ABSN February 2025-2026 Assessment 2
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Free ABSN February 2025-2026 Assessment 2 Questions
The nurse is discharging a client who underwent an open reduction with internal fixation of the right hip secondary to a fracture related to osteoporosis. The client is prescribed a bisphosphonate to be taken daily. What should the nurse include in the discharge instructions regarding this medication?
- A The medication must be taken on an empty stomach, only with water.
- B Calcium supplements are not needed when taking a bisphosphonate.
- C The client must lie down for 30 minutes following ingestion of the drug.
- D Calcium supplements are recommended in lieu of calcium taken with food.
Explanation
Explanation
Bisphosphonates must be taken first thing in the morning on an empty stomach with a full glass of plain water to ensure proper absorption. Food, beverages, and other medications significantly reduce absorption of the drug. Proper administration maximizes effectiveness in strengthening bone and reducing fracture risk, which is especially important in clients with osteoporosis following hip fracture and surgical repair.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 environmentClients 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.
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.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.The nurse is planning care for a child who has tinea pedis. Which action should the nurse include in the plan of care?
- A Treat infected house pets
- B Use moist, warm compresses
- C Use selenium sulfide shampoo
- D Apply a topical antifungal cream
Explanation
Explanation
Tinea pedis, also known as athlete's foot, is a fungal infection of the feet. The primary treatment involves applying a topical antifungal cream to the affected area. These creams help to eradicate the fungal infection and relieve symptoms such as itching and redness. Consistent use of the medication as prescribed is key to effective treatment.The nurse is receiving morning report on several clients with diseases causing inflammation. What client is the priority for the nurse to assess first?
- A A client with cholecystitis who is nauseous when they eat fatty foods
- B A client with bronchitis who has a productive cough
- C A client with appendicitis who has a rigid abdomen and a temperature
- D A client with nephritis and a urine output of 30 mL/hour
Explanation
Explanation
A rigid abdomen combined with fever in a client with appendicitis suggests possible peritonitis or appendiceal rupture, which is a life-threatening emergency. These findings indicate acute abdominal inflammation requiring immediate assessment and intervention to prevent sepsis and further complications. This condition takes priority over chronic or expected inflammatory symptoms seen in the other clients.The nurse is educating staff on factors that affect grief. Which type of influence is most likely to impact a person's expression of grief?
- A Geographical influences
- B Socioeconomic influences
- C Cause of death as an influence
- D Cultural influences
Explanation
Explanation
Cultural influences are the most likely to impact how a person expresses and processes grief. Different cultures have unique rituals, beliefs, and practices surrounding death and mourning. Cultural norms dictate the behaviors considered appropriate for grieving, such as how openly a person may express emotions or whether certain rituals are observed. This significantly influences how individuals cope with loss and may shape their grief experience.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.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.The nurse is planning discharge education for a client with multiple sclerosis (MS). What should the nurse include in the client's education?
- A The goal of treatment for MS is to delay the progression of the disease.
- B Fatigue that interferes with activities of daily living is treated with the drug baclofen.
- C Although MS involves remissions and exacerbations, it can be cured.
- D There are only two classifications of drugs that are used in the management of MS.
Explanation
Explanation
The primary goal of treatment for multiple sclerosis (MS) is to manage symptoms, reduce the frequency and severity of relapses, and delay disease progression. MS is a chronic, progressive neurological condition with no known cure. Treatments typically focus on disease-modifying therapies (DMTs) to manage the immune system and prevent further nerve damage. Baclofen is used to treat muscle spasticity, not fatigue. Additionally, there are more than two classes of drugs available for managing MS, including DMTs, corticosteroids, and symptomatic treatments.How to Order
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