SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Introduction: Role & Scope of the Critical Care Nurse
Stem
A 58-year-old post-op abdominal surgery patient is transferred
to the step-down unit. The nurse notes persistent tachycardia
112 bpm, BP 98/56 mmHg, urine output 15 mL/hr over the last
2 hours, and mucous membranes slightly dry. The surgeon asks
the nurse to ambulate the patient now. What is the nurse’s best
next action?
,Options
A. Ambulate the patient as requested to reduce atelectasis risk.
B. Request a bolus of IV fluid and reassess urine output and
vitals.
C. Document current status and follow the surgeon’s
ambulation order.
D. Call the surgeon to ask about changing the plan to continued
bedrest.
Correct Answer
B
Rationales
Correct (B): The combination of tachycardia, low-normal BP,
and oliguria suggests relative hypovolemia or early
postoperative hypoperfusion. Administering a fluid bolus (per
protocol) and reassessing perfusion and urine output treats the
likely reversible cause and is a priority before ambulation. This
aligns with critical-care principles of treating physiologic
instability prior to activity.
A: Ambulation risks worsening hypoperfusion and syncope
without first optimizing intravascular volume—premature.
C: Simply documenting ignores the immediate physiologic
instability and fails to prioritize patient safety.
D: Calling the surgeon creates delay; the nurse can initiate
standing fluid protocols and then notify the surgeon if patient
fails to respond.
,Teaching Point
Stabilize perfusion before activity; oliguria + tachycardia often
signals inadequate intravascular volume.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1 — Role & Scope of the Critical Care
Nurse.
2
Reference
Ch. 1 — Clinical Judgment Measurement Model
Stem
During simulation, a senior student must decide whether to
escalate care for a patient with sudden mental status change.
The student hesitates, citing uncertainty about when to call for
rapid response. Which behavior best demonstrates clinical
judgment consistent with the Clinical Judgment Measurement
Model?
Options
A. Wait 10 minutes while repeating neuro checks to gather
more data.
B. Call the rapid response team immediately and provide
focused SBAR.
C. Document the change and inform the primary nurse at the
end of the shift.
, D. Ask a peer to watch the patient while the student finishes
other tasks.
Correct Answer
B
Rationales
Correct (B): Immediate escalation with a concise SBAR reflects
recognizing a concerning cue (acute neuro change),
prioritization, and taking decisive action—core components of
the Clinical Judgment Measurement Model. Timely escalation
prevents deterioration.
A: Repeating assessments without escalation delays care for a
potentially unstable patient.
C: Deferring communication until shift end is unsafe and
violates escalation standards.
D: Delegating observation to a peer without escalation in
presence of acute decline is unsafe.
Teaching Point
Recognize critical cues and escalate immediately using concise
SBAR communication.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1 — Clinical Judgment Measurement
Model.
3
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Introduction: Role & Scope of the Critical Care Nurse
Stem
A 58-year-old post-op abdominal surgery patient is transferred
to the step-down unit. The nurse notes persistent tachycardia
112 bpm, BP 98/56 mmHg, urine output 15 mL/hr over the last
2 hours, and mucous membranes slightly dry. The surgeon asks
the nurse to ambulate the patient now. What is the nurse’s best
next action?
,Options
A. Ambulate the patient as requested to reduce atelectasis risk.
B. Request a bolus of IV fluid and reassess urine output and
vitals.
C. Document current status and follow the surgeon’s
ambulation order.
D. Call the surgeon to ask about changing the plan to continued
bedrest.
Correct Answer
B
Rationales
Correct (B): The combination of tachycardia, low-normal BP,
and oliguria suggests relative hypovolemia or early
postoperative hypoperfusion. Administering a fluid bolus (per
protocol) and reassessing perfusion and urine output treats the
likely reversible cause and is a priority before ambulation. This
aligns with critical-care principles of treating physiologic
instability prior to activity.
A: Ambulation risks worsening hypoperfusion and syncope
without first optimizing intravascular volume—premature.
C: Simply documenting ignores the immediate physiologic
instability and fails to prioritize patient safety.
D: Calling the surgeon creates delay; the nurse can initiate
standing fluid protocols and then notify the surgeon if patient
fails to respond.
,Teaching Point
Stabilize perfusion before activity; oliguria + tachycardia often
signals inadequate intravascular volume.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1 — Role & Scope of the Critical Care
Nurse.
2
Reference
Ch. 1 — Clinical Judgment Measurement Model
Stem
During simulation, a senior student must decide whether to
escalate care for a patient with sudden mental status change.
The student hesitates, citing uncertainty about when to call for
rapid response. Which behavior best demonstrates clinical
judgment consistent with the Clinical Judgment Measurement
Model?
Options
A. Wait 10 minutes while repeating neuro checks to gather
more data.
B. Call the rapid response team immediately and provide
focused SBAR.
C. Document the change and inform the primary nurse at the
end of the shift.
, D. Ask a peer to watch the patient while the student finishes
other tasks.
Correct Answer
B
Rationales
Correct (B): Immediate escalation with a concise SBAR reflects
recognizing a concerning cue (acute neuro change),
prioritization, and taking decisive action—core components of
the Clinical Judgment Measurement Model. Timely escalation
prevents deterioration.
A: Repeating assessments without escalation delays care for a
potentially unstable patient.
C: Deferring communication until shift end is unsafe and
violates escalation standards.
D: Delegating observation to a peer without escalation in
presence of acute decline is unsafe.
Teaching Point
Recognize critical cues and escalate immediately using concise
SBAR communication.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1 — Clinical Judgment Measurement
Model.
3
