SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
Q1
Reference: Ch. 1 — Clinical Judgment Measurement Model
Stem: A 68-year-old postoperative CABG patient on the ICU
telemetry strip has a new sustained narrowing of pulse pressure
(BP 112/86 → 104/92 mm Hg), HR 110, urine output decreased
from 40 mL/hr to 10 mL/hr over the last hour, and cool
extremities. Which nursing action best reflects clinical judgment
per the CJMM?
A. Document findings and continue hourly vital sign checks.
B. Notify the surgeon and request hemodynamic monitoring
(e.g., arterial line) and fluid/vasopressor evaluation.
,C. Increase the IV crystalloid infusion rate without notifying the
team.
D. Administer a PRN analgesic for presumed pain-related
tachycardia.
Correct Answer: B
Rationale — Correct (B): The Clinical Judgment Measurement
Model emphasizes recognition of changes, interpretation, and
taking prioritized action. Narrowing pulse pressure, rising HR,
oliguria, and cool extremities indicate early shock/cardiac
output drop; notifying the surgeon and escalating to invasive
hemodynamic monitoring and team-based fluid/vasopressor
assessment is highest priority. This aligns with evidence-based
escalation and collaborative care.
Rationale — Incorrect:
A. Passive documentation delays intervention for potential
cardiogenic or hypovolemic compromise.
C. Increasing fluids without team evaluation may worsen
cardiogenic failure if the etiology is cardiac.
D. Giving analgesic assumes pain is cause; it misses oliguria and
perfusion signs that require hemodynamic assessment.
Teaching Point: Recognize pattern changes and escalate to the
team for hemodynamic assessment immediately.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
,Q2
Reference: Ch. 1 — Standards
Stem: A new nurse on the unit is unsure whether to remove an
arterial line dressing that is soiled. The unit policy is unclear.
The nurse recalls mandatory standards of practice require
maintaining aseptic technique. What is the best immediate
nursing action?
A. Remove the dressing and change it using sterile technique,
then document.
B. Leave the soiled dressing and call infection control tomorrow.
C. Place an additional transparent dressing over the existing
soiled dressing.
D. Ask a colleague to decide and follow their action without
documenting.
Correct Answer: A
Rationale — Correct (A): Standards require immediate
maintenance of device integrity and aseptic technique. A soiled
arterial line dressing increases infection risk; removing and
changing with sterile technique immediately minimizes harm
and adheres to professional standards. Documentation of the
procedure and rationale follows standard practice.
Rationale — Incorrect:
B. Delaying increases infection risk and violates prompt
standard-based care.
C. Adding another dressing over a soiled one traps
, contaminants—unsafe.
D. Deferring decision-making to a colleague without
independent action or documentation neglects professional
accountability.
Teaching Point: Follow standards: address device contamination
promptly using sterile technique and document.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
Q3
Reference: Ch. 1 — Critical Care Nurse Characteristics
Stem: During shift report, a patient with sepsis is assigned to
you: T 38.9°C, HR 124, BP 88/52 on norepinephrine 6 mcg/min,
lactate 3.8 mmol/L, mottled skin. Your manager says “maintain
current orders.” What nurse characteristic is most needed now?
A. Task-focused efficiency to complete all medication admin
quickly.
B. Autonomy and assertive clinical advocacy to request urgent
reassessment and bundle care.
C. Passive acceptance of the manager’s direction to avoid
conflict.
D. Avoidance of escalation to reduce alarm fatigue for the team.
Correct Answer: B
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
Q1
Reference: Ch. 1 — Clinical Judgment Measurement Model
Stem: A 68-year-old postoperative CABG patient on the ICU
telemetry strip has a new sustained narrowing of pulse pressure
(BP 112/86 → 104/92 mm Hg), HR 110, urine output decreased
from 40 mL/hr to 10 mL/hr over the last hour, and cool
extremities. Which nursing action best reflects clinical judgment
per the CJMM?
A. Document findings and continue hourly vital sign checks.
B. Notify the surgeon and request hemodynamic monitoring
(e.g., arterial line) and fluid/vasopressor evaluation.
,C. Increase the IV crystalloid infusion rate without notifying the
team.
D. Administer a PRN analgesic for presumed pain-related
tachycardia.
Correct Answer: B
Rationale — Correct (B): The Clinical Judgment Measurement
Model emphasizes recognition of changes, interpretation, and
taking prioritized action. Narrowing pulse pressure, rising HR,
oliguria, and cool extremities indicate early shock/cardiac
output drop; notifying the surgeon and escalating to invasive
hemodynamic monitoring and team-based fluid/vasopressor
assessment is highest priority. This aligns with evidence-based
escalation and collaborative care.
Rationale — Incorrect:
A. Passive documentation delays intervention for potential
cardiogenic or hypovolemic compromise.
C. Increasing fluids without team evaluation may worsen
cardiogenic failure if the etiology is cardiac.
D. Giving analgesic assumes pain is cause; it misses oliguria and
perfusion signs that require hemodynamic assessment.
Teaching Point: Recognize pattern changes and escalate to the
team for hemodynamic assessment immediately.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
,Q2
Reference: Ch. 1 — Standards
Stem: A new nurse on the unit is unsure whether to remove an
arterial line dressing that is soiled. The unit policy is unclear.
The nurse recalls mandatory standards of practice require
maintaining aseptic technique. What is the best immediate
nursing action?
A. Remove the dressing and change it using sterile technique,
then document.
B. Leave the soiled dressing and call infection control tomorrow.
C. Place an additional transparent dressing over the existing
soiled dressing.
D. Ask a colleague to decide and follow their action without
documenting.
Correct Answer: A
Rationale — Correct (A): Standards require immediate
maintenance of device integrity and aseptic technique. A soiled
arterial line dressing increases infection risk; removing and
changing with sterile technique immediately minimizes harm
and adheres to professional standards. Documentation of the
procedure and rationale follows standard practice.
Rationale — Incorrect:
B. Delaying increases infection risk and violates prompt
standard-based care.
C. Adding another dressing over a soiled one traps
, contaminants—unsafe.
D. Deferring decision-making to a colleague without
independent action or documentation neglects professional
accountability.
Teaching Point: Follow standards: address device contamination
promptly using sterile technique and document.
Citation: Makic, M. B. F. (2025). Sole’s Introduction to Critical
Care Nursing (9th ed.). Ch. 1.
Q3
Reference: Ch. 1 — Critical Care Nurse Characteristics
Stem: During shift report, a patient with sepsis is assigned to
you: T 38.9°C, HR 124, BP 88/52 on norepinephrine 6 mcg/min,
lactate 3.8 mmol/L, mottled skin. Your manager says “maintain
current orders.” What nurse characteristic is most needed now?
A. Task-focused efficiency to complete all medication admin
quickly.
B. Autonomy and assertive clinical advocacy to request urgent
reassessment and bundle care.
C. Passive acceptance of the manager’s direction to avoid
conflict.
D. Avoidance of escalation to reduce alarm fatigue for the team.
Correct Answer: B
