ABSN February 2025-2026 Assessment 2

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Ace Your Test with ABSN February 2025-2026 Assessment 2 Actual Questions and Solutions - Full Set

Free ABSN February 2025-2026 Assessment 2 Questions

1.

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.
2.

The nurse is preparing to educate a client with Influenza A about the necessary safety measures to prevent the spread of infection. What action is most appropriate to include when developing the teaching plan?

  • A All visitors will need to wear gloves if they are touching you
  • B Visitors can only stay in your room for 10 minutes at a time.
  • C Only your family may come to visit you while you are here.
  • D Visitors will need to wear a mask when they are in your room.

Explanation

Explanation
Influenza A is a highly contagious viral infection that spreads primarily through respiratory droplets. To prevent transmission, it is essential that visitors wear a mask when entering the room of a client with influenza. This helps reduce the risk of spreading respiratory droplets that may contain the virus. Proper precautions such as mask use, along with hand hygiene, are vital in controlling the spread of influenza.
3.

The nurse is caring for a client with dehydration with vital signs as follows: blood pressure 96/72, heart rate 106, respiration rate of 18 breaths/minute, and temperature of 101°F. After receiving intravenous fluids, which assessment finding is the best way to determine improvement in fluid status?

  • A Blood pressure 115/76 mmHg
  • B Heart rate 106 beats per minute
  • C Temperature to 101° Farenheit
  • D Respiratory rate of 18 breaths/min

Explanation

Explanation
Blood pressure is a critical indicator of fluid status. In the case of dehydration, the blood pressure may be low (as seen with 96/72 mmHg), and after fluid resuscitation, a rise in blood pressure to a more normal level (e.g., 115/76 mmHg) suggests an improvement in circulating blood volume and overall hydration status. While heart rate, temperature, and respiratory rate are also important, blood pressure is a more direct measure of fluid balance and perfusion.
4.

The nurse is caring for a child with chronic otitis media infections. Which prescription by the health care provider will the nurse anticipate?

  • A Monospot test
  • B MRI of the ear
  • C Lumbar puncture
  • D Audiology consult

Explanation

Explanation
Chronic otitis media can lead to conductive hearing loss due to persistent middle ear effusion or damage to middle ear structures. An audiology consult is anticipated to assess the child’s hearing status, identify any degree of hearing impairment, and guide further management or interventions. Early identification of hearing loss is essential to prevent delays in speech, language, and cognitive development.
5.

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.
6.

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.
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 school nurse is educating a group of parents about impetigo. Which statement indicates understanding by the parents?

  • A "I should squeeze the lesions to help them heal faster."
  • B "It is caused by a group of closely related filamentous fungi."
  • C "I should apply the mupirocin ointment directly to the lesions."
  • D "I do not need to worry about this being spread to other children."

Explanation

Explanation
Impetigo is a highly contagious bacterial skin infection commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics such as mupirocin are the treatment of choice for mild, localized impetigo and should be applied directly to the affected lesions as prescribed. Proper application helps eradicate the bacteria, promote healing, and reduce the risk of spreading the infection to others.
9.

The nurse is caring for a client who was recently diagnosed with chronic renal failure. Which is the most appropriate nursing intervention to assist the client in coping with the diagnosis?

  • A Offer the client a brochure about hemodialysis and renal transplantation.
  • B Suggest that the client get affairs in order and identify a health care proxy.
  • C Tell the client their family will be trained so they are able to care for them at home.
  • D Encourage the client to join a local support group for people with renal disease.

Explanation

Explanation
Encouraging the client to join a support group provides emotional and psychological support from others who are coping with similar challenges. Support groups offer opportunities to share experiences, gain information, and reduce feelings of isolation. This intervention helps the client manage the stress and emotional impact of chronic renal failure, which is crucial for coping and overall well-being.
10.

The nurse is caring for several clients with acute kidney injury. Which client is most at risk for developing postrenal acute kidney injury?

  • A The client with hypovolemic shock following surgery.
  • B The client taking NSAIDs every 8 hours for arthritis pain.
  • C The client recovering from acute glomerulonephritis.
  • D The client diagnosed with benign prostatic hyperplasia.

Explanation

Explanation
Postrenal acute kidney injury occurs when urine flow is obstructed distal to the kidneys, leading to increased pressure in the urinary tract and reduced kidney function. Benign prostatic hyperplasia commonly causes bladder outlet obstruction by compressing the urethra, resulting in urinary retention and backflow of urine into the kidneys. This obstruction places the client at the highest risk for postrenal acute kidney injury among the options listed.

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