Author Question: The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for ... (Read 54 times)

Pea0909berry · **on:** Jul 22, 2018

The standing orders for a patient include acetaminophen (Tylenol) 650 mg every 4 hours prn for headache.

After assessing the patient, identifying the need for headache relief, and determining that the patient has not had Tylenol in the past 4 hours, the nurse a. Notifies the health care provider to obtain a verbal order.
b. Directs the nursing assistant to give the Tylenol.
c. Administers the Tylenol.
d. Performs a pain assessment only after administering the Tylenol.

Question 2

The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement?

a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.

Eunice618 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Notifying the health care provider is not necessary if a standing order exists. The nursing assistant is not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.

Answer to Question 2

C
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.