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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
incorpo 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.
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