1
HESI MED-SURG III REVIEW 2026/2027 | Advanced
Complex Care Verified Q&A | Complete Level 3 Test Bank
| Pass Guaranteed - A+ Graded
Section 1: Complex Cardiovascular & Advanced Hemodynamics
(Questions 1-18)
Q1. A 68-year-old male with acute anterior STEMI develops cardiogenic shock with
BP 78/52 mmHg, HR 110 bpm, cool clammy skin, and urine output 15 mL/hr. PA
catheter shows CI 1.8 L/min/m², PCWP 24 mmHg, SVR 1800 dynes·sec/cm⁵. Which
vasoactive agent is most appropriate as first-line inotrope?
A. Norepinephrine to increase afterload and coronary perfusion
B. Dobutamine to improve contractility and reduce preload with mild afterload
reduction [CORRECT]
C. Phenylephrine for pure alpha-mediated vasoconstriction
D. Nitroprusside for afterload reduction
Rationale: Cardiogenic shock with elevated PCWP and low CI indicates pump failure;
dobutamine is the first-line inotrope to increase contractility and cardiac output with
mild afterload reduction. Norepinephrine is reserved for persistent hypotension after
inotropy, phenylephrine worsens cardiac output, and nitroprusside causes dangerous
hypotension in this profile.
Correct Answer: B
Q2. A patient has a PA catheter in place. The waveform shows a mean PAOP of 18
mmHg with prominent v-waves. CVP is 8 mmHg. Which hemodynamic condition is
most consistent with this profile?
A. Hypovolemic shock
B. Cardiac tamponade with equalization of pressures
C. Mitral regurgitation causing elevated PAOP with prominent v-waves [CORRECT]
D. Pulmonary hypertension with isolated PA elevation
,2
Rationale: Prominent PAOP v-waves indicate regurgitant flow into the left atrium
during systole, characteristic of mitral regurgitation. Hypovolemia would show low
PAOP, tamponade shows equalized diastolic pressures, and isolated pulmonary
hypertension elevates PA pressures without prominent PAOP v-waves.
Correct Answer: C
Q3. A patient with cardiogenic shock is placed on an intra-aortic balloon pump
(IABP). The nurse notes the diastolic augmentation waveform is occurring after the
dicrotic notch. Which action is indicated?
A. Increase balloon inflation volume
B. Advance the timing to inflate earlier before the dicrotic notch [CORRECT]
C. Decrease the helium gas volume
D. Increase heart rate
Rationale: Late inflation after the dicrotic notch misses diastolic augmentation and
increases afterload; the balloon must inflate just before or at the dicrotic notch to
maximize coronary perfusion. Increasing volume or heart rate does not correct
timing error.
Correct Answer: B
Q4. A patient with acute decompensated heart failure and reduced ejection fraction
receives milrinone. Which mechanism of action and adverse effect profile require
closest monitoring?
A. Beta-1 agonism causing tachycardia and arrhythmias
B. Phosphodiesterase-3 inhibition increasing cAMP and contractility with
vasodilation; risk of hypotension and ventricular arrhythmias [CORRECT]
C. Alpha-1 blockade causing reflex tachycardia
D. Direct renin inhibition causing hyperkalemia
,3
Rationale: Milrinone inhibits phosphodiesterase-3, increasing cAMP to enhance
contractility and cause vasodilation; it does not act on beta or alpha receptors.
Hypotension from vasodilation and ventricular arrhythmias from increased cAMP
require continuous monitoring.
Correct Answer: B
Q5. A patient in septic shock has BP 82/48 mmHg, CVP 4 mmHg, PAOP 8 mmHg, CI
5.2 L/min/m², SVR 600 dynes·sec/cm⁵. Which hemodynamic parameter best explains
the hypotension?
A. Decreased preload from hypovolemia
B. Decreased afterload from pathologic vasodilation [CORRECT]
C. Decreased contractility from cardiomyopathy
D. Increased afterload from vasoconstriction
Rationale: The low SVR (normal 900-1400) with high CI indicates distributive shock
from pathologic vasodilation despite adequate preload and hyperdynamic cardiac
function. Preload is adequate (CVP/PAOP normal), contractility is increased (high CI),
and afterload is decreased, not increased.
