After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?

Question

a. Eliminate headache from the nursing care plan.
b. Direct the nursing assistive personnel to ask if the headache is relieved.
c. Reassess the patient's pain level in 30 minutes.
d. Revise the plan of care.

Answer 1

ANS: C
The nurse's priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective. The nurse does not have enough evaluative data at this point to determine whether headache needs to be discontinued. Assessment is the nurse's responsibility and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.