue perfusion, and physiologic stability. While skin protection, probiotics, and diagnostic testing are important, they do not take precedence over correcting potentially life-threatening fluid deficits.
4.

The school nurse is conducting screenings for pediculosis capitis. Which assessment finding most supports a positive finding?

  • A Scales, redness and flakes on the scalp that fall off easily when scratched.
  • B Patches of redness and alopecia with a history of recent contact with infected animals.
  • C Linear burrows appearing under the skin with severe pruritus, especially at night.
  • D Tiny, white, clear or brown oval specs, adhering tightly to hair shafts.

Explanation

Explanation
The tiny oval specs described are nits (lice eggs) attached to the hair shafts, a key indicator of pediculosis capitis (head lice). Nits are usually white or light brown and are very difficult to remove. Unlike dandruff or flakes, which fall off easily, nits are firmly attached and require careful removal. Their presence, along with pruritus (itching), confirms the diagnosis of head lice.
5.

The nurse is assessing a client with chronic kidney disease. Which assessment finding is the priority for the nurse to report?

  • A Weight gain of 3 pounds in 24 hours
  • B Decreased muscle strength
  • C BUN 28 mg/dL (Ref. 10-20 mg/dL)
  • D Bilateral 2+ pedal pulses

Explanation

Explanation
A weight gain of 3 pounds in 24 hours is a significant finding that may indicate fluid retention, which can be a sign of worsening kidney function or fluid overload in clients with chronic kidney disease (CKD). This can lead to complications such as hypertension, edema, or heart failure. Rapid weight gain is often the first noticeable sign of fluid retention, and it should be reported promptly to the healthcare provider for further evaluation and possible intervention. While BUN and decreased muscle strength are relevant, they do not represent an immediate clinical emergency like fluid overload.
6.

The emergency department nurse has several clients present to triage with eye complaints. Which client will the nurse assess first?

  • A The client who suddenly has periocular pain and loss of central vision in the left eye for an hour
  • B The client who has noticed decreased peripheral vision in both eyes during the past year
  • C The client who has reduced vision bilaterally after spending two hours skiing on a sunny day
  • D The client who has reduced vision on one side when coming out of a dark place into sunlight

Explanation

Explanation
Sudden periocular pain accompanied by acute loss of central vision is an ophthalmic emergency and may indicate conditions such as acute angle-closure glaucoma or retinal artery occlusion. These conditions can lead to permanent vision loss if not treated immediately. Rapid assessment and intervention are critical to preserve vision, making this client the highest priority for triage.
7.

The nurse is admitting a client with an exacerbation of multiple sclerosis. The client states, "I have been in remission for years and cannot imagine what might have caused this." Which question would be the best one to ask in trying to determine the cause of the relapse?

  • A "Have you been under any emotional and physical stress lately?"
  • B "Have you recently received the influenza vaccine?"
  • C "Have you added any grapefruit juice to your diet lately?"
  • D "Have you been out of the country in the past couple of months?"

Explanation

Explanation
Stress, both emotional and physical, is a known trigger for exacerbations of multiple sclerosis. The body's immune response can be significantly impacted by stress, potentially leading to a relapse in MS. Asking about recent stressors is an appropriate and effective way to identify potential triggers for the client's current symptoms. While the influenza vaccine can occasionally trigger a relapse in MS, it is less common than stress as a contributing factor. The other options (grapefruit juice or traveling abroad) are unlikely to be direct causes of an MS relapse.
8.

The nurse is caring for a client who states they have swelling in their knee, pain, and crepitus after running. What part of the client's health history will the nurse note as a possible cause of their symptoms?

  • A The client drinks wine at night.
  • B The client takes acetaminophen for pain.
  • C The client has a body mass index (BMI) of 33.
  • D The client is of childbearing age.

Explanation

Explanation
A BMI of 33 indicates that the client is overweight or obese, which is a significant risk factor for joint stress and conditions like osteoarthritis. Excess body weight increases the load on weight-bearing joints like the knees, leading to increased wear and tear, inflammation, and symptoms like pain, swelling, and crepitus (the sensation of grating or popping). This factor is most likely contributing to the client's knee symptoms.
9.

The nurse is caring for a client who had a left total hip replacement three days ago. The client suddenly has severe left hip pain and the nurse notes a shortening of the left lower extremity. What complication does the nurse suspect?

  • A The hip has dislocated
  • B The incision has dehisced
  • C There is bleeding at the operative site
  • D An infection has developed suddenly

Explanation

Explanation
A dislocated hip is a serious complication following hip replacement surgery. It can cause severe pain, shortening, and deformity of the affected leg. The nurse should suspect hip dislocation based on the client's pain and the physical sign of shortening of the leg. Immediate intervention is necessary, including contacting the healthcare provider to assess the dislocation and perform reduction if needed. Dislocation is typically associated with improper positioning, trauma, or inadequate postoperative care.
10.

The nurse in the emergency department (ED) has just received a client with bright red emesis and a suspected stomach perforation related to peptic ulcer disease (PUD). What is the priority nursing action?

  • A Document and continue to monitor
  • B Evaluate for tachycardia, hypotension, and tachypnea
  • C Draw a set of serum laboratory tests
  • D Place in a prone position and prepare for surgery

Explanation

Explanation
The priority action is to assess for signs of shock, which can result from a perforated ulcer leading to internal bleeding and peritonitis. Tachycardia, hypotension, and tachypnea are key indicators of hypovolemic shock, which is a life-threatening emergency requiring immediate intervention. Early recognition of shock symptoms is crucial for timely treatment, such as fluid resuscitation, blood transfusion, and possibly surgery. Monitoring vital signs and assessing for these symptoms takes precedence over documentation or laboratory tests in this acute situation.

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