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Chapter 19: Implementing Nursing Care
Chapter 19: Implementing Nursing Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
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 eӄectiveness of interventions.
DIF:Understand (comprehension)REF:257
OBJ: Explain the relationship of implementation to the nursing diagnostic process.
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,10/15/2016 Chapter 19: Implementing Nursing Care | Nursing Test Banks
TOP: Implementation MSC: Basic Care and Comfort
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.
b. Protocols assist the clinician in making decisions and choosing interventions for speciӄc health care problems or
conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics.
d. 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 speciӄc clinical
situations. This guideline establishes interventions for speciӄc 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 speciӄc group of patients. A protocol is not a prescriptive order form like a standing
order.
DIF:Understand (comprehension)REF:258
OBJ iscuss the diӄerences between protocols and standing orders.
TOP:Teaching/LearningMSC:Management of Care
3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After
assessing the patient, the nurse identiӄes the need for headache relief and determines that the patient has not
had acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
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, 10/15/2016 Chapter 19: Implementing Nursing Care | Nursing Test Banks
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.
ANS: A
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring
guidelines, and/or diagnostic procedures for speciӄc patients with identiӄed clinical problems. The nurse will
administer the medication. Notifying the health care provider is not necessary if a standing order exists. The
nursing assistive personnel are not licensed to administer medications; therefore, medication administration
should not be delegated to this person. A pain assessment should be performed before and after pain
medication administration to assess the need for and eӄectiveness of the medication.
DIF:Apply (application)REF:258
OBJ iscuss the diӄerences between protocols and standing orders.
TOP: Implementation MSC: Basic Care and Comfort
4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
a. Determines whether an intervention is correct and appropriate for the given situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the eӄectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to conӄrm 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 eӄectively. The nurse needs to
recognize the safety hazards of performing an intervention without clinical competency and seek assistance
from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need
ongoing assessment before establishing goals because patient conditions can change very rapidly.
http://boostgrade.info/chapter19implementingnursingcare/ 3/17
Nursing Test Banks
One Account Get all Test Banks
Chapter 19: Implementing Nursing Care
Chapter 19: Implementing Nursing Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
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 eӄectiveness of interventions.
DIF:Understand (comprehension)REF:257
OBJ: Explain the relationship of implementation to the nursing diagnostic process.
http://boostgrade.info/chapter19implementingnursingcare/ 1/17
,10/15/2016 Chapter 19: Implementing Nursing Care | Nursing Test Banks
TOP: Implementation MSC: Basic Care and Comfort
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.
b. Protocols assist the clinician in making decisions and choosing interventions for speciӄc health care problems or
conditions.
c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics.
d. 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 speciӄc clinical
situations. This guideline establishes interventions for speciӄc 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 speciӄc group of patients. A protocol is not a prescriptive order form like a standing
order.
DIF:Understand (comprehension)REF:258
OBJ iscuss the diӄerences between protocols and standing orders.
TOP:Teaching/LearningMSC:Management of Care
3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After
assessing the patient, the nurse identiӄes the need for headache relief and determines that the patient has not
had acetaminophen in the past 4 hours. Which action will the nurse take next?
a. Administer the acetaminophen.
b. Notify the health care provider to obtain a verbal order.
http://boostgrade.info/chapter19implementingnursingcare/ 2/17
, 10/15/2016 Chapter 19: Implementing Nursing Care | Nursing Test Banks
c. Direct the nursing assistive personnel to give the acetaminophen.
d. Perform a pain assessment only after administering the acetaminophen.
ANS: A
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring
guidelines, and/or diagnostic procedures for speciӄc patients with identiӄed clinical problems. The nurse will
administer the medication. Notifying the health care provider is not necessary if a standing order exists. The
nursing assistive personnel are not licensed to administer medications; therefore, medication administration
should not be delegated to this person. A pain assessment should be performed before and after pain
medication administration to assess the need for and eӄectiveness of the medication.
DIF:Apply (application)REF:258
OBJ iscuss the diӄerences between protocols and standing orders.
TOP: Implementation MSC: Basic Care and Comfort
4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
a. Determines whether an intervention is correct and appropriate for the given situation
b. Reads over the steps and performs a procedure despite lack of clinical competency
c. Establishes goals for a particular patient without assessment
d. Evaluates the eӄectiveness of interventions
ANS: A
As you implement interventions, use critical thinking to conӄrm 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 eӄectively. The nurse needs to
recognize the safety hazards of performing an intervention without clinical competency and seek assistance
from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need
ongoing assessment before establishing goals because patient conditions can change very rapidly.
http://boostgrade.info/chapter19implementingnursingcare/ 3/17
