Nurse's Pocket Guide, 16th Edition
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
Q1
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
A 68-year-old postoperative client has a pulse oximetry reading
of 90% on room air, respiratory rate 26/min, bibasilar crackles
on auscultation, and reports shortness of breath when
ambulating to the bedside commode. Using the nursing
,process, which nursing diagnosis is the most appropriate to
document?
A. Activity Intolerance
B. Impaired Gas Exchange
C. Ineffective Airway Clearance
D. Anxiety
Correct answer: B
Rationales
Correct (B): The defining characteristics—low SpO₂, tachypnea,
adventitious breath sounds, and dyspnea with exertion—match
Impaired Gas Exchange per Doenges’ nursing diagnosis
framework; priority is oxygenation.
Incorrect (A): Activity Intolerance may be present but the
immediate physiologic problem is gas exchange; it is secondary.
Incorrect (C): Ineffective Airway Clearance focuses on
secretions/obstruction; adventitious sounds and low SpO₂
signal impaired diffusion/ventilation rather than only clearance.
Incorrect (D): Anxiety could coexist but does not explain
hypoxemia and crackles; it is lower priority for immediate
physiologic stabilization.
Teaching point: Low SpO₂ + tachypnea + adventitious sounds =
prioritize impaired gas exchange.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
,Q2
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
A nurse writes the outcome: “Client will have oxygen saturation
≥ 95% within 2 hours.” Which aspect of outcome-writing is
being evaluated and is this outcome appropriate?
A. It is patient-centered but not time-limited; revise time frame.
B. It is measurable and time-limited; appropriate as written.
C. It is not observable; change to “reports less dyspnea.”
D. It is broad and non-specific; add interventions.
Correct answer: B
Rationales
Correct (B): The outcome is specific (SpO₂ ≥ 95%), measurable,
time-limited (within 2 hours), and patient-centered—meeting
SMART criteria described in Chapter 1.
Incorrect (A): The outcome includes a clear time frame (2
hours); time-limited criterion is satisfied.
Incorrect (C): SpO₂ is an observable, objective measure;
“reports less dyspnea” is subjective and less precise.
Incorrect (D): The outcome is specific and measurable; adding
interventions is planning, not a correction of outcome wording.
Teaching point: Outcomes must be specific, measurable,
attainable, relevant, time-limited (SMART).
, Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
Q3
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
During admission assessment the nurse documents the
problem list and assigns priority. Which principle most directly
guides priority setting according to Chapter 1?
A. Patient preference always overrides physiologic needs.
B. Use ABCs (Airway, Breathing, Circulation) and safety to set
priorities.
C. Complete psychosocial needs first to build therapeutic
rapport.
D. Address chronic problems before acute problems for
continuity.
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes prioritizing using physiologic
stability—ABCs and safety—before less urgent needs.
Incorrect (A): Patient preference is important but does not
override immediate physiologic threats to life.
Incorrect (C): Psychosocial needs matter but are lower priority
than airway/breathing/circulatory threats.
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
Q1
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
A 68-year-old postoperative client has a pulse oximetry reading
of 90% on room air, respiratory rate 26/min, bibasilar crackles
on auscultation, and reports shortness of breath when
ambulating to the bedside commode. Using the nursing
,process, which nursing diagnosis is the most appropriate to
document?
A. Activity Intolerance
B. Impaired Gas Exchange
C. Ineffective Airway Clearance
D. Anxiety
Correct answer: B
Rationales
Correct (B): The defining characteristics—low SpO₂, tachypnea,
adventitious breath sounds, and dyspnea with exertion—match
Impaired Gas Exchange per Doenges’ nursing diagnosis
framework; priority is oxygenation.
Incorrect (A): Activity Intolerance may be present but the
immediate physiologic problem is gas exchange; it is secondary.
Incorrect (C): Ineffective Airway Clearance focuses on
secretions/obstruction; adventitious sounds and low SpO₂
signal impaired diffusion/ventilation rather than only clearance.
Incorrect (D): Anxiety could coexist but does not explain
hypoxemia and crackles; it is lower priority for immediate
physiologic stabilization.
Teaching point: Low SpO₂ + tachypnea + adventitious sounds =
prioritize impaired gas exchange.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
,Q2
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
A nurse writes the outcome: “Client will have oxygen saturation
≥ 95% within 2 hours.” Which aspect of outcome-writing is
being evaluated and is this outcome appropriate?
A. It is patient-centered but not time-limited; revise time frame.
B. It is measurable and time-limited; appropriate as written.
C. It is not observable; change to “reports less dyspnea.”
D. It is broad and non-specific; add interventions.
Correct answer: B
Rationales
Correct (B): The outcome is specific (SpO₂ ≥ 95%), measurable,
time-limited (within 2 hours), and patient-centered—meeting
SMART criteria described in Chapter 1.
Incorrect (A): The outcome includes a clear time frame (2
hours); time-limited criterion is satisfied.
Incorrect (C): SpO₂ is an observable, objective measure;
“reports less dyspnea” is subjective and less precise.
Incorrect (D): The outcome is specific and measurable; adding
interventions is planning, not a correction of outcome wording.
Teaching point: Outcomes must be specific, measurable,
attainable, relevant, time-limited (SMART).
, Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
Q3
Reference
The Nursing Process and Planning Client Care — Chapter 1
Stem
During admission assessment the nurse documents the
problem list and assigns priority. Which principle most directly
guides priority setting according to Chapter 1?
A. Patient preference always overrides physiologic needs.
B. Use ABCs (Airway, Breathing, Circulation) and safety to set
priorities.
C. Complete psychosocial needs first to build therapeutic
rapport.
D. Address chronic problems before acute problems for
continuity.
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes prioritizing using physiologic
stability—ABCs and safety—before less urgent needs.
Incorrect (A): Patient preference is important but does not
override immediate physiologic threats to life.
Incorrect (C): Psychosocial needs matter but are lower priority
than airway/breathing/circulatory threats.
