ABSN February 2025-2026 Assessment 2
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Free ABSN February 2025-2026 Assessment 2 Questions
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.The school nurse is educating parents on how to care for their child with pediculosis capitis. What will the nurse include when explaining to the parents how to manage pediculosis capitis?
- A Wash all nits out of hair with a regular shampoo
- B Remove nits with an extra-fine tooth comb or tweezers
- C Distinguish viable from nonviable nits, and remove all viable ones
- D Cut hair shorter if infestation and nits are severe
Explanation
Explanation
B Remove nits with an extra-fine tooth comb or tweezersThe most effective method for removing nits (lice eggs) from the hair is to use an extra-fine-toothed comb or tweezers. Nits are firmly attached to the hair shafts near the scalp, so careful removal is essential to fully eliminate the lice infestation.
C Distinguish viable from nonviable nits, and remove all viable ones
It’s important to differentiate between viable nits (those that are capable of hatching) and nonviable ones (those that are no longer alive). Viable nits should be removed to prevent re-infestation, as they can hatch into new lice.
The nurse is assessing a client in the clinic. Which assessment findings indicate that the client may have benign prostatic hyperplasia (BPH)? (Select all that apply)
- A Nocturia
- B Urinary dribbling
- C Urinary frequency
- D Elevated temperature
- E Weak stream
Explanation
Explanation
A NocturiaNocturia is a common manifestation of benign prostatic hyperplasia due to incomplete bladder emptying and increased urinary retention. As the enlarged prostate obstructs urine flow, the bladder fills more quickly, causing the client to wake frequently during the night to urinate.
B Urinary dribbling
Urinary dribbling occurs in BPH because the enlarged prostate interferes with complete bladder emptying. Residual urine remains in the bladder and leaks after voiding, leading to post-void dribbling, which is a classic lower urinary tract symptom associated with prostate enlargement.
C Urinary frequency
Urinary frequency results from bladder irritation and reduced bladder capacity caused by chronic obstruction from an enlarged prostate. The bladder must contract more often to expel smaller volumes of urine, leading to frequent urges to void throughout the day.
E Weak stream
A weak urinary stream is a hallmark sign of BPH. Prostate enlargement narrows the urethra, reducing urine flow force and causing difficulty initiating and maintaining a steady stream during urination.
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 assessing a pediatric client and notes crop lesions that have spread to the face, trunk, and arms. Some appear as a pruritic macular rash and others have started to develop into vesicles. What intervention(s) will the nurse implement? (Select all that apply)
- A Implement standard precautions and guidelines only.
- B Place the child in a tepid bath to decrease pruritis.
- C Strict airborne and contact isolation precautions.
- D Allow unexposed friends of the child to come visit.
- E Strict droplet precautions and enforce handwashing
Explanation
Explanation
B Place the child in a tepid bath to decrease pruritis.Varicella causes intense itching due to widespread vesicular skin lesions. Tepid baths help soothe the skin, reduce itching, and decrease the likelihood of scratching, which lowers the risk of secondary bacterial infection and scarring.
C Strict airborne and contact isolation precautions.
Varicella is highly contagious and spreads through airborne respiratory droplets and direct contact with vesicular fluid. Strict airborne and contact precautions are required to prevent transmission to other clients and healthcare workers, especially those who are immunocompromised or unvaccinated.
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 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.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.The nurse is educating a client's spouse about anticipatory grief. Which statement made by the spouse indicates understanding?
- A "I might cry uncontrollably and feel physically ill whenever I visit."
- B "I might prepare for the loss by reducing the time I spend with my spouse."
- C "I cannot believe that a merciful God would allow my leg to be amputated."
- D "I may refuse to leave the bedside regardless of the reason."
Explanation
Explanation
Anticipatory grief involves the emotional response to the expected loss of a loved one, and it often manifests as sadness, anxiety, crying, and physical symptoms such as nausea. The spouse's recognition that they may cry uncontrollably and feel physically ill reflects the emotional and physical distress typical of anticipatory grief. This response shows an understanding of the emotional impact that the impending loss may have.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.How to Order
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