SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Introduction / Evolution of Critical Care Nursing
Stem
A nurse on a mixed-medical ICU notes that a post-op CABG
patient’s MAP fell from 82 to 60 mm Hg over 15 minutes; HR
115 bpm, UO decreased to 10 mL/hr in past hour, and the
patient is diaphoretic. The nurse’s unit is short-staffed and a
novice nurse asks what to do first.
A. Delegate insertion of a Foley catheter to the novice nurse
while you prepare vasopressor infusion.
,B. Immediately assess the patient at the bedside and notify the
physician of hemodynamic deterioration.
C. Complete medication reconciliation and chart the change in
urine output for the shift report.
D. Call rapid response team (RRT) and step away to start
paperwork.
Correct answer
B
Rationale — Correct (B)
The nurse must first perform a focused bedside assessment to
identify reversible causes of hypotension (bleeding,
hypovolemia, arrhythmia). Immediate assessment guides timely
interventions (fluid bolus vs. vasopressor) and informs
physician/RRT notification. Prioritization of direct assessment
aligns with critical-care standards for early detection of
deterioration.
Rationale — Incorrect
A: Premature—Foley insertion is not the priority before
assessing cause of hypotension and stabilizing the patient.
C: Inappropriate timing—charting is secondary to immediate
bedside action.
D: Calling RRT may be appropriate, but the nurse should first
perform an immediate assessment and then activate RRT if
needed; stepping away is unsafe.
,Teaching Point
Immediate bedside assessment is the first action for acute
hemodynamic decline.
Citation (Simplified APA)
Makic, M. B. F. (2024). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Critical Care Nurse Characteristics / Scope of Practice
Stem
During orientation, a new graduate is assigned to an ICU patient
receiving multiple vasoactive infusions. The charge nurse
expects the graduate to titrate vasoactive meds per protocol.
The graduate states they have never titrated pressors
independently.
A. Allow the graduate to titrate the pressor immediately to
promote autonomy.
B. Assign the graduate to monitor and document while an
experienced nurse performs titration.
C. Remove the patient from the graduate’s assignment and have
them observe from the hall.
D. Tell the graduate to call the provider every time the infusion
needs adjustment.
, Correct answer
B
Rationale — Correct (B)
Safe delegation and competency-based assignment require
matching nurse competency to patient complexity. Having the
graduate monitor and document while an experienced nurse
performs titration provides supervised exposure and maintains
patient safety. This aligns with critical-care competence
expectations.
Rationale — Incorrect
A: Unsafe—independent titration requires demonstrated
competency.
C: Overprotection—complete removal denies learning
opportunities; supervised participation is preferable.
D: Inefficient—nurse-driven protocols exist to allow timely
bedside adjustments by competent staff; calling provider for
every change can delay care.
Teaching Point
Match patient complexity with nurse competency; supervise
until competency is demonstrated.
Citation (Simplified APA)
Makic, M. B. F. (2024). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Introduction / Evolution of Critical Care Nursing
Stem
A nurse on a mixed-medical ICU notes that a post-op CABG
patient’s MAP fell from 82 to 60 mm Hg over 15 minutes; HR
115 bpm, UO decreased to 10 mL/hr in past hour, and the
patient is diaphoretic. The nurse’s unit is short-staffed and a
novice nurse asks what to do first.
A. Delegate insertion of a Foley catheter to the novice nurse
while you prepare vasopressor infusion.
,B. Immediately assess the patient at the bedside and notify the
physician of hemodynamic deterioration.
C. Complete medication reconciliation and chart the change in
urine output for the shift report.
D. Call rapid response team (RRT) and step away to start
paperwork.
Correct answer
B
Rationale — Correct (B)
The nurse must first perform a focused bedside assessment to
identify reversible causes of hypotension (bleeding,
hypovolemia, arrhythmia). Immediate assessment guides timely
interventions (fluid bolus vs. vasopressor) and informs
physician/RRT notification. Prioritization of direct assessment
aligns with critical-care standards for early detection of
deterioration.
Rationale — Incorrect
A: Premature—Foley insertion is not the priority before
assessing cause of hypotension and stabilizing the patient.
C: Inappropriate timing—charting is secondary to immediate
bedside action.
D: Calling RRT may be appropriate, but the nurse should first
perform an immediate assessment and then activate RRT if
needed; stepping away is unsafe.
,Teaching Point
Immediate bedside assessment is the first action for acute
hemodynamic decline.
Citation (Simplified APA)
Makic, M. B. F. (2024). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Critical Care Nurse Characteristics / Scope of Practice
Stem
During orientation, a new graduate is assigned to an ICU patient
receiving multiple vasoactive infusions. The charge nurse
expects the graduate to titrate vasoactive meds per protocol.
The graduate states they have never titrated pressors
independently.
A. Allow the graduate to titrate the pressor immediately to
promote autonomy.
B. Assign the graduate to monitor and document while an
experienced nurse performs titration.
C. Remove the patient from the graduate’s assignment and have
them observe from the hall.
D. Tell the graduate to call the provider every time the infusion
needs adjustment.
, Correct answer
B
Rationale — Correct (B)
Safe delegation and competency-based assignment require
matching nurse competency to patient complexity. Having the
graduate monitor and document while an experienced nurse
performs titration provides supervised exposure and maintains
patient safety. This aligns with critical-care competence
expectations.
Rationale — Incorrect
A: Unsafe—independent titration requires demonstrated
competency.
C: Overprotection—complete removal denies learning
opportunities; supervised participation is preferable.
D: Inefficient—nurse-driven protocols exist to allow timely
bedside adjustments by competent staff; calling provider for
every change can delay care.
Teaching Point
Match patient complexity with nurse competency; supervise
until competency is demonstrated.
Citation (Simplified APA)
Makic, M. B. F. (2024). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
