Author Question: The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. ... (Read 67 times)

abern · **on:** Jul 22, 2018

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?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.

Question 2

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

a. Protocols are guidelines to follow that replace the nursing care plan.
b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.
c. Protocols are policies designating each nurse's duty according to standards of care and a code of ethics.
d. Protocols are prescriptive order forms that help individualize the plan of care.

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

Answer to Question 1

ANS: A
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. The nurse will administer the medication. Notifying the health care provider is not necessary if a standing order exists. The nursing assistive personnel are 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

ANS: B
A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order.