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COMPLETE SOLUTION.
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.
COMPLETE SOLUTION.
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. 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
not a prescriptive order form like a standing order.
COMPLETE SOLUTION.
c. Establishes goals for a particular patient without assessment
d. Evaluates the effectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient’s clinical situation. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse. The
COMPLETE SOLUTION.
nurse cannot evaluate interventions until they are implemented. Patients need 2 ongoing assessment before establishing goals because patient conditions can
PROCTORED COMPLETE
SOLUTION
The patient’s pain is a 7, indicating the priority is pain relief (administer pain medication). Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing.
7. The nurse is caring for a patient who requires a complex dressing
change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
a. Gathers and organizes needed supplies
PROCTORED COMPLETE
SOLUTION
b. Decides on goals and outcomes for the patient
PROCTORED COMPLETE
SOLUTION
assistance to the bathroom for the first time. Which action should the nurse take initially?
a. Ask for at least two other assistive personnel to come to the room.
b. Medicate the patient to alleviate discomfort while ambulating.
c. Review the patient’s activity orders.
PROCTORED COMPLETE
SOLUTION
d. Offer the patient a walker.
