NIGHTINGALE BSN 246 EXAM WITH 180 QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES
ALREADY GRADED A+ (NEW)//2025 GRADED A+
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks
C
Treatment of acute osteomyelitis requires the administration of high doses of parenteral
antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks
We have an expert-written solution to this problem!
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A. Mid-Fowlers with knees supported.
B. Supine with trochanter rolls to the hips.
C. Sim's position alternated with right lateral position q2 hours.
Left lateral, supine, brief periods on the right side, and prone
D
Rationale
After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side,
which can impair circulation and cause pain, and includes the prone position to help prevent
flexion contractures of the hips, prepares the client for optimal functioning and ambulation.
We have an expert-written solution to this problem!
,A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The
nurse should implement which protocols to prepare the client for this procedure? (Select all that
apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure
D,E
Rationale
The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent
to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an
enema, and fasting on the morning of the procedure.
We have an expert-written solution to this problem!
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most
important for the nurse to report to the healthcare provider?
A. Suprapublic pain and distention.
B. Bounding pulse at 100 beats/minute.
C. Fingerstick glucose of 300 mg/dl.
D. Small vesicular perineal lesions.
C
Rationale
Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care
can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine
and provide a medium for bacterial growth
When planning care for a client with right renal calculi, which nursing diagnosis has the highest
priority?
A. Acute pain related to movement of the stone.
B. Impaired urinary elimination related to obstructed flow of urine.
C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.
,A
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
We have an expert-written solution to this problem!
A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is
still very small. Which information supports the explanation that the nurse should provide?
A. Side effects are less likely if therapy is started early.
B. Collateral circulation increases as the tumor grows.
C. The sensitivity of cancer cells to CT is based on cell cycle rate.
D. The cell count of the tumor reduces by half with each dose
D
Rationale
Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer
cells because 50% of cancer cells or tumor cells are killed with each dose.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence
of asterixis. To assess the client for asterixis, what position should the nurse ask the client to
demonstrate?
A. Extend the left arm laterally with the left palm upward.
B. Extend the arm, dorsiflex the wrist, and extend the fingers.
C. Extend the arms and hold this position for 30 seconds.
D. Extend arms with both legs adducted to shoulder width.
B
Rationale
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
The nurse is caring for a client who is two days postoperative. Which observation should alert the
nurse to call the Rapid Response Team (RRT)?
A. Fresh bleeding noted on abdominal surgical wound dressing.
B. Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
C. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
, D. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.
B
Rationale
The RRT should be called to intervene for a client with an acute life-threatening change, such as a
pulse change resulting in tachycardia for a prolonged time in a post-operative client.
We have an expert-written solution to this problem!
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care?
A. Perform active range of motion three times daily.
B. Monitor for Battle's sign every four hours.
C. Teach measures to avoid the Valsalva maneuver.
Maintain the head of bed in a flat position
C
Rationale
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels
We have an expert-written solution to this problem!
A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to
hear what the nurse is saying during post-test counseling. Which information should the nurse
offer to facilitate the client’s adjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
D. Discuss retesting to verify the results, which will ensure continuing contact.
D
Rationale
Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although
post-test counseling should include education, retesting encourages the client to maintain medical
follow-up and management.
AND 100% CORRECT ANSWERS WITH RATIONALES
ALREADY GRADED A+ (NEW)//2025 GRADED A+
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and
asks the nurse how long will antibiotics have to be administered. Which information should the
nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks
C
Treatment of acute osteomyelitis requires the administration of high doses of parenteral
antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks
We have an expert-written solution to this problem!
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which
positioning should the nurse should use to maintain optimal functioning?
A. Mid-Fowlers with knees supported.
B. Supine with trochanter rolls to the hips.
C. Sim's position alternated with right lateral position q2 hours.
Left lateral, supine, brief periods on the right side, and prone
D
Rationale
After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side,
which can impair circulation and cause pain, and includes the prone position to help prevent
flexion contractures of the hips, prepares the client for optimal functioning and ambulation.
We have an expert-written solution to this problem!
,A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The
nurse should implement which protocols to prepare the client for this procedure? (Select all that
apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure
D,E
Rationale
The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent
to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an
enema, and fasting on the morning of the procedure.
We have an expert-written solution to this problem!
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most
important for the nurse to report to the healthcare provider?
A. Suprapublic pain and distention.
B. Bounding pulse at 100 beats/minute.
C. Fingerstick glucose of 300 mg/dl.
D. Small vesicular perineal lesions.
C
Rationale
Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care
can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine
and provide a medium for bacterial growth
When planning care for a client with right renal calculi, which nursing diagnosis has the highest
priority?
A. Acute pain related to movement of the stone.
B. Impaired urinary elimination related to obstructed flow of urine.
C. Risk for infection related to urinary stasis.
D. Deficient knowledge related to need for prevention of recurrence of calculi.
,A
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
We have an expert-written solution to this problem!
A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is
still very small. Which information supports the explanation that the nurse should provide?
A. Side effects are less likely if therapy is started early.
B. Collateral circulation increases as the tumor grows.
C. The sensitivity of cancer cells to CT is based on cell cycle rate.
D. The cell count of the tumor reduces by half with each dose
D
Rationale
Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer
cells because 50% of cancer cells or tumor cells are killed with each dose.
The nurse is caring for a client with end stage liver disease who is being assessed for the presence
of asterixis. To assess the client for asterixis, what position should the nurse ask the client to
demonstrate?
A. Extend the left arm laterally with the left palm upward.
B. Extend the arm, dorsiflex the wrist, and extend the fingers.
C. Extend the arms and hold this position for 30 seconds.
D. Extend arms with both legs adducted to shoulder width.
B
Rationale
Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in
hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist
causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
The nurse is caring for a client who is two days postoperative. Which observation should alert the
nurse to call the Rapid Response Team (RRT)?
A. Fresh bleeding noted on abdominal surgical wound dressing.
B. Pulse change from 85 to160 beats/minute lasting more than 10 minutes.
C. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3.
, D. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.
B
Rationale
The RRT should be called to intervene for a client with an acute life-threatening change, such as a
pulse change resulting in tachycardia for a prolonged time in a post-operative client.
We have an expert-written solution to this problem!
The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action
should be included in the plan of care?
A. Perform active range of motion three times daily.
B. Monitor for Battle's sign every four hours.
C. Teach measures to avoid the Valsalva maneuver.
Maintain the head of bed in a flat position
C
Rationale
The Valsalva maneuver, straining with bowel movements while holding one's breath, increases
intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels
We have an expert-written solution to this problem!
A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to
hear what the nurse is saying during post-test counseling. Which information should the nurse
offer to facilitate the client’s adjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
D. Discuss retesting to verify the results, which will ensure continuing contact.
D
Rationale
Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although
post-test counseling should include education, retesting encourages the client to maintain medical
follow-up and management.