Correct Answer: B
Q6. A patient with cardiogenic shock refractory to IABP is being evaluated for
mechanical circulatory support. Which statement accurately compares Impella to
IABP?
A. Impella provides greater hemodynamic support by directly pumping blood from
left ventricle to aorta, unloading the ventricle and increasing cardiac output more
than IABP [CORRECT]
B. IABP provides superior left ventricular unloading compared to Impella
C. Impella requires surgical cutdown for all catheter sizes
D. IABP increases cardiac output more than Impella
, 4
Rationale: The Impella percutaneous ventricular assist device actively pumps blood
from LV to aorta, providing greater cardiac output support (up to 5.0 L/min) and
superior ventricular unloading compared to IABP, which provides only diastolic
augmentation and mild afterload reduction.
Correct Answer: A
Q7. A patient with cardiogenic shock has BP 74/50 mmHg after dobutamine
initiation. Which medication should be added to maintain perfusion pressure while
preserving dobutamine's inotropic benefits?
A. Nitroglycerin for afterload reduction
B. Norepinephrine for vasoconstriction and blood pressure support [CORRECT]
C. Propranolol for rate control
D. Nesiritide for vasodilation
Rationale: When cardiogenic shock remains hypotensive despite inotropy,
norepinephrine is added for alpha-mediated vasoconstriction to maintain MAP >65
mmHg while dobutamine continues providing inotropic support. Vasodilators worsen
hypotension, and beta-blockers are contraindicated in acute decompensated shock.
Correct Answer: B
Q8. An arterial line waveform shows a slurred upstroke, absent dicrotic notch, and
falsely low systolic pressure with normal diastolic pressure. Which technical problem
is present?
A. Underdamping with artifactual oscillations
B. Overdamping from air bubbles, clots, or excessive tubing length reducing
waveform fidelity [CORRECT]
C. Catheter whip from patient movement
D. Optimal damping with accurate pressure transmission
HESI MED-SURG III REVIEW 2026/2027 | Advanced
Complex Care Verified Q&A | Complete Level 3 Test Bank
| Pass Guaranteed - A+ Graded
Section 1: Complex Cardiovascular & Advanced Hemodynamics
(Questions 1-18)
Q1. A 68-year-old male with acute anterior STEMI develops cardiogenic shock with
BP 78/52 mmHg, HR 110 bpm, cool clammy skin, and urine output 15 mL/hr. PA
catheter shows CI 1.8 L/min/m², PCWP 24 mmHg, SVR 1800 dynes·sec/cm⁵. Which
vasoactive agent is most appropriate as first-line inotrope?
A. Norepinephrine to increase afterload and coronary perfusion
B. Dobutamine to improve contractility and reduce preload with mild afterload
reduction [CORRECT]
C. Phenylephrine for pure alpha-mediated vasoconstriction
D. Nitroprusside for afterload reduction
Rationale: Cardiogenic shock with elevated PCWP and low CI indicates pump failure;
dobutamine is the first-line inotrope to increase contractility and cardiac output with
mild afterload reduction. Norepinephrine is reserved for persistent hypotension after
inotropy, phenylephrine worsens cardiac output, and nitroprusside causes dangerous
hypotension in this profile.
Correct Answer: B
Q2. A patient has a PA catheter in place. The waveform shows a mean PAOP of 18
mmHg with prominent v-waves. CVP is 8 mmHg. Which hemodynamic condition is
most consistent with this profile?
A. Hypovolemic shock
B. Cardiac tamponade with equalization of pressures
C. Mitral regurgitation causing elevated PAOP with prominent v-waves [CORRECT]
D. Pulmonary hypertension with isolated PA elevation
,2
Rationale: Prominent PAOP v-waves indicate regurgitant flow into the left atrium
during systole, characteristic of mitral regurgitation. Hypovolemia would show low
PAOP, tamponade shows equalized diastolic pressures, and isolated pulmonary
hypertension elevates PA pressures without prominent PAOP v-waves.
