The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action by the nurse is the most appropriate?
1. Report the lack of achievement of the goals to the healthcare provider.
2. Review the data and modify the plan.
3. Reformulate the nursing diagnosis to a more realistic one.
4. Request a consult for the client to be seen by a pulmonologist.
Correct Answer: 2
The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. Reformulating the nursing diagnosis to a more realistic one is not the best course of action, as the diagnosis established came from subjective and objective data specific to that diagnosis. There are no data to support the need for additional medical consultations.
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