ABSN February 2025-2026 Assessment 2
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Free ABSN February 2025-2026 Assessment 2 Questions
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 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.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.The nurse is preparing discharge instructions for the family of a newborn. What will the nurse include in educating the parents about body temperature regulation? (Select all that apply)
- A Newborns lack shivering ability to produce heat until 3 months old.
- B Newborns have a small surface area to body mass ratio.
- C Newborns have limited use of voluntary muscle activity or movement to produce heat.
- D Newborns have limited stores of metabolic substrates (glucose, glycogen, fat).
- E Newborns have a large surface area to body mass ratio.
Explanation
Explanation
A Newborns lack shivering ability to produce heat until 3 months old.Newborns cannot generate heat through shivering like older children and adults. Instead, they rely on nonshivering thermogenesis using brown fat. This limited ability makes them more vulnerable to heat loss and hypothermia, requiring careful temperature regulation by caregivers.
C Newborns have limited use of voluntary muscle activity or movement to produce heat.
Newborns have minimal voluntary muscle control and activity, which reduces their ability to generate heat through movement. This limitation contributes to difficulty maintaining body temperature, especially in cool environments.
D Newborns have limited stores of metabolic substrates (glucose, glycogen, fat).
Newborns have small energy reserves needed for heat production. Because their glucose, glycogen, and fat stores are limited, prolonged cold exposure can quickly lead to hypoglycemia and impaired thermoregulation.
E Newborns have a large surface area to body mass ratio.
A large surface area relative to body mass causes newborns to lose heat rapidly through the skin. This characteristic significantly increases the risk of heat loss and makes maintaining a neutral thermal environment essential.
The nurse is caring for a client who was admitted to the emergency department after receiving a chemical burn to the eye. What is the priority nursing action for this client?
- A Call the health care provider immediately to assess the eye
- B Apply direct pressure to the affected eye
- C Generously flush the affected eye with normal saline
- D Generously flush the affected eye with an antibiotic solution
Explanation
Explanation
The priority action in the case of a chemical burn to the eye is to immediately flush the affected eye with generous amounts of normal saline or water to dilute and remove the chemical substance. This helps to minimize further injury and neutralize the chemical before further assessment or treatment is provided. Flushing should continue for at least 15-20 minutes. Applying direct pressure or using an antibiotic solution may worsen the injury or delay proper treatment.The nurse is caring for a client who is legally blind as a result of macular degeneration. When attempting to meet this client’s psychosocial needs, what nursing action is most appropriate?
- A Promote the client’s hope for recovery.
- B Encourage the client to focus on use of other senses.
- C Assess and promote the client’s coping skills.
- D Emphasize that lifestyle will be unchanged.
Explanation
Explanation
Macular degeneration causes permanent vision loss, which can significantly affect a client’s emotional well-being and adjustment to daily life. Assessing and promoting coping skills helps the nurse identify how the client is managing the loss, address feelings such as grief or frustration, and support healthy adaptation. This approach focuses on emotional support, realistic adjustment, and long-term psychosocial well-being rather than false reassurance or minimizing the impact of the condition.The nurse is educating a client taking an H2 blocker about peptic ulcer disease. The client is asking the nurse what factors increase the risk of peptic ulcer disease and how to prevent them. What is the most appropriate response by the nurse?
- A Eat several small meals a day rather than three larger meals
- B Attend screening clinics at least twice per year.
- C Exercise for at least 30 minutes, three times a week
- D Clients who smoke should attend smoking cessation classes
Explanation
Explanation
Smoking is a well-established risk factor for the development and exacerbation of peptic ulcers. It reduces the production of bicarbonate in the stomach, impairs blood flow to the stomach lining, and delays healing. Smoking cessation is a key preventive measure to reduce the risk of peptic ulcer disease and improve treatment outcomes. While eating smaller meals (option A) and exercising (option C) may be beneficial for overall health, they are not as directly related to preventing peptic ulcers as smoking cessation. Screening clinics (option B) are not typically required unless there is a specific indication or family history of gastrointestinal issues.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.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 nurse is educating a group of older adults at a community meeting regarding the risk factors for osteoporosis. Which risk factors should the nurse include in the presentation?
- A Small frame and female biologic sex.
- B Prolonged use of ibuprofen.
- C Male biologic sex, diabetes and high protein intake.
- D Elevated estrogen levels and increased body mass.
Explanation
Explanation
Individuals with a small body frame have less bone mass to draw from as they age, increasing the risk of osteoporosis. Female biologic sex is a significant risk factor due to lower peak bone mass and the decline in estrogen levels after menopause, which accelerates bone loss. These factors make older women with small frames particularly vulnerable to osteoporosis and related fractures.How to Order
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