ABSN February 2025-2026 Assessment 2

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Free ABSN February 2025-2026 Assessment 2 Questions

1.

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.
2.

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.
3.

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.
4.

The nurse is receiving morning report on several clients with mobility concerns. Which client is the priority for the nurse to assess?

  • A The client with Parkinson's Disease who needs to use the bathroom.
  • B The client with osteoporosis who refuses to take their bisphosphonate.
  • C The client with a hip fracture who is 3 days post-operative.
  • D The older adult client who was ambulating around the unit.

Explanation

Explanation
The client with Parkinson's disease is the priority because the combination of impaired mobility, potential for falls, and the need for assistance with basic activities like using the bathroom can increase the risk of injury. Parkinson’s disease affects coordination, muscle control, and balance, making these clients more susceptible to falls and accidents. Timely assistance is necessary to prevent further complications. The other clients, while important, do not present an immediate risk as significant as this.
5.

The nurse is caring for a client with a headache, nuchal rigidity, petechial rash, and fever. What interventions are the priority for the nurse to implement? Select all that apply.

  • A Keep the client in a low stimulus environment
  • B Assist with lumbar puncture
  • C Administer the meningococcal vaccine for treatment
  • D Initiate intravenous antibiotics
  • E Assess neurologic status daily

Explanation

Explanation
A Keep the client in a low stimulus environment
Clients with suspected meningitis are highly sensitive to light and noise due to meningeal irritation. A low stimulus environment helps reduce discomfort, headache severity, and neurologic stress, which supports client comfort and prevents symptom exacerbation during the acute phase of illness.

B Assist with lumbar puncture
A lumbar puncture is essential for confirming the diagnosis of meningitis by analyzing cerebrospinal fluid. Assisting with this procedure is a priority nursing intervention to support timely diagnosis and guide appropriate treatment based on the causative organism.

D Initiate intravenous antibiotics
Suspected bacterial meningitis is a medical emergency that requires immediate administration of intravenous antibiotics. Early initiation of antibiotics significantly reduces morbidity and mortality and should not be delayed once meningitis is suspected, even if diagnostic testing is still underway.
6.

The nurse is caring for a client who has just returned to the post-surgical unit following cholecystectomy for gallbladder disease. What assessment finding should the nurse immediately report to the health care provider?

  • A The client has acute pain with movement
  • B The client is not taking deep breaths
  • C Bile-colored fluid in the Jackson Pratt drain
  • D Rigidity of the abdomen

Explanation

Explanation
Abdominal rigidity following a cholecystectomy is an alarming finding that may indicate peritonitis, internal bleeding, or bile leakage into the abdominal cavity. Rigidity suggests involuntary muscle guarding caused by severe irritation of the peritoneum and represents a potential surgical emergency. This finding requires immediate provider notification and prompt intervention to prevent sepsis, shock, or further complications.
7.

The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest?

  • A Increasing the dose of muscle relaxants
  • B Taking a hot bath at least three times a week
  • C Avoiding naps during the day
  • D Working with Occupational and Physical Therapy

Explanation

Explanation
Fatigue is one of the most common and disabling symptoms of multiple sclerosis. Collaboration with Occupational and Physical Therapy helps the client learn energy conservation techniques, activity pacing, proper body mechanics, and adaptive strategies to reduce fatigue during daily activities. These therapies focus on maximizing function while minimizing energy expenditure, which is a cornerstone of fatigue management in MS.
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 providing discharge teaching to the parent of a 10-month-old who had tympanostomy tubes (PE tubes) placed. What statement(s) indicate understanding? (Select all that apply).

  • A "It is important to continue to keep my baby's immunizations current."
  • B "I may give my baby a bottle of formula in bed at nap-time for comfort."
  • C "Immediately return to the emergency department if a tube ever falls out."
  • D "Report any incidents of purulent drainage to the health care provider."
  • E "I can save the leftover antibiotic to use whenever the tubes are draining."

Explanation

Explanation
A "It is important to continue to keep my baby's immunizations current."
Keeping immunizations up to date helps reduce the risk of infections, including those that can lead to otitis media. Vaccines such as pneumococcal and influenza decrease the frequency and severity of ear infections, which is especially important for infants with a history requiring tympanostomy tubes.

D "Report any incidents of purulent drainage to the health care provider."
Purulent drainage from the ear may indicate infection and requires evaluation and possible treatment. Prompt reporting allows the healthcare provider to assess tube function and initiate appropriate therapy to prevent complications or hearing issues.
10.

What is the most appropriate question for the nurse to ask to help determine a potential contributing factor when assessing a client recently diagnosed with acute glomerulonephritis?

  • A "Has anyone in your family had syncope?"
  • B "Have you been sexually active in the last year?"
  • C "Have you been sick within the last 10 days?"
  • D "Have you had low blood pressure the last week?"

Explanation

Explanation
Acute glomerulonephritis commonly develops as a post-infectious complication, most often following a recent streptococcal infection such as strep throat or a skin infection. Symptoms typically appear 1 to 3 weeks after the initial illness. Asking about recent illness helps the nurse identify a likely infectious trigger that contributed to the inflammatory response in the glomeruli, supporting accurate assessment and management.

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