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 Collection
& Clustering (Chapter 1: The Nursing Process and Planning
Client Care)
Stem: A 68-year-old postoperative patient reports
shortness of breath and is observed leaning forward,
speaking in short sentences, and having an SpO₂ of 88% on
room air. The nurse’s focused respiratory assessment
reveals bilateral wheezes and accessory muscle use. Which
, nursing action best reflects appropriate assessment
clustering and next step in the nursing process?
A. Document the SpO₂ and airway sounds and continue
routine postoperative checks.
B. Administer PRN opioid for pain to reduce breathing
effort.
C. Immediately initiate oxygen therapy and notify the
provider while preparing for further respiratory
interventions.
D. Encourage deep-breathing and ambulation to mobilize
secretions.
Correct Answer: C
Rationales:
• Correct (C): Per the nursing process, clustered data
(dyspnea, low SpO₂, accessory muscle use, wheezes)
indicate impaired oxygenation requiring immediate
intervention. Initiating oxygen and notifying the provider
are priority actions to prevent deterioration. The Nurse’s
Pocket Guide emphasizes prioritizing interventions that
address ABCs.
• Incorrect (A): Passive documentation without action
ignores hypoxemia; unsafe given SpO₂ 88%.
• Incorrect (B): Opioids depress respiration and are
contraindicated as an immediate response to hypoxia.
, • Incorrect (D): Ambulation/deep-breathing may be
appropriate for mild atelectasis prevention but is unsafe as
first action in acute hypoxemia.
Teaching Point: Cluster assessment cues to identify ABC threats
and act immediately.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2024). Nurse’s Pocket Guide (16th ed.). Chapter 1: The Nursing
Process and Planning Client Care.
2. Reference: Nursing Diagnosis Formation — Distinguishing
Problem & Etiology (Chapter 1)
Stem: A 45-year-old with uncontrolled diabetes reports
numbness and burning in both feet. Blood glucose at 360
mg/dL and decreased peripheral sensation are
documented. Which nursing statement best formats a
NANDA-style nursing diagnosis from these data?
A. Diabetic neuropathy related to elevated blood glucose.
B. Risk for injury related to decreased peripheral sensation.
C. Impaired physical mobility related to burning feet.
D. Peripheral neuropathy due to diabetes mellitus.
Correct Answer: B
Rationales:
• Correct (B): The nursing process identifies a risk diagnosis
when hazard exists without current injury. "Risk for injury
, related to decreased peripheral sensation" follows the
problem–etiology format recommended in planning care.
• Incorrect (A): States a medical label (diabetic neuropathy)
rather than a nursing diagnosis focused on patient
response.
• Incorrect (C): Impaired mobility is not clearly supported;
data show sensation loss and pain but not mobility
limitation.
• Incorrect (D): Uses a medical diagnosis and causal phrasing
rather than a nursing diagnostic statement focused on
risk/response.
Teaching Point: Nursing diagnoses state patient responses or
risks, not medical labels.
Citation: Doenges et al., (2024). Chapter 1.
3. Reference: Outcomes/Goals — Writing Measurable,
Patient-Centered Outcomes (Chapter 1)
Stem: A patient with impaired skin integrity has a 4-cm
surgical wound. The nurse writes the goal: “Wound will
heal.” Which revision best makes the expected outcome
measurable and time-limited?
A. “Wound will improve.”
B. “Wound will decrease in size within 2 weeks.”
C. “Patient’s wound will heal completely.”
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 Collection
& Clustering (Chapter 1: The Nursing Process and Planning
Client Care)
Stem: A 68-year-old postoperative patient reports
shortness of breath and is observed leaning forward,
speaking in short sentences, and having an SpO₂ of 88% on
room air. The nurse’s focused respiratory assessment
reveals bilateral wheezes and accessory muscle use. Which
, nursing action best reflects appropriate assessment
clustering and next step in the nursing process?
A. Document the SpO₂ and airway sounds and continue
routine postoperative checks.
B. Administer PRN opioid for pain to reduce breathing
effort.
C. Immediately initiate oxygen therapy and notify the
provider while preparing for further respiratory
interventions.
D. Encourage deep-breathing and ambulation to mobilize
secretions.
Correct Answer: C
Rationales:
• Correct (C): Per the nursing process, clustered data
(dyspnea, low SpO₂, accessory muscle use, wheezes)
indicate impaired oxygenation requiring immediate
intervention. Initiating oxygen and notifying the provider
are priority actions to prevent deterioration. The Nurse’s
Pocket Guide emphasizes prioritizing interventions that
address ABCs.
• Incorrect (A): Passive documentation without action
ignores hypoxemia; unsafe given SpO₂ 88%.
• Incorrect (B): Opioids depress respiration and are
contraindicated as an immediate response to hypoxia.
, • Incorrect (D): Ambulation/deep-breathing may be
appropriate for mild atelectasis prevention but is unsafe as
first action in acute hypoxemia.
Teaching Point: Cluster assessment cues to identify ABC threats
and act immediately.
Citation: Doenges, M. E., Moorhouse, M. F., & Murr, A. C.
(2024). Nurse’s Pocket Guide (16th ed.). Chapter 1: The Nursing
Process and Planning Client Care.
2. Reference: Nursing Diagnosis Formation — Distinguishing
Problem & Etiology (Chapter 1)
Stem: A 45-year-old with uncontrolled diabetes reports
numbness and burning in both feet. Blood glucose at 360
mg/dL and decreased peripheral sensation are
documented. Which nursing statement best formats a
NANDA-style nursing diagnosis from these data?
A. Diabetic neuropathy related to elevated blood glucose.
B. Risk for injury related to decreased peripheral sensation.
C. Impaired physical mobility related to burning feet.
D. Peripheral neuropathy due to diabetes mellitus.
Correct Answer: B
Rationales:
• Correct (B): The nursing process identifies a risk diagnosis
when hazard exists without current injury. "Risk for injury
, related to decreased peripheral sensation" follows the
problem–etiology format recommended in planning care.
• Incorrect (A): States a medical label (diabetic neuropathy)
rather than a nursing diagnosis focused on patient
response.
• Incorrect (C): Impaired mobility is not clearly supported;
data show sensation loss and pain but not mobility
limitation.
• Incorrect (D): Uses a medical diagnosis and causal phrasing
rather than a nursing diagnostic statement focused on
risk/response.
Teaching Point: Nursing diagnoses state patient responses or
risks, not medical labels.
Citation: Doenges et al., (2024). Chapter 1.
3. Reference: Outcomes/Goals — Writing Measurable,
Patient-Centered Outcomes (Chapter 1)
Stem: A patient with impaired skin integrity has a 4-cm
surgical wound. The nurse writes the goal: “Wound will
heal.” Which revision best makes the expected outcome
measurable and time-limited?
A. “Wound will improve.”
B. “Wound will decrease in size within 2 weeks.”
C. “Patient’s wound will heal completely.”
