From Anxiety to Assurance: Your 2026 Guide to Nursing Diagnoses & NCLEX Care Plans

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
Reference: Nursing Process — Assessment → Diagnosis →
Planning (Chapter 1: The Nursing Process and Planning Client
Care)
Stem: A 68-year-old postoperative hip fracture patient reports
shortness of breath and has an SpO₂ of 88% on room air,
respiratory rate 28/min, and bilateral crackles at lung bases.
Which nursing diagnosis statement is most appropriate to write
in the plan of care?
A. Risk for Infection related to surgical incision.

,B. Impaired Gas Exchange related to alveolar-capillary
membrane changes as evidenced by SpO₂ 88% and dyspnea.
C. Activity Intolerance related to recent surgery.
D. Ineffective Airway Clearance related to weak cough.
Correct Answer: B
Rationale — Correct: According to Doenges et al., an actual
diagnosis requires defining characteristics (subjective &
objective data). The low SpO₂, dyspnea, tachypnea, and crackles
support Impaired Gas Exchange; this links assessment cues to a
focused diagnosis and guides oxygenation-focused
outcomes/interventions.
Rationale — Incorrect:
A. Incision infection risk is plausible post-op but lacks
supporting assessment cues (fever, erythema).
C. Activity Intolerance may coexist but oxygenation data make
gas exchange the priority.
D. Ineffective Airway Clearance emphasizes secretions and
inability to clear airway — crackles and poor oxygenation point
more directly to gas exchange impairment.
Teaching Point: Use objective respiratory data plus symptoms
to justify Impaired Gas Exchange.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
section.


2.

,Reference: Planning → Writing Patient-Centered Outcomes
(Chapter 1)
Stem: A nurse is writing an outcome for a patient with
congestive heart failure and shortness of breath. Which of the
following is the best-written short-term outcome?
A. Patient will feel less short of breath.
B. Patient will maintain oxygen saturation ≥ 95% on
supplemental O₂ within 2 hours.
C. Patient’s breathing will improve.
D. Oxygenation status will be acceptable.
Correct Answer: B
Rationale — Correct: Doenges et al. emphasize outcomes that
are specific, measurable, attainable, realistic, and time-limited
(SMART). "Maintain SpO₂ ≥ 95% on supplemental O₂ within 2
hours" is measurable and time-bound.
Rationale — Incorrect:
A/C/D. These are vague, non-measurable, and lack a
timeframe—do not meet SMART criteria for effective nursing
outcomes.
Teaching Point: Outcomes must be specific, measurable, and
time-limited (SMART).
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Planning client care
section.


3.

, Reference: Prioritizing Nursing Diagnoses — ABCs & Maslow
(Chapter 1)
Stem: Three diagnoses are identified for a client: (1) Acute Pain
8/10 after surgery, (2) Risk for Aspiration related to decreased
swallow reflex, and (3) Impaired Gas Exchange with SpO₂ 82%.
Which should be addressed first in the plan of care?
A. Acute Pain.
B. Risk for Aspiration.
C. Impaired Gas Exchange.
D. All are equal priority.
Correct Answer: C
Rationale — Correct: Doenges et al. and basic priority-setting
place airway/oxygenation first (ABCs). Impaired Gas Exchange
with SpO₂ 82% is immediately life-threatening and must be
prioritized.
Rationale — Incorrect:
A. Pain is important but secondary to life-threatening hypoxia.
B. Aspiration risk is serious but current hypoxia demands
immediate intervention.
D. Not all problems have equal priority—immediate physiologic
threats come first.
Teaching Point: Prioritize airway and oxygenation before
comfort or risk problems.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Priority-setting section.