SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference: Ch. 1 — Overview of Critical Care Nursing — Clinical
Judgment Measurement Model
Stem: A newly hired ICU nurse observes that a veteran nurse
skips a bedside shift report and documents vital signs from
memory instead. The unit has a validated clinical judgment
measurement tool. The new nurse is unsure whether to
escalate. Which action should the new nurse take first?
A. Notify the unit manager immediately to report unsafe
practice.
B. Ask the veteran nurse at bedside for a brief bedside report
,and offer to help gather missing data.
C. File an anonymous incident report through the hospital
safety portal.
D. Wait until the end of shift to speak with the veteran peer
privately.
Correct Answer: B
Rationale — Correct: Asking for a bedside report and offering
help immediately addresses patient safety (real-time
correction), models collaborative practice, and uses the clinical
judgment measurement model’s focus on situational awareness
and immediate remediation. This action prioritizes patient data
accuracy and uses a low-confrontational, evidence-based
approach.
Rationale — Incorrect:
A. Escalation to manager is appropriate for persistent unsafe
behavior but first-line should be immediate correction to
protect the patient.
C. Anonymous reporting delays immediate correction; it does
not retrieve accurate, current patient data.
D. Waiting risks continued misinformation and potential harm;
immediate correction is higher priority.
Teaching point: Prioritize immediate bedside correction to
secure patient safety before formal reporting.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
,2
Reference: Ch. 1 — Overview — Standards & Quality/Safety
Emphasis
Stem: During a multidisciplinary rounding, a patient’s
postoperative oxygen saturation dropped to 88% but the
circulating nurse documented SpO₂ as 95% without mention.
You are the bedside RN. What is the best immediate nursing
action?
A. Document your own SpO₂ reading and continue routine care.
B. Ask the circulating nurse to correct the chart later to avoid
conflict.
C. Verbally raise the discrepant assessment at the rounding
table and initiate an immediate bedside reassessment.
D. Wait 30 minutes to see whether SpO₂ improves before
escalating.
Correct Answer: C
Rationale — Correct: Voicing the discrepancy promptly
maintains accuracy, supports a culture of safety, and triggers
immediate reassessment and interventions for hypoxemia. This
aligns with quality/safety standards requiring timely
communication of abnormal findings in multidisciplinary
settings.
Rationale — Incorrect:
A. Sole documentation without team communication fails to
correct the record and delays interventions.
B. Asking for correction later delays needed immediate action.
, D. Waiting risks patient deterioration and violates rapid
recognition principles.
Teaching point: Immediately communicate assessment
discrepancies during rounds to protect the patient.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
3
Reference: Ch. 1 — Overview — Evidence-Based Practice
Stem: The ICU is considering a new evidence-based sepsis
bundle proven to reduce mortality but requires hourly lactate
draws and strict nurse-driven protocols. Staff express concerns
about workload and feasibility. As charge nurse, what is the
best first step?
A. Implement the bundle immediately because evidence
supports it.
B. Convene a rapid pilot with a representative nurse team to
test feasibility and workflows.
C. Decline implementation until staffing improves.
D. Ask physicians to order the bundle selectively for high-risk
patients only.
Correct Answer: B
Rationale — Correct: Piloting translates evidence into practice
while evaluating workflow, staffing impact, and barriers—
consistent with EBP implementation strategies and quality
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference: Ch. 1 — Overview of Critical Care Nursing — Clinical
Judgment Measurement Model
Stem: A newly hired ICU nurse observes that a veteran nurse
skips a bedside shift report and documents vital signs from
memory instead. The unit has a validated clinical judgment
measurement tool. The new nurse is unsure whether to
escalate. Which action should the new nurse take first?
A. Notify the unit manager immediately to report unsafe
practice.
B. Ask the veteran nurse at bedside for a brief bedside report
,and offer to help gather missing data.
C. File an anonymous incident report through the hospital
safety portal.
D. Wait until the end of shift to speak with the veteran peer
privately.
Correct Answer: B
Rationale — Correct: Asking for a bedside report and offering
help immediately addresses patient safety (real-time
correction), models collaborative practice, and uses the clinical
judgment measurement model’s focus on situational awareness
and immediate remediation. This action prioritizes patient data
accuracy and uses a low-confrontational, evidence-based
approach.
Rationale — Incorrect:
A. Escalation to manager is appropriate for persistent unsafe
behavior but first-line should be immediate correction to
protect the patient.
C. Anonymous reporting delays immediate correction; it does
not retrieve accurate, current patient data.
D. Waiting risks continued misinformation and potential harm;
immediate correction is higher priority.
Teaching point: Prioritize immediate bedside correction to
secure patient safety before formal reporting.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
,2
Reference: Ch. 1 — Overview — Standards & Quality/Safety
Emphasis
Stem: During a multidisciplinary rounding, a patient’s
postoperative oxygen saturation dropped to 88% but the
circulating nurse documented SpO₂ as 95% without mention.
You are the bedside RN. What is the best immediate nursing
action?
A. Document your own SpO₂ reading and continue routine care.
B. Ask the circulating nurse to correct the chart later to avoid
conflict.
C. Verbally raise the discrepant assessment at the rounding
table and initiate an immediate bedside reassessment.
D. Wait 30 minutes to see whether SpO₂ improves before
escalating.
Correct Answer: C
Rationale — Correct: Voicing the discrepancy promptly
maintains accuracy, supports a culture of safety, and triggers
immediate reassessment and interventions for hypoxemia. This
aligns with quality/safety standards requiring timely
communication of abnormal findings in multidisciplinary
settings.
Rationale — Incorrect:
A. Sole documentation without team communication fails to
correct the record and delays interventions.
B. Asking for correction later delays needed immediate action.
, D. Waiting risks patient deterioration and violates rapid
recognition principles.
Teaching point: Immediately communicate assessment
discrepancies during rounds to protect the patient.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
3
Reference: Ch. 1 — Overview — Evidence-Based Practice
Stem: The ICU is considering a new evidence-based sepsis
bundle proven to reduce mortality but requires hourly lactate
draws and strict nurse-driven protocols. Staff express concerns
about workload and feasibility. As charge nurse, what is the
best first step?
A. Implement the bundle immediately because evidence
supports it.
B. Convene a rapid pilot with a representative nurse team to
test feasibility and workflows.
C. Decline implementation until staffing improves.
D. Ask physicians to order the bundle selectively for high-risk
patients only.
Correct Answer: B
Rationale — Correct: Piloting translates evidence into practice
while evaluating workflow, staffing impact, and barriers—
consistent with EBP implementation strategies and quality
