1. The nurse completes a thorough assessment of a patient and analyzes the

data to identify nursing diagnoses. Which step will the nurse take next in the

nursing process?

a. Assessment

b. Diagnosis

c. Planning

d. Implementation

ANS: C

After identifying a patient’s nursing diagnoses and collaborative problems, a nurse

prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and

chooses nursing interventions appropriate for each diagnosis. This is the third step

of the nursing process, planning. The assessment phase of the nursing process

involves gathering data. The implementation phase involves carrying out

appropriate nursing interventions. During the evaluation phase, the nurse assesses

the achievement of goals and effectiveness of interventions.

2. A patient’s plan of care includes the goal of increasing mobility this shift. As

the patient is ambulating to the bathroom at the beginning of the shift, the patient

suffers a fall. Which initial action will the nurse take next to revise the plan of

care?

a. Consult physical therapy.

b. Establish a new plan of care.

c. Set new priorities for the patient.

d. Assess the patient.

ANS: D

Nurses revise a plan when a patient’s status changes; assessment is the first step.

Know also that a plan of care is dynamic and changes as the patient’s needs