A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?

Choice A reason: Providing competencies for the nurses to achieve before licensure is not a description of standards of practice, but rather a function of the nursing education and accreditation system. Standards of practice are authoritative statements that define the expected level of performance for nurses after they obtain their license.

Choice B reason: Establishing a protocol for care to provide for a specific health problem is not a description of standards of practice, but rather a function of the clinical practice guidelines and evidence based practice. Standards of practice are broader and more general statements that apply to all nurses regardless of their specialty or setting.

Choice C reason: Specifying that nurses provide care that reflects current and competent level of behavior when providing client care is a description of standards of practice, as it captures the essence of what standards of practice are and why they are important. Standards of practice are based on the best available evidence and professional consensus, and they guide nurses in delivering safe, quality, and ethical care to their clients.

Choice D reason: Listing a set of skills that all nurses should be competent in performing, outlining responsibilities that every nurse is expected to provide regardless of their role is not a description of standards of practice, but rather a function of the scope of practice. Scope of practice describes the services that a qualified health professional is deemed competent to perform, and permitted to undertake, in keeping with the terms of their professional license..

Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.