A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In

which step of the nursing process is the nurse?

Assessment

Planning

Implementation

Evaluation

ANS: C

Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care.

With a care plan based on clear and relevant nursing diagnoses, a nurse initiates interventions that are

designed to assist the patient in achieving the goals and expected outcomes needed to support or improve

the patient’s health status. The nurse gathers data during the assessment phase and mutually sets goals and

prioritizes care during the planning phase. During the evaluation phase, the nurse determines the achievement

of goals and effectiveness of interventions.

The nurse is teaching a new nurse about protocols. Which

information from the new nurse indicates a correct understanding of theteaching?

Protocols are guidelines to follow that replace the nursing care plan.

Protocols assist the clinician in making decisions and choosing

interventions for specific health care problems or conditions.

Protocols are policies designating each nurse’s duty according to

standards of care and a code of ethics.

Protocols are prescriptive order forms that help individualize the plan of

care.

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

1

not a prescriptive order form like a standing order.