Evolve HESI Practice Exam

When a desired outcome is not achieved in a client’s plan of care, what is the nurse's first action?

1. Revise the care plan

2. Note which actions were not implemented

3. Inform the physician

4. Evaluate patient feedback

The correct answer is: Note which actions were not implemented

When a desired outcome is not achieved in a client’s plan of care, the nurse's first action involves noting which actions were not implemented. This step is crucial because it allows the nurse to identify specific discrepancies in the care delivered versus what was planned. By understanding what interventions were not carried out, the nurse can assess whether the failure to meet outcomes is due to incomplete care, lack of patient adherence, or possibly ineffective interventions. This initial assessment enables the nurse to gather necessary data before taking further corrective actions. Noting unimplemented actions can lead to more informed decision-making regarding the subsequent steps needed to adjust the care plan effectively. Therefore, this approach ensures that any revisions to the care plan or further discussions with the healthcare team, including the physician, are based on factual insights regarding what occurred during the implementation phase of the care plan.