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, Diagnosis, &
Planning (Chapter 1: The Nursing Process and Planning Client
Care)
Stem: A 68-year-old client admitted with congestive heart
failure reports shortness of breath on minimal exertion.
Respirations are 28/min, SpO₂ is 88% on room air, bilateral
crackles are heard in the bases, and the client is anxious. As the
,nurse begins planning care, which action best reflects accurate
priority setting for this client's immediate nursing plan?
A. Arrange for a home oxygen concentrator and teach energy
conservation techniques.
B. Administer supplemental oxygen per protocol, place the
client in high-Fowler’s position, and assess breath sounds and
SpO₂.
C. Begin discharge teaching about low-sodium diet and weight
monitoring.
D. Contact social services to arrange for home health follow-up.
Correct answer: B
Rationales
Correct (B): This choice addresses immediate physiologic
airway/oxygenation problems (ABCs). High-Fowler’s and oxygen
and focused respiratory assessment are priority interventions to
improve oxygenation and guide further nursing actions.
Incorrect (A): A home oxygen concentrator and energy
conservation are appropriate later (discharge/planning), not
immediate stabilization.
Incorrect (C): Diet teaching is important but is a lower priority
until respiratory status stabilizes.
Incorrect (D): Social services coordination is a planning activity
for discharge—not the immediate priority in acute respiratory
compromise.
Teaching point: Address ABCs and stabilize oxygenation before
teaching or discharge planning.
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (16th
ed.). Nurse’s Pocket Guide. Nursing process section.
2
Reference: Expected Outcomes / Goal Writing — SMART
Outcomes (Chapter 1)
Stem: A nurse writes an expected outcome: “Client will have
improved breathing.” During interdisciplinary review, which
revision makes this outcome measurable and appropriate for
the plan of care?
A. “Client will feel better within 2 days.”
B. “Client will report less shortness of breath.”
C. “Client will maintain SpO₂ ≥ 94% on room air within 4 hours.”
D. “Client will have fewer respiratory symptoms as tolerated.”
Correct answer: C
Rationales
Correct (C): This outcome is specific, measurable, time-bound,
and directly related to respiratory status (SpO₂), meeting
SMART criteria and allowing evaluation.
Incorrect (A): “Feel better” is subjective and vague; timeframe
alone does not make it measurable.
Incorrect (B): Reporting is subjective and lacks measurable
criteria (e.g., rating scale, SpO₂).
Incorrect (D): “As tolerated” and “fewer” are vague and not
measurable.
, Teaching point: Write outcomes that are specific, measurable,
achievable, relevant, and time-bound.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (16th
ed.). Nurse’s Pocket Guide. Nursing process section.
3
Reference: Initial vs Ongoing Planning (Chapter 1)
Stem: A newly admitted post-op client is stable but has poorly
controlled pain according to the numeric pain scale 8/10. Which
planning action is an initial nursing plan responsibility?
A. Evaluate effectiveness of analgesia at 60 minutes and revise
plan.
B. Document baseline pain level, notify
surgeon/anesthesiologist, and implement prescribed PRN
analgesic.
C. Teach the client about opioid side effects and long-term pain
management.
D. Arrange referrals for chronic pain clinic follow-up.
Correct answer: B
Rationales
Correct (B): Initial planning includes immediate assessment
documentation and initiating prescribed interventions to relieve
acute pain—actions necessary at admission.
Incorrect (A): Evaluation is part of ongoing care that follows the
initial intervention.
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, Diagnosis, &
Planning (Chapter 1: The Nursing Process and Planning Client
Care)
Stem: A 68-year-old client admitted with congestive heart
failure reports shortness of breath on minimal exertion.
Respirations are 28/min, SpO₂ is 88% on room air, bilateral
crackles are heard in the bases, and the client is anxious. As the
,nurse begins planning care, which action best reflects accurate
priority setting for this client's immediate nursing plan?
A. Arrange for a home oxygen concentrator and teach energy
conservation techniques.
B. Administer supplemental oxygen per protocol, place the
client in high-Fowler’s position, and assess breath sounds and
SpO₂.
C. Begin discharge teaching about low-sodium diet and weight
monitoring.
D. Contact social services to arrange for home health follow-up.
Correct answer: B
Rationales
Correct (B): This choice addresses immediate physiologic
airway/oxygenation problems (ABCs). High-Fowler’s and oxygen
and focused respiratory assessment are priority interventions to
improve oxygenation and guide further nursing actions.
Incorrect (A): A home oxygen concentrator and energy
conservation are appropriate later (discharge/planning), not
immediate stabilization.
Incorrect (C): Diet teaching is important but is a lower priority
until respiratory status stabilizes.
Incorrect (D): Social services coordination is a planning activity
for discharge—not the immediate priority in acute respiratory
compromise.
Teaching point: Address ABCs and stabilize oxygenation before
teaching or discharge planning.
,Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (16th
ed.). Nurse’s Pocket Guide. Nursing process section.
2
Reference: Expected Outcomes / Goal Writing — SMART
Outcomes (Chapter 1)
Stem: A nurse writes an expected outcome: “Client will have
improved breathing.” During interdisciplinary review, which
revision makes this outcome measurable and appropriate for
the plan of care?
A. “Client will feel better within 2 days.”
B. “Client will report less shortness of breath.”
C. “Client will maintain SpO₂ ≥ 94% on room air within 4 hours.”
D. “Client will have fewer respiratory symptoms as tolerated.”
Correct answer: C
Rationales
Correct (C): This outcome is specific, measurable, time-bound,
and directly related to respiratory status (SpO₂), meeting
SMART criteria and allowing evaluation.
Incorrect (A): “Feel better” is subjective and vague; timeframe
alone does not make it measurable.
Incorrect (B): Reporting is subjective and lacks measurable
criteria (e.g., rating scale, SpO₂).
Incorrect (D): “As tolerated” and “fewer” are vague and not
measurable.
, Teaching point: Write outcomes that are specific, measurable,
achievable, relevant, and time-bound.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (16th
ed.). Nurse’s Pocket Guide. Nursing process section.
3
Reference: Initial vs Ongoing Planning (Chapter 1)
Stem: A newly admitted post-op client is stable but has poorly
controlled pain according to the numeric pain scale 8/10. Which
planning action is an initial nursing plan responsibility?
A. Evaluate effectiveness of analgesia at 60 minutes and revise
plan.
B. Document baseline pain level, notify
surgeon/anesthesiologist, and implement prescribed PRN
analgesic.
C. Teach the client about opioid side effects and long-term pain
management.
D. Arrange referrals for chronic pain clinic follow-up.
Correct answer: B
Rationales
Correct (B): Initial planning includes immediate assessment
documentation and initiating prescribed interventions to relieve
acute pain—actions necessary at admission.
Incorrect (A): Evaluation is part of ongoing care that follows the
initial intervention.
