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 67-year-old post-op abdominal surgery patient in the ICU has
an increasing respiratory rate from 18 to 28/min over 30
minutes, SpO₂ falling from 96% to 90% on 2 L NC, and new
confusion. The charge nurse asks you to prioritize the next
nursing action. Which is best?
,A. Increase the oxygen flow to 4 L/min via nasal cannula.
B. Perform a focused respiratory assessment and call the rapid
response team if findings confirm deterioration.
C. Administer PRN opioid for presumed pain causing shallow
breathing.
D. Obtain an arterial blood gas (ABG) immediately.
Correct Answer
B
Rationale — Correct
A focused respiratory assessment integrates cues (RR up, SpO₂
down, confusion), applies clinical judgment, and determines
immediate interventions or escalation. It’s the priority to
confirm deterioration and triggers rapid response appropriately
per the measurement model. This action balances assessment,
interpretation, and timely escalation.
Rationale — Incorrect
A: Increasing oxygen without assessment may mask cause and
may be insufficient if airway/ventilation compromised.
C: Giving opioids risks worsening respiratory drive without
confirming pain as cause.
D: ABG can help but is diagnostic—assessment and escalation
come first to ensure immediate safety.
Teaching Point
Assess first—identify deterioration cues, then escalate if
necessary.
,Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Overview — Standards; Quality and Safety Emphasis
Stem
During handoff, you notice nurse-to-nurse verbal reports are
inconsistent and omit allergy status. Which action best
addresses this safety gap?
A. Tell the outgoing nurse to be more thorough next time.
B. Implement a standardized bedside handoff checklist and pilot
it on your unit.
C. Document the missing allergy info yourself and continue
current handoff practice.
D. Require that physicians repeat allergy status on rounds.
Correct Answer
B
Rationale — Correct
Standardized handoff tools reduce information loss and align
with quality/safety standards. Implementing and piloting a
checklist is an evidence-based systems solution addressing the
root cause rather than blaming individuals.
, Rationale — Incorrect
A: Reprimand is individual-focused and unlikely to sustainably
improve system reliability.
C: Documenting fixes the immediate omission but doesn't
prevent recurrence.
D: Relying on physicians duplicates work and doesn’t improve
nursing handoff processes.
Teaching Point
Standardize handoffs to reduce information loss and enhance
patient safety.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Overview — Healthy Work Environment
Stem
Your unit has frequent lateral violence and interrupted breaks,
and staff report moral distress. As the unit educator, which
intervention most likely improves the healthy work
environment?
A. Increase clinical workload to force team cohesion.
B. Introduce a structured debrief and conflict resolution training
program.
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 67-year-old post-op abdominal surgery patient in the ICU has
an increasing respiratory rate from 18 to 28/min over 30
minutes, SpO₂ falling from 96% to 90% on 2 L NC, and new
confusion. The charge nurse asks you to prioritize the next
nursing action. Which is best?
,A. Increase the oxygen flow to 4 L/min via nasal cannula.
B. Perform a focused respiratory assessment and call the rapid
response team if findings confirm deterioration.
C. Administer PRN opioid for presumed pain causing shallow
breathing.
D. Obtain an arterial blood gas (ABG) immediately.
Correct Answer
B
Rationale — Correct
A focused respiratory assessment integrates cues (RR up, SpO₂
down, confusion), applies clinical judgment, and determines
immediate interventions or escalation. It’s the priority to
confirm deterioration and triggers rapid response appropriately
per the measurement model. This action balances assessment,
interpretation, and timely escalation.
Rationale — Incorrect
A: Increasing oxygen without assessment may mask cause and
may be insufficient if airway/ventilation compromised.
C: Giving opioids risks worsening respiratory drive without
confirming pain as cause.
D: ABG can help but is diagnostic—assessment and escalation
come first to ensure immediate safety.
Teaching Point
Assess first—identify deterioration cues, then escalate if
necessary.
,Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Overview — Standards; Quality and Safety Emphasis
Stem
During handoff, you notice nurse-to-nurse verbal reports are
inconsistent and omit allergy status. Which action best
addresses this safety gap?
A. Tell the outgoing nurse to be more thorough next time.
B. Implement a standardized bedside handoff checklist and pilot
it on your unit.
C. Document the missing allergy info yourself and continue
current handoff practice.
D. Require that physicians repeat allergy status on rounds.
Correct Answer
B
Rationale — Correct
Standardized handoff tools reduce information loss and align
with quality/safety standards. Implementing and piloting a
checklist is an evidence-based systems solution addressing the
root cause rather than blaming individuals.
, Rationale — Incorrect
A: Reprimand is individual-focused and unlikely to sustainably
improve system reliability.
C: Documenting fixes the immediate omission but doesn't
prevent recurrence.
D: Relying on physicians duplicates work and doesn’t improve
nursing handoff processes.
Teaching Point
Standardize handoffs to reduce information loss and enhance
patient safety.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Overview — Healthy Work Environment
Stem
Your unit has frequent lateral violence and interrupted breaks,
and staff report moral distress. As the unit educator, which
intervention most likely improves the healthy work
environment?
A. Increase clinical workload to force team cohesion.
B. Introduce a structured debrief and conflict resolution training
program.
