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 B

Explanation

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

A. Collaborative problem B. Nursing diagnosis C. Etiology D. Defining characteristic

Correct Answer is C

Explanation

A. Collaborative problem. This is incorrect because a collaborative problem involves complications requiring both medical and nursing interventions. The statement is a nursing diagnosis, not a collaborative problem.

B. Nursing diagnosis. This is incorrect because "Impaired Physical Mobility" is an appropriate NANDA-I approved nursing diagnosis.

C. Etiology. This is correct because "tibial fracture" is a medical diagnosis, and nursing diagnoses should not include medical conditions as the etiology. Instead, the etiology should focus on the patient’s response, such as "pain and muscle weakness" related to the fracture.

D. Defining characteristic. This is incorrect because "patient's inability to ambulate" is an appropriate defining characteristic that supports the diagnosis of impaired mobility.

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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 nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Correct Answer is B

Explanation

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is C

Explanation

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