, 2026 HESI MED SURG EXAM V2 – NGN STYLE
CASE SCENARIO 1 (Questions 1–8)
Heart Failure with Reduced Ejection Fraction (HFrEF)
Patient Presentation:
Mr. J.T., 68 years old, is admitted with worsening shortness of breath,
orthopnea, and 4+ pitting edema to the knees. Past medical history:
hypertension, type 2 diabetes, CKD stage 3. Vital signs: HR 112 (irregular), BP
98/62, RR 28, SpO2 89% on 2L NC. Lungs: crackles 2/3 up bilaterally. ECG
shows atrial fibrillation. BNP > 1800 pg/mL.
1. Drag and drop (Cloze): The nurse should first administer oxygenoxygen to
maintain SpO2 >90%, then furosemideIVfurosemideIV for diuresis, and
prepare for continuousECGmonitoringcontinuousECGmonitoring due to
irregular rhythm.
Rationale: Oxygen corrects hypoxemia; IV furosemide reduces preload; AFib
requires rate control and anticoagulation. Priority is ABCs plus hemodynamic
support.
2. Multiple Response (Select all that apply): Which findings support the
diagnosis of acute decompensated heart failure (ADHF)? Select all that apply.
• xx BNP > 1800 pg/mL
,• xx Crackles in bilateral lung bases
• x] Jugular venous distention (not listed but implied) – wait, let me correct:
from stem – JVD is present but not in choices? I will adjust:
Actual correct from stem:
• xx Orthopnea
• xx 4+ pitting edema
• *x] S3 gallop (though not listed, it’s classic)
Rationale: Elevated BNP, orthopnea, crackles, edema, and S3 are hallmark
signs of HFrEF exacerbation.
3. Bowtie Question (NGN format):
Place the 1 most likely condition in the center, 2 interventions on the left,
and 2 complications on the right.
Interventions (Left) Condition (Center) Complications (R
Administer IV Acute decompensated heart failure Acute respiratory
furosemide (ADHF) failure
Apply BiPAP if SpO2
Cardiogenic shoc
falls
Rationale: ADHF requires rapid diuresis and respiratory support.
Complications include respiratory failure and worsening low output state.
, 4. The nurse notes the patient has a potassium level of 3.1 mEq/L after two
doses of furosemide 40 mg IV. Which action is most appropriate?
• A) Give a third dose of furosemide as ordered
• B) Hold next furosemide and notify provider for potassium replacement
• C) Administer digoxin immediately
• D) Give normal saline bolus
Rationale: Severe hypokalemia (3.1) increases risk of digoxin toxicity and
arrhythmias. Replace potassium before further diuresis.
5. The patient is started on carvedilol. Which finding would require
holding the medication?
• A) HR 68 bpm
• B) Systolic BP 86 mmHg
• C) RR 20
• D) Weight gain 0.5 kg
*Rationale: Carvedilol (beta-blocker) can worsen hypotension. Hold if SBP
<90 mmHg or signs of shock.*
6. NGN Case Study – Matrix (Select rows that apply):
Which patient findings indicate that treatment is improving? Check all that
apply.
CASE SCENARIO 1 (Questions 1–8)
Heart Failure with Reduced Ejection Fraction (HFrEF)
Patient Presentation:
Mr. J.T., 68 years old, is admitted with worsening shortness of breath,
orthopnea, and 4+ pitting edema to the knees. Past medical history:
hypertension, type 2 diabetes, CKD stage 3. Vital signs: HR 112 (irregular), BP
98/62, RR 28, SpO2 89% on 2L NC. Lungs: crackles 2/3 up bilaterally. ECG
shows atrial fibrillation. BNP > 1800 pg/mL.
1. Drag and drop (Cloze): The nurse should first administer oxygenoxygen to
maintain SpO2 >90%, then furosemideIVfurosemideIV for diuresis, and
prepare for continuousECGmonitoringcontinuousECGmonitoring due to
irregular rhythm.
Rationale: Oxygen corrects hypoxemia; IV furosemide reduces preload; AFib
requires rate control and anticoagulation. Priority is ABCs plus hemodynamic
support.
2. Multiple Response (Select all that apply): Which findings support the
diagnosis of acute decompensated heart failure (ADHF)? Select all that apply.
• xx BNP > 1800 pg/mL
,• xx Crackles in bilateral lung bases
• x] Jugular venous distention (not listed but implied) – wait, let me correct:
from stem – JVD is present but not in choices? I will adjust:
Actual correct from stem:
• xx Orthopnea
• xx 4+ pitting edema
• *x] S3 gallop (though not listed, it’s classic)
Rationale: Elevated BNP, orthopnea, crackles, edema, and S3 are hallmark
signs of HFrEF exacerbation.
3. Bowtie Question (NGN format):
Place the 1 most likely condition in the center, 2 interventions on the left,
and 2 complications on the right.
Interventions (Left) Condition (Center) Complications (R
Administer IV Acute decompensated heart failure Acute respiratory
furosemide (ADHF) failure
Apply BiPAP if SpO2
Cardiogenic shoc
falls
Rationale: ADHF requires rapid diuresis and respiratory support.
Complications include respiratory failure and worsening low output state.
, 4. The nurse notes the patient has a potassium level of 3.1 mEq/L after two
doses of furosemide 40 mg IV. Which action is most appropriate?
• A) Give a third dose of furosemide as ordered
• B) Hold next furosemide and notify provider for potassium replacement
• C) Administer digoxin immediately
• D) Give normal saline bolus
Rationale: Severe hypokalemia (3.1) increases risk of digoxin toxicity and
arrhythmias. Replace potassium before further diuresis.
5. The patient is started on carvedilol. Which finding would require
holding the medication?
• A) HR 68 bpm
• B) Systolic BP 86 mmHg
• C) RR 20
• D) Weight gain 0.5 kg
*Rationale: Carvedilol (beta-blocker) can worsen hypotension. Hold if SBP
<90 mmHg or signs of shock.*
6. NGN Case Study – Matrix (Select rows that apply):
Which patient findings indicate that treatment is improving? Check all that
apply.
