SOLE’S INTRODUCTION TO
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Clinical Judgment Measurement Model / Rapid
Deterioration Recognition
Stem
A 68-year-old postoperative patient on the step-down unit has
HR 112, BP 98/56, RR 24, SpO₂ 90% on 2 L nasal cannula, and
urine output 20 mL over past hour. The nurse notes the patient
is more confused than on previous assessment. The unit is
staffed with one RN for three patients. What is the nurse’s best
immediate action?
,A. Give a 500 mL IV bolus of normal saline.
B. Call the rapid response team (RRT) immediately.
C. Increase oxygen to 4 L nasal cannula and recheck in 15
minutes.
D. Document findings and notify the physician during morning
rounds.
Correct Answer
B
Rationales
Correct (B): The combination of hypotension, tachycardia, rising
RR, hypoxemia, oliguria, and acute confusion signals early
deterioration — possible shock or respiratory failure. Activating
the RRT prioritizes rapid, multidisciplinary assessment and
management per clinical judgment measurement models. Early
team response reduces time to interventions and improves
outcomes.
A: A fluid bolus may be appropriate after assessment but is
premature without urgent evaluation of cause (e.g.,
hemorrhage, cardiogenic shock). Immediate team activation is
higher priority.
C: Increasing oxygen alone may temporarily improve SpO₂ but
fails to address hypotension, oliguria, and altered mental status
— risks delaying definitive evaluation.
D: Waiting until rounds dangerously delays care for a potentially
unstable patient.
,Teaching Point
Acute change in vitals + mental status → immediate team
activation (RRT).
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Standards & Quality and Safety Emphasis
Stem
An ICU nurse notes a pattern of missed central line dressing
changes on the evening shift. This has correlated with three
central line–associated bloodstream infections (CLABSIs) in 6
weeks. The nurse wants to improve unit performance. Which
action aligns best with evidence-based quality improvement
practices?
A. Report the staff to nurse manager and request disciplinary
action.
B. Collect root-cause data, convene stakeholders, and
implement a standardized dressing protocol.
C. Schedule mandatory overtime for evening staff to ensure
work is completed.
D. Place reminders on the chart for individual nurses to perform
dressing changes.
, Correct Answer
B
Rationales
Correct (B): Evidence-based QI emphasizes system analysis
(root cause), stakeholder engagement, and standardized
protocols to reduce infection risk. This approach targets process
failures rather than individual blame, aligning with safety
culture.
A: Punitive responses ignore systemic contributors and harm
culture of safety, reducing incident reporting.
C: Mandatory overtime may worsen fatigue-related errors and
not address process deficiencies.
D: Reminders are low-reliability interventions; system redesign
is superior for preventing CLABSIs.
Teaching Point
Root-cause analysis + standardized protocols improve patient
safety and reduce infections.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Evidence-Based Practice / Professional Organizations
CRITICAL CARE NURSING
9TH EDITION
• AUTHOR(S)MARY MAKIC
TEST BANK
1
Reference
Ch. 1 — Clinical Judgment Measurement Model / Rapid
Deterioration Recognition
Stem
A 68-year-old postoperative patient on the step-down unit has
HR 112, BP 98/56, RR 24, SpO₂ 90% on 2 L nasal cannula, and
urine output 20 mL over past hour. The nurse notes the patient
is more confused than on previous assessment. The unit is
staffed with one RN for three patients. What is the nurse’s best
immediate action?
,A. Give a 500 mL IV bolus of normal saline.
B. Call the rapid response team (RRT) immediately.
C. Increase oxygen to 4 L nasal cannula and recheck in 15
minutes.
D. Document findings and notify the physician during morning
rounds.
Correct Answer
B
Rationales
Correct (B): The combination of hypotension, tachycardia, rising
RR, hypoxemia, oliguria, and acute confusion signals early
deterioration — possible shock or respiratory failure. Activating
the RRT prioritizes rapid, multidisciplinary assessment and
management per clinical judgment measurement models. Early
team response reduces time to interventions and improves
outcomes.
A: A fluid bolus may be appropriate after assessment but is
premature without urgent evaluation of cause (e.g.,
hemorrhage, cardiogenic shock). Immediate team activation is
higher priority.
C: Increasing oxygen alone may temporarily improve SpO₂ but
fails to address hypotension, oliguria, and altered mental status
— risks delaying definitive evaluation.
D: Waiting until rounds dangerously delays care for a potentially
unstable patient.
,Teaching Point
Acute change in vitals + mental status → immediate team
activation (RRT).
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
2
Reference
Ch. 1 — Standards & Quality and Safety Emphasis
Stem
An ICU nurse notes a pattern of missed central line dressing
changes on the evening shift. This has correlated with three
central line–associated bloodstream infections (CLABSIs) in 6
weeks. The nurse wants to improve unit performance. Which
action aligns best with evidence-based quality improvement
practices?
A. Report the staff to nurse manager and request disciplinary
action.
B. Collect root-cause data, convene stakeholders, and
implement a standardized dressing protocol.
C. Schedule mandatory overtime for evening staff to ensure
work is completed.
D. Place reminders on the chart for individual nurses to perform
dressing changes.
, Correct Answer
B
Rationales
Correct (B): Evidence-based QI emphasizes system analysis
(root cause), stakeholder engagement, and standardized
protocols to reduce infection risk. This approach targets process
failures rather than individual blame, aligning with safety
culture.
A: Punitive responses ignore systemic contributors and harm
culture of safety, reducing incident reporting.
C: Mandatory overtime may worsen fatigue-related errors and
not address process deficiencies.
D: Reminders are low-reliability interventions; system redesign
is superior for preventing CLABSIs.
Teaching Point
Root-cause analysis + standardized protocols improve patient
safety and reduce infections.
Citation
Makic, M. B. F. (2025). Sole’s Introduction to Critical Care
Nursing (9th ed.). Ch. 1.
3
Reference
Ch. 1 — Evidence-Based Practice / Professional Organizations
