SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference: Ch. 1 — Overview of Critical Care Nursing — Rapid
Response & Early Recognition
Stem: A 66-year-old postop CABG patient in the step-down unit
becomes tachycardic (HR 122), hypotensive (BP 88/52), with
new confusion and urine output 10 mL/hr for the past hour. The
nurse notes a temperature of 38.4°C and WBC trending up.
Which action is the nurse’s priority?
A. Increase IV crystalloid bolus and recheck BP in 10 minutes.
B. Call the rapid response team for immediate bedside
assessment.
C. Administer PRN antipyretic and continue close monitoring.
,D. Obtain blood cultures and start broad-spectrum antibiotics
per protocol.
Correct Answer: B
Rationale — Correct: Calling the rapid response team (RRT) is
priority because the patient demonstrates acute deterioration
(hemodynamic instability, oliguria, altered mental status) that
requires immediate bedside assessment and coordinated
intervention. RRT mobilizes skilled personnel to rapidly evaluate
for causes (e.g., sepsis, bleeding, cardiogenic shock) and initiate
stabilization. This aligns with early recognition and team-based
response principles in critical care.
Rationale — Incorrect:
A. A fluid bolus may be needed but initiating one before rapid
assessment risks delay if other causes (bleeding, tamponade)
require different actions.
C. Antipyretic alone is insufficient for hypotension, tachycardia,
and mental status change—this is not just fever management.
D. Obtaining cultures and antibiotics is important for suspected
sepsis, but immediate bedside stabilization via RRT is higher
priority.
Teaching Point: Acute hemodynamic deterioration requires
immediate team mobilization (RRT) before protocolized tasks.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
2
,Reference: Ch. 1 — Overview — Evidence-Based Practice &
Protocol Use
Stem: A unit recently implemented an evidence-based sepsis
bundle. A nurse notices a septic patient with lactate 3.6
mmol/L; SBP 92 after 500 mL crystalloid; central line
unavailable. The provider orders vasopressors but
documentation is delayed. What should the nurse do first?
A. Start peripheral norepinephrine via large-bore IV with pump
while obtaining central access per policy.
B. Wait for provider signature before starting vasopressor.
C. Repeat a lactate in 2 hours and reassess need for
vasopressors.
D. Administer another 500 mL crystalloid and reassess BP.
Correct Answer: A
Rationale — Correct: Evidence-based sepsis protocols support
early vasopressor initiation when hypotension persists despite
fluid resuscitation. Many ICU policies permit starting
norepinephrine peripherally through a large-bore IV with an
infusion pump while arranging central access, to avoid delays
that worsen tissue hypoperfusion. The nurse should follow
institutional standing orders and safety measures when
initiating.
Rationale — Incorrect:
B. Waiting for signature delays a time-sensitive intervention and
conflicts with sepsis bundle goals.
C. Delaying allows ongoing hypoperfusion; lactate trend is
useful but not before treating persistent hypotension.
, D. Additional fluids may be reasonable but vasopressors are
indicated after initial resuscitation when hypotension persists.
Teaching Point: Start time-sensitive sepsis interventions per
protocol—don’t delay vasopressors when indicated.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
3
Reference: Ch. 1 — Overview — Standards & Scope of Practice
Stem: On orientation, a new critical care nurse is asked to
perform insertion of an arterial line, which is not in the unit’s
RN competency list. The charge RN instructs them to proceed
because an emergent ABG is needed and no experienced RN is
available. What is the nurse’s best action?
A. Proceed with the arterial line insertion since the patient
needs urgent ABG.
B. Refuse and call the nurse manager to report the charge RN.
C. Explain lack of competency and request an experienced
clinician or physician perform the procedure.
D. Attempt an ABG via peripheral arterial puncture instead
without supervision.
