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 D

Explanation

A. Pain is subjective, and patients experience it differently. Dismissing their report based on the procedure undermines their experience and may lead to inadequate pain management.

B. Pain levels fluctuate, and treatment should be based on current assessment rather than past administration. This approach lacks critical thinking and fails to address the patient's individual needs.

C. While following provider orders is necessary, blindly administering medication without assessing the patient's current pain level and preferences is not critical thinking.

D. This approach individualizes care and involves the patient in decision-making, which is a key component of critical thinking in nursing.

A. The patient will be educated about the signs of infection. B. The patient will know how to manage diabetes effectively. C. The patient will understand the importance of medication adherence. D. The patient will walk 50 feet with a walker unassisted by the end of the week. E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication.

Correct Answer is ["D","E","F"]

Explanation

A. The patient will be educated about the signs of infection. This is incorrect because it is not specific or measurable. The statement does not describe how the nurse will evaluate whether the patient has understood the information.

B. The patient will know how to manage diabetes effectively. This is incorrect because "know" is not measurable. A better outcome statement would describe a specific action the patient will perform to demonstrate their understanding of diabetes management.

C. The patient will understand the importance of medication adherence. This is incorrect because "understand" is not an observable or measurable behavior. Instead, an outcome should describe an action the patient will take, such as demonstrating how to take medication correctly.

D. The patient will walk 50 feet with a walker unassisted by the end of the week. This is correct because it is specific, measurable, and time-bound. It describes a clear action that the nurse can assess.

E. The patient will demonstrate correct use of an inhaler by the end of the teaching session. This is correct because it is measurable and observable. The nurse can directly assess whether the patient correctly uses the inhaler.

F. The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication. This is correct because it is specific, includes a measurable criterion (pain scale), and has a clear timeframe.

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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

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Correct Answer is D

Explanation

A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)

Correct Answer is ["D","E","F"]

Explanation

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