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 →
Implementation → Evaluation
Stem
A 68-year-old post-op patient is 8 hours after abdominal
surgery. Vital signs: T 37.8°C, HR 102 bpm, RR 22, BP 130/78
mmHg. The patient reports incisional pain 7/10 with shallow
,respirations and tells you, “I’m worried about coughing because
it hurts.” Which nursing action reflects the first step of the
nursing process for this patient?
A. Administer PRN opioid for pain per protocol.
B. Ask about pain characteristics and inspect the surgical
incision.
C. Document that the patient is “in pain” and continue routine
checks.
D. Teach the patient incentive spirometry and deep-breathing
exercises.
Correct answer: B
Rationales
Correct (B): Assessment is the first step; asking focused
questions about pain (onset, quality, intensity) and inspecting
the incision are essential subjective and objective data
collection needed before diagnosis and planning. This aligns
with Chapter 1 emphasis on systematic data gathering.
A (incorrect): Administering medication is an implementation
action that requires prior assessment and a decision about
appropriateness. Doing so before adequate assessment risks
missing contraindications.
C (incorrect): Vague documentation without detailed
assessment is inadequate; Chapter 1 stresses organized,
accurate data recording.
D (incorrect): Teaching is a planning/implementation activity
,appropriate after assessment and establishing readiness; it is
not the first step.
Teaching point: Always assess (subjective + objective) before
diagnosing or implementing care.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
chapter.
2
Reference
Priority Setting — ABCs and safety (Maslow and acute vs.
chronic)
Stem
A nurse receives report on four clients. Which client should be
seen first based on priority-setting frameworks described in
Chapter 1?
A. A postoperative patient 24 hours after surgery who requests
repositioning for comfort.
B. A client with oxygen saturation 88% on room air and
dyspnea.
C. A client scheduled for discharge who needs teaching on
wound care.
D. A stable chronic COPD patient requesting a routine
medication.
Correct answer: B
, Rationales
Correct (B): Airway/breathing problems are highest priority
(ABCs). An SpO₂ of 88% with dyspnea indicates impaired
oxygenation requiring immediate assessment and intervention
per Chapter 1 prioritization logic.
A (incorrect): Comfort needs are important but lower than
threats to airway/breathing.
C (incorrect): Discharge teaching is important but not emergent
if the patient is otherwise stable.
D (incorrect): Routine medication for a stable chronic patient is
lower priority than acute hypoxemia.
Teaching point: Acute threats to airway/breathing outrank
comfort and discharge tasks.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
chapter.
3
Reference
Writing Outcomes — Measurable, time-bound, client-centered
(SMART)
Stem
An older adult with limited mobility is at risk for impaired skin
integrity. Which of the following is the best measurable short-
term outcome for the plan of care?
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 →
Implementation → Evaluation
Stem
A 68-year-old post-op patient is 8 hours after abdominal
surgery. Vital signs: T 37.8°C, HR 102 bpm, RR 22, BP 130/78
mmHg. The patient reports incisional pain 7/10 with shallow
,respirations and tells you, “I’m worried about coughing because
it hurts.” Which nursing action reflects the first step of the
nursing process for this patient?
A. Administer PRN opioid for pain per protocol.
B. Ask about pain characteristics and inspect the surgical
incision.
C. Document that the patient is “in pain” and continue routine
checks.
D. Teach the patient incentive spirometry and deep-breathing
exercises.
Correct answer: B
Rationales
Correct (B): Assessment is the first step; asking focused
questions about pain (onset, quality, intensity) and inspecting
the incision are essential subjective and objective data
collection needed before diagnosis and planning. This aligns
with Chapter 1 emphasis on systematic data gathering.
A (incorrect): Administering medication is an implementation
action that requires prior assessment and a decision about
appropriateness. Doing so before adequate assessment risks
missing contraindications.
C (incorrect): Vague documentation without detailed
assessment is inadequate; Chapter 1 stresses organized,
accurate data recording.
D (incorrect): Teaching is a planning/implementation activity
,appropriate after assessment and establishing readiness; it is
not the first step.
Teaching point: Always assess (subjective + objective) before
diagnosing or implementing care.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
chapter.
2
Reference
Priority Setting — ABCs and safety (Maslow and acute vs.
chronic)
Stem
A nurse receives report on four clients. Which client should be
seen first based on priority-setting frameworks described in
Chapter 1?
A. A postoperative patient 24 hours after surgery who requests
repositioning for comfort.
B. A client with oxygen saturation 88% on room air and
dyspnea.
C. A client scheduled for discharge who needs teaching on
wound care.
D. A stable chronic COPD patient requesting a routine
medication.
Correct answer: B
, Rationales
Correct (B): Airway/breathing problems are highest priority
(ABCs). An SpO₂ of 88% with dyspnea indicates impaired
oxygenation requiring immediate assessment and intervention
per Chapter 1 prioritization logic.
A (incorrect): Comfort needs are important but lower than
threats to airway/breathing.
C (incorrect): Discharge teaching is important but not emergent
if the patient is otherwise stable.
D (incorrect): Routine medication for a stable chronic patient is
lower priority than acute hypoxemia.
Teaching point: Acute threats to airway/breathing outrank
comfort and discharge tasks.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2022). Nurse’s Pocket Guide (16th ed.). Nursing process
chapter.
3
Reference
Writing Outcomes — Measurable, time-bound, client-centered
(SMART)
Stem
An older adult with limited mobility is at risk for impaired skin
integrity. Which of the following is the best measurable short-
term outcome for the plan of care?
