PROCTORED LATEST EXAM
QUESTIONS WITH COMPLETE &
VERIFIED RATIONALES AND
ANSWERS 2024/2025
A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. Inwhich 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 ofcare.
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
1
orders contain orders for the care of a specific group of patients. A protocol is
not a prescriptive order form like a standing order.
, The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. Afterassessing the
patient, the nurse identifies 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?
Administer the acetaminophen.
Notify the health care provider to obtain a verbal order.
Direct the nursing assistive personnel to give the acetaminophen. Perform a pain assessment only afteradministeringthe
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 specific patients with identified 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 andafter pain medication administration to assess the need for and
effectivenessof the medication.
Which action indicates a nurse is using critical thinking forimplementation of nursing care to patients?
Determines whether an intervention is correct and appropriate for the
a. given situation
Rea d s over the steps and performs a procedure despite lack of clinicalcompetency
b .
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
nurse cannot evaluate interventions until they are implemented. Patients need 2 ongoing
assessment before establishing goals because patient conditions can