Correct Answer: C
Rationale — Correct: The nurse must practice within their
documented scope and competencies. Explaining inability to
perform the procedure and requesting a competent clinician
respects standards of practice and patient safety. The nurse
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference: Ch. 1 — Overview of Critical Care Nursing — Rapid
Response & Early Recognition
Stem: A 66-year-old postop CABG patient in the step-down unit
becomes tachycardic (HR 122), hypotensive (BP 88/52), with
new confusion and urine output 10 mL/hr for the past hour. The
nurse notes a temperature of 38.4°C and WBC trending up.
Which action is the nurse’s priority?
A. Increase IV crystalloid bolus and recheck BP in 10 minutes.
B. Call the rapid response team for immediate bedside
assessment.
C. Administer PRN antipyretic and continue close monitoring.
,D. Obtain blood cultures and start broad-spectrum antibiotics
per protocol.
Correct Answer: B
Rationale — Correct: Calling the rapid response team (RRT) is
priority because the patient demonstrates acute deterioration
(hemodynamic instability, oliguria, altered mental status) that
requires immediate bedside assessment and coordinated
intervention. RRT mobilizes skilled personnel to rapidly evaluate
for causes (e.g., sepsis, bleeding, cardiogenic shock) and initiate
stabilization. This aligns with early recognition and team-based
response principles in critical care.
Rationale — Incorrect:
A. A fluid bolus may be needed but initiating one before rapid
assessment risks delay if other causes (bleeding, tamponade)
require different actions.
C. Antipyretic alone is insufficient for hypotension, tachycardia,
and mental status change—this is not just fever management.
D. Obtaining cultures and antibiotics is important for suspected
sepsis, but immediate bedside stabilization via RRT is higher
priority.
Teaching Point: Acute hemodynamic deterioration requires
immediate team mobilization (RRT) before protocolized tasks.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
2
,Reference: Ch. 1 — Overview — Evidence-Based Practice &
Protocol Use
Stem: A unit recently implemented an evidence-based sepsis
bundle. A nurse notices a septic patient with lactate 3.6
mmol/L; SBP 92 after 500 mL crystalloid; central line
unavailable. The provider orders vasopressors but
documentation is delayed. What should the nurse do first?
A. Start peripheral norepinephrine via large-bore IV with pump
while obtaining central access per policy.
B. Wait for provider signature before starting vasopressor.
C. Repeat a lactate in 2 hours and reassess need for
vasopressors.
D. Administer another 500 mL crystalloid and reassess BP.
Correct Answer: A
Rationale — Correct: Evidence-based sepsis protocols support
early vasopressor initiation when hypotension persists despite
fluid resuscitation. Many ICU policies permit starting
norepinephrine peripherally through a large-bore IV with an
infusion pump while arranging central access, to avoid delays
that worsen tissue hypoperfusion. The nurse should follow
institutional standing orders and safety measures when
initiating.
Rationale — Incorrect:
B. Waiting for signature delays a time-sensitive intervention and
conflicts with sepsis bundle goals.
C. Delaying allows ongoing hypoperfusion; lactate trend is
useful but not before treating persistent hypotension.
, D. Additional fluids may be reasonable but vasopressors are
indicated after initial resuscitation when hypotension persists.
Teaching Point: Start time-sensitive sepsis interventions per
protocol—don’t delay vasopressors when indicated.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
3
Reference: Ch. 1 — Overview — Standards & Scope of Practice
Stem: On orientation, a new critical care nurse is asked to
perform insertion of an arterial line, which is not in the unit’s
RN competency list. The charge RN instructs them to proceed
because an emergent ABG is needed and no experienced RN is
available. What is the nurse’s best action?
A. Proceed with the arterial line insertion since the patient
needs urgent ABG.
B. Refuse and call the nurse manager to report the charge RN.
C. Explain lack of competency and request an experienced
clinician or physician perform the procedure.
D. Attempt an ABG via peripheral arterial puncture instead
without supervision.
Correct Answer: C
Rationale — Correct: The nurse must practice within their
documented scope and competencies. Explaining inability to
perform the procedure and requesting a competent clinician
respects standards of practice and patient safety. The nurse
