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. Skipping breaks can lead to burnout.

B. Taking on another nurse’s task may cause delays in primary responsibilities.

C. Planning for interruptions improves efficiency and prioritization.

D. Completing the easiest tasks first may not be the most efficient approach.

A. A patient who is scheduled for a routine follow-up visit for hypertension management. B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. C. A patient who is recovering from an appendectomy and is asking about discharge instructions. D. A patient who is complaining of sudden onset chest pain and shortness of breath. E. Answer: D

Correct Answer is D

Explanation

A. A patient who is scheduled for a routine follow-up visit for hypertension management. This is incorrect because this patient is stable and does not require immediate assessment. Routine follow-ups do not take priority over acute conditions.

B. A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene. This is incorrect because while personal hygiene is important, it is not urgent or life-threatening.

C. A patient who is recovering from an appendectomy and is asking about discharge instructions. This is incorrect because discharge teaching is important but can be scheduled later in the shift when more urgent needs have been addressed.

D. A patient who is complaining of sudden onset chest pain and shortness of breath. This is correct because sudden onset chest pain and shortness of breath can indicate a life-threatening condition such as myocardial infarction or pulmonary embolism. The nurse must immediately assess this patient to determine the cause and initiate emergency interventions if necessary.

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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 is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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