ABSN February 2025-2026 Assessment 2

The nurse is caring for a client admitted to the ambulatory surgery unit for a procedure. The client was placed in a private room. The admitting nurse reads in the surgeon's current history and physical document that the client has methicillin-resistant staphylococcus aureus (MRSA) in a right leg wound. What is the nurse's first action?

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)

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?

The nurse is providing teaching to a young adult who is at risk for early-onset osteoporosis. Which intervention should the nurse suggest?

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?

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?

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?

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.

The emergency room nurse is admitting a client who is very drowsy. The client reports a sudden onset of fever, headache, vomiting, and neck pain. The nurse notes a Glasgow Coma Scale of 11. What is the priority nursing action?