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
Nursing Process — Assessment (Data Sources & Types)
Stem
A 68-year-old post-op patient reports “I feel short of breath”
and pulse oximetry reads 89% on room air. The nurse notes
bilateral crackles and increased respiratory rate. Which action
,most directly addresses proper data collection for accurate
diagnosis?
A. Document the pulse oximetry value and proceed to plan
interventions.
B. Ask the patient whether the shortness of breath is new and
obtain baseline respiratory status from the medical record.
C. Notify the provider immediately and request an arterial
blood gas (ABG).
D. Administer prescribed oxygen and record the intervention
without additional assessment.
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes combining subjective and
objective data and verifying baseline/previous data to validate
findings. Asking about onset and checking baseline records
helps distinguish acute from chronic changes and supports
accurate diagnostic reasoning.
Incorrect (A): Recording the SpO₂ is necessary but incomplete—
additional history and baseline comparison are required before
planning.
Incorrect (C): Notifying the provider may be appropriate after
assessment, but ordering tests before confirming data sources
and trends bypasses nursing assessment responsibilities.
Incorrect (D): Administering oxygen may be required, but doing
so without clarifying the timeline and prior status risks missing
assessment cues and appropriate priority-setting.
,Teaching point: Always validate subjective cues with baseline
data and focused questioning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1: The Nursing
Process and Planning Client Care.
2
Reference
Nursing Process — Assessment (Subjective vs. Objective Data)
Stem
A 34-year-old patient says, “I can’t sleep because of pain,” and
grimaces when changing position. Which pairing correctly
classifies the data collected?
A. Subjective: grimacing; Objective: “I can’t sleep because of
pain.”
B. Subjective: “I can’t sleep because of pain.”; Objective:
grimacing.
C. Subjective: increased heart rate; Objective: patient report of
poor sleep.
D. Subjective: respiratory rate; Objective: report of pain level.
Correct answer: B
Rationales
Correct (B): Chapter 1 defines subjective data as patient-
reported information and objective data as
observable/measurable signs. The patient report (“I can’t
, sleep…”) is subjective; grimacing is an objective sign.
Incorrect (A): This reverses the classifications.
Incorrect (C): Heart rate is objective, not subjective; the pairing
is inverted.
Incorrect (D): Respiratory rate is objective; the report of pain is
subjective—this option misclassifies both.
Teaching point: Subjective = patient report; objective =
observable/measurable sign.
Citation: Doenges et al., (2022). Chapter 1.
3
Reference
Nursing Process — Data Validation & Clustering Cues
Stem
During admission assessment, a nurse documents low urine
output, elevated BUN, and dry mucous membranes. According
to the nursing process, what is the nurse’s next best step before
selecting a nursing diagnosis?
A. Initiate fluid replacement per standing protocol.
B. Cluster these cues and validate with the patient’s intake
records and medication list.
C. Write a nursing diagnosis of Deficient Fluid Volume
immediately.
D. Order a serum electrolyte panel.
Correct answer: B
Diagnoses, Prioritized Interventions,
And Rationales
16th Edition
• Author(S)Marilynn E. Doenges; Mary
Frances Moorhouse; Alice C. Murr
TEST BANK
1
Reference
Nursing Process — Assessment (Data Sources & Types)
Stem
A 68-year-old post-op patient reports “I feel short of breath”
and pulse oximetry reads 89% on room air. The nurse notes
bilateral crackles and increased respiratory rate. Which action
,most directly addresses proper data collection for accurate
diagnosis?
A. Document the pulse oximetry value and proceed to plan
interventions.
B. Ask the patient whether the shortness of breath is new and
obtain baseline respiratory status from the medical record.
C. Notify the provider immediately and request an arterial
blood gas (ABG).
D. Administer prescribed oxygen and record the intervention
without additional assessment.
Correct answer: B
Rationales
Correct (B): Chapter 1 emphasizes combining subjective and
objective data and verifying baseline/previous data to validate
findings. Asking about onset and checking baseline records
helps distinguish acute from chronic changes and supports
accurate diagnostic reasoning.
Incorrect (A): Recording the SpO₂ is necessary but incomplete—
additional history and baseline comparison are required before
planning.
Incorrect (C): Notifying the provider may be appropriate after
assessment, but ordering tests before confirming data sources
and trends bypasses nursing assessment responsibilities.
Incorrect (D): Administering oxygen may be required, but doing
so without clarifying the timeline and prior status risks missing
assessment cues and appropriate priority-setting.
,Teaching point: Always validate subjective cues with baseline
data and focused questioning.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Chapter 1: The Nursing
Process and Planning Client Care.
2
Reference
Nursing Process — Assessment (Subjective vs. Objective Data)
Stem
A 34-year-old patient says, “I can’t sleep because of pain,” and
grimaces when changing position. Which pairing correctly
classifies the data collected?
A. Subjective: grimacing; Objective: “I can’t sleep because of
pain.”
B. Subjective: “I can’t sleep because of pain.”; Objective:
grimacing.
C. Subjective: increased heart rate; Objective: patient report of
poor sleep.
D. Subjective: respiratory rate; Objective: report of pain level.
Correct answer: B
Rationales
Correct (B): Chapter 1 defines subjective data as patient-
reported information and objective data as
observable/measurable signs. The patient report (“I can’t
, sleep…”) is subjective; grimacing is an objective sign.
Incorrect (A): This reverses the classifications.
Incorrect (C): Heart rate is objective, not subjective; the pairing
is inverted.
Incorrect (D): Respiratory rate is objective; the report of pain is
subjective—this option misclassifies both.
Teaching point: Subjective = patient report; objective =
observable/measurable sign.
Citation: Doenges et al., (2022). Chapter 1.
3
Reference
Nursing Process — Data Validation & Clustering Cues
Stem
During admission assessment, a nurse documents low urine
output, elevated BUN, and dry mucous membranes. According
to the nursing process, what is the nurse’s next best step before
selecting a nursing diagnosis?
A. Initiate fluid replacement per standing protocol.
B. Cluster these cues and validate with the patient’s intake
records and medication list.
C. Write a nursing diagnosis of Deficient Fluid Volume
immediately.
D. Order a serum electrolyte panel.
Correct answer: B
