1. 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?

a. Assessment

b. Planning

c. Implementation

d. 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.

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.

Protocols assist the clinician in making decisions and choosing

b. interventions for specific health care problems or conditions.

Protocols are policies designating each nurse’s duty according to

c. standards of care and a code of ethics.

Protocols are prescriptive order forms that help individualize the plan

d. 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. Evidencebased 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.