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
1
Reference
The Nursing Process and Planning Client Care — Data Clustering
& Diagnostic Reasoning
Stem
A 68-year-old post-op client has SpO₂ 88% on room air, RR 30,
accessory muscle use, and restless behavior. Breath sounds
,reveal diminished air entry bilaterally. The nurse clusters these
findings and selects the priority nursing diagnosis. Which is the
best nursing diagnosis?
A. Ineffective Airway Clearance
B. Impaired Gas Exchange
C. Anxiety
D. Activity Intolerance
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes clustering subjective and
objective respiratory cues (low SpO₂, tachypnea, accessory
muscle use, diminished breath sounds, restlessness) to identify
gas-exchange problems. These signs indicate inadequate
oxygenation at the alveolar-capillary level, making Impaired Gas
Exchange the priority.
Incorrect (A): Ineffective Airway Clearance focuses on inability
to clear secretions; the findings more strongly indicate an
oxygenation/ventilation deficit rather than isolated secretion
obstruction.
Incorrect (C): While restlessness can reflect anxiety, in this
context it is a sign of hypoxemia; treating anxiety would miss
the physiologic priority.
Incorrect (D): Activity Intolerance is a chronic/performance
problem and not the immediate priority when oxygenation is
compromised.
,Teaching point: Cluster respiratory cues—low SpO₂ + tachypnea
+ accessory use → prioritize gas-exchange problems.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
The Nursing Process and Planning Client Care — Outcome
Writing (Measurable Outcomes)
Stem
A nurse writes an outcome for a client with risk for falls: “Client
will be safe.” Which revision best reflects the chapter’s guidance
for measurable outcomes?
A. Client will remain free from falls during hospital stay.
B. Client will state fall prevention techniques by discharge.
C. Client will demonstrate safe transfer technique with minimal
assistance by tomorrow morning.
D. Client will have no injuries.
Correct answer: C
Rationales
Correct (C): Chapter 1 instructs that outcomes be specific,
measurable, achievable, relevant, and time-bound (SMART).
Option C specifies behavior (demonstrate safe transfer),
criterion (with minimal assistance), and time (by tomorrow
, morning).
Incorrect (A): Although safety-focused, “remain free from falls”
is a desirable outcome but lacks measurable behavior and time
specificity and may be unrealistic as written.
Incorrect (B): Teaching/knowledge outcome is measurable but
does not directly measure safe performance—less prioritized
than demonstrated skill for fall prevention.
Incorrect (D): Vague and non-measurable.
Teaching point: Outcomes must be SMART: describe observable
behavior, criterion, and timeframe.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
The Nursing Process and Planning Client Care — Prioritization
(ABCs & Maslow)
Stem
A client admitted with dehydration has BP 88/54, dry mucous
membranes, and dizziness on standing. Which nursing
intervention is highest priority?
A. Encourage oral fluid intake every hour.
B. Apply sequential compression devices to lower extremities.
C. Initiate IV fluids per order and monitor BP closely.
D. Assist with ambulation as tolerated.
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
The Nursing Process and Planning Client Care — Data Clustering
& Diagnostic Reasoning
Stem
A 68-year-old post-op client has SpO₂ 88% on room air, RR 30,
accessory muscle use, and restless behavior. Breath sounds
,reveal diminished air entry bilaterally. The nurse clusters these
findings and selects the priority nursing diagnosis. Which is the
best nursing diagnosis?
A. Ineffective Airway Clearance
B. Impaired Gas Exchange
C. Anxiety
D. Activity Intolerance
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes clustering subjective and
objective respiratory cues (low SpO₂, tachypnea, accessory
muscle use, diminished breath sounds, restlessness) to identify
gas-exchange problems. These signs indicate inadequate
oxygenation at the alveolar-capillary level, making Impaired Gas
Exchange the priority.
Incorrect (A): Ineffective Airway Clearance focuses on inability
to clear secretions; the findings more strongly indicate an
oxygenation/ventilation deficit rather than isolated secretion
obstruction.
Incorrect (C): While restlessness can reflect anxiety, in this
context it is a sign of hypoxemia; treating anxiety would miss
the physiologic priority.
Incorrect (D): Activity Intolerance is a chronic/performance
problem and not the immediate priority when oxygenation is
compromised.
,Teaching point: Cluster respiratory cues—low SpO₂ + tachypnea
+ accessory use → prioritize gas-exchange problems.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
2
Reference
The Nursing Process and Planning Client Care — Outcome
Writing (Measurable Outcomes)
Stem
A nurse writes an outcome for a client with risk for falls: “Client
will be safe.” Which revision best reflects the chapter’s guidance
for measurable outcomes?
A. Client will remain free from falls during hospital stay.
B. Client will state fall prevention techniques by discharge.
C. Client will demonstrate safe transfer technique with minimal
assistance by tomorrow morning.
D. Client will have no injuries.
Correct answer: C
Rationales
Correct (C): Chapter 1 instructs that outcomes be specific,
measurable, achievable, relevant, and time-bound (SMART).
Option C specifies behavior (demonstrate safe transfer),
criterion (with minimal assistance), and time (by tomorrow
, morning).
Incorrect (A): Although safety-focused, “remain free from falls”
is a desirable outcome but lacks measurable behavior and time
specificity and may be unrealistic as written.
Incorrect (B): Teaching/knowledge outcome is measurable but
does not directly measure safe performance—less prioritized
than demonstrated skill for fall prevention.
Incorrect (D): Vague and non-measurable.
Teaching point: Outcomes must be SMART: describe observable
behavior, criterion, and timeframe.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1.
3
Reference
The Nursing Process and Planning Client Care — Prioritization
(ABCs & Maslow)
Stem
A client admitted with dehydration has BP 88/54, dry mucous
membranes, and dizziness on standing. Which nursing
intervention is highest priority?
A. Encourage oral fluid intake every hour.
B. Apply sequential compression devices to lower extremities.
C. Initiate IV fluids per order and monitor BP closely.
D. Assist with ambulation as tolerated.
