The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Direct the nursing assistive personnel to give the acetaminophen.

Perform a pain assessment only after administering the acetaminophen.

Notify the health care provider to obtain a verbal order.

Administer the acetaminophen.

Answer and Explanation

The Correct Answer is D

A. Direct the nursing assistive personnel to give the acetaminophen. This is incorrect because administering medication is outside the scope of practice for nursing assistive personnel. Only licensed nurses are authorized to administer medications.

B. Perform a pain assessment only after administering the acetaminophen. This is incorrect because a pain assessment should be conducted before administering a PRN medication to determine the severity and characteristics of the pain.

C. Notify the health care provider to obtain a verbal order. This is incorrect because the medication is already included in the standing orders. There is no need to obtain a verbal order when the medication has already been prescribed with specific administration parameters.

D. Administer the acetaminophen. This is correct because the nurse has assessed the patient’s need for pain relief, confirmed that the patient has not received the medication in the past four hours, and verified that it falls within the provider’s orders. Since all criteria are met, the nurse should proceed with administering the medication as prescribed.

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Correct Answer is C

Explanation

A. A warm compress is not appropriate for an unclear abdominal issue.

B. Pain medication should be given after determining the cause.

C. The nurse must assess before taking action to identify possible complications (e.g., bowel obstruction).

D. The physician should be notified after an assessment.

A. Nurse's lounge B. Conference area C. Client's bedside D. Outside client's room

Correct Answer is C

Explanation

A. Nurse’s lounge. This is incorrect because the nurse’s lounge is not a private or appropriate setting for a report. It may not be secure, and other personnel who are not directly involved in the client’s care may overhear confidential information, which violates privacy regulations such as HIPAA.

B. Conference area. This is incorrect because, while a conference room provides some privacy, bedside reporting is preferred as it allows for direct patient involvement, immediate clarification, and continuity of care.

C. Client’s bedside. This is correct because bedside reporting enhances communication, ensures the oncoming nurse can visually assess the client, and allows the client to participate in their care. This approach promotes safety and reduces the risk of errors during the handoff.

D. Outside client’s room. This is incorrect because it does not ensure privacy and may not allow for direct verification of client information. Discussing a report outside the room could also expose confidential information to unintended listeners.

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The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who recently underwent abdominal surgery is complaining of severe abdominal pain and has a distended abdomen. Which of the following interventions should the nurse do first?

Correct Answer is C

Explanation

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

Correct Answer is C

Explanation

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