Correct Answer: C
Q3. A patient with cardiogenic shock is placed on an intra-aortic balloon pump
(IABP). The nurse notes the diastolic augmentation waveform is occurring after the
dicrotic notch. Which action is indicated?
A. Increase balloon inflation volume
B. Advance the timing to inflate earlier before the dicrotic notch [CORRECT]
C. Decrease the helium gas volume
D. Increase heart rate
Rationale: Late inflation after the dicrotic notch misses diastolic augmentation and
increases afterload; the balloon must inflate just before or at the dicrotic notch to
maximize coronary perfusion. Increasing volume or heart rate does not correct
timing error.
Correct Answer: B
Q4. A patient with acute decompensated heart failure and reduced ejection fraction
receives milrinone. Which mechanism of action and adverse effect profile require
closest monitoring?
A. Beta-1 agonism causing tachycardia and arrhythmias
B. Phosphodiesterase-3 inhibition increasing cAMP and contractility with
vasodilation; risk of hypotension and ventricular arrhythmias [CORRECT]
C. Alpha-1 blockade causing reflex tachycardia
D. Direct renin inhibition causing hyperkalemia
,3
Rationale: Milrinone inhibits phosphodiesterase-3, increasing cAMP to enhance
contractility and cause vasodilation; it does not act on beta or alpha receptors.
Hypotension from vasodilation and ventricular arrhythmias from increased cAMP
require continuous monitoring.
Correct Answer: B
Q5. A patient in septic shock has BP 82/48 mmHg, CVP 4 mmHg, PAOP 8 mmHg, CI
5.2 L/min/m², SVR 600 dynes·sec/cm⁵. Which hemodynamic parameter best explains
the hypotension?
A. Decreased preload from hypovolemia
B. Decreased afterload from pathologic vasodilation [CORRECT]
C. Decreased contractility from cardiomyopathy
D. Increased afterload from vasoconstriction
Rationale: The low SVR (normal 900-1400) with high CI indicates distributive shock
from pathologic vasodilation despite adequate preload and hyperdynamic cardiac
function. Preload is adequate (CVP/PAOP normal), contractility is increased (high CI),
and afterload is decreased, not increased.
Correct Answer: B
Q6. A patient with cardiogenic shock refractory to IABP is being evaluated for
mechanical circulatory support. Which statement accurately compares Impella to
IABP?
A. Impella provides greater hemodynamic support by directly pumping blood from
left ventricle to aorta, unloading the ventricle and increasing cardiac output more
than IABP [CORRECT]
B. IABP provides superior left ventricular unloading compared to Impella
C. Impella requires surgical cutdown for all catheter sizes
D. IABP increases cardiac output more than Impella
, 4
Rationale: The Impella percutaneous ventricular assist device actively pumps blood
from LV to aorta, providing greater cardiac output support (up to 5.0 L/min) and
superior ventricular unloading compared to IABP, which provides only diastolic
augmentation and mild afterload reduction.
Correct Answer: A
Q7. A patient with cardiogenic shock has BP 74/50 mmHg after dobutamine
initiation. Which medication should be added to maintain perfusion pressure while
preserving dobutamine's inotropic benefits?
A. Nitroglycerin for afterload reduction
B. Norepinephrine for vasoconstriction and blood pressure support [CORRECT]
C. Propranolol for rate control
D. Nesiritide for vasodilation
Rationale: When cardiogenic shock remains hypotensive despite inotropy,
norepinephrine is added for alpha-mediated vasoconstriction to maintain MAP >65
mmHg while dobutamine continues providing inotropic support. Vasodilators worsen
hypotension, and beta-blockers are contraindicated in acute decompensated shock.
Correct Answer: B
Q8. An arterial line waveform shows a slurred upstroke, absent dicrotic notch, and
falsely low systolic pressure with normal diastolic pressure. Which technical problem
is present?
A. Underdamping with artifactual oscillations
B. Overdamping from air bubbles, clots, or excessive tubing length reducing
waveform fidelity [CORRECT]
C. Catheter whip from patient movement
D. Optimal damping with accurate pressure transmission
