2026 HESI RN Medical-Surgical Exams - NGN
Nursing Questions, 2026 HESI Exit Med surg Exam
Prep (Guarantee Pass)
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled mechanical
ventilation with FiO2 0.8, PEEP 14 cm H2O, and tidal volume 6 mL/kg ideal body weight. Arterial
blood gas shows pH 7.25, PaCO2 50 mm Hg, PaO2 65 mm Hg, HCO3- 22 mEq/L. Which
intervention should the nurse anticipate to improve oxygenation while minimizing
ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to 18 cm H2O and perform a recruitment maneuver
C. Decrease FiO2 to 0.6 to reduce oxygen toxicity
D. Switch to pressure-controlled ventilation with inverse ratio
Answer: B
Rationale: In ARDS, increasing PEEP recruits alveoli, improves oxygenation, and allows reduction of
FiO2, reducing oxygen toxicity. Recruitment maneuvers help open collapsed alveoli. Increasing tidal
volume (A) risks volutrauma. Decreasing FiO2 (C) without improving oxygenation is unsafe.
Pressure-controlled inverse ratio ventilation (D) may be considered but is not first-line and can cause
hemodynamic compromise; increasing PEEP is more direct.
2. A patient with cirrhosis and ascites develops sudden onset of confusion, asterixis, and a musty
odor on the breath. Vital signs: BP 90/60 mm Hg, HR 110 bpm, temperature 37.2°C. Serum
ammonia is 120 mcg/dL (normal 15-45). Which intervention should the nurse implement first?
A. Administer lactulose 30 mL orally
B. Start a normal saline bolus at 500 mL/hr
C. Prepare for paracentesis to relieve ascites
D. Administer intravenous ceftriaxone 1 g
Answer: A
Rationale: The patient is experiencing hepatic encephalopathy, as evidenced by confusion, asterixis, fetor
hepaticus, and elevated ammonia. Lactulose reduces serum ammonia by acidifying the colon and
promoting excretion. This is the priority intervention. IV fluids (B) may be needed but are not first-line
for encephalopathy. Paracentesis (C) does not address encephalopathy. Ceftriaxone (D) is for
spontaneous bacterial peritonitis, not indicated here without signs of infection.
Page 1
,3. A patient with type 2 diabetes mellitus is admitted with hyperglycemic hyperosmolar state
(HHS). Serum glucose 680 mg/dL, serum sodium 148 mEq/L (corrected 152), BUN 42 mg/dL,
creatinine 1.8 mg/dL, serum osmolality 340 mOsm/kg. The patient is awake and oriented. The
nurse starts 0.9% normal saline at 1 L/hr. After 2 liters, reassessment shows glucose 550 mg/dL,
sodium 146 mEq/L, osmolality 320 mOsm/kg. What is the nurse's next best action?
A. Continue 0.9% normal saline at 1 L/hr
B. Switch to 0.45% normal saline at 250 mL/hr
C. Start intravenous regular insulin at 0.1 units/kg bolus then 0.1 units/kg/hr
D. Administer sodium bicarbonate 50 mEq IV push
Answer: B
Rationale: In HHS, initial fluid resuscitation with 0.9% NS corrects hypovolemia. After hemodynamic
stability and falling glucose, the corrected sodium is elevated (hypernatremia), indicating free water
deficit. Switching to 0.45% NS provides free water to correct hypernatremia. Continuing 0.9% NS (A)
risks worsening hypernatremia. Insulin (C) is typically started after fluid resuscitation when glucose
stops falling, but here glucose is still dropping; insulin may be considered but fluid correction takes
priority to avoid rapid osmotic shifts. Sodium bicarbonate (D) is not indicated without severe acidosis
(pH <7.0).
4. A patient with a history of heart failure (HFrEF, LVEF 30%) is admitted with acute
decompensation. The nurse notes jugular venous distention, bilateral crackles up to the
mid-scapulae, and 3+ pitting edema to the knees. Vital signs: BP 142/88 mm Hg, HR 98 bpm, RR
22, SpO2 91% on room air. Which prescription should the nurse question?
A. Furosemide 40 mg IV push now
B. Metoprolol succinate 50 mg PO daily
C. Nitroglycerin 0.4 mg sublingual every 5 minutes for chest pain
D. Oxygen 2 L nasal cannula to maintain SpO2 >92%
Answer: B
Rationale: In acute decompensated heart failure, beta-blockers like metoprolol succinate are typically
held until the patient is euvolemic and hemodynamically stable, as they can reduce cardiac contractility
and worsen acute failure. Furosemide (A) is appropriate for diuresis. Nitroglycerin (C) is used for
angina; there is no indication of chest pain, but the prescription is not inherently wrong. Oxygen (D) is
appropriate for hypoxemia. Holding the beta-blocker is the priority.
5. A patient in the intensive care unit develops new-onset atrial fibrillation with rapid ventricular
response (HR 150 bpm). The patient is hemodynamically stable, BP 110/70 mm Hg, and denies
chest pain. Which intervention should the nurse prepare for first?
A. Synchronized cardioversion at 100 J
B. Intravenous amiodarone bolus and infusion
C. Intravenous metoprolol 5 mg over 2 minutes
D. Transesophageal echocardiogram to rule out clot
Answer: C
Rationale: For hemodynamically stable atrial fibrillation with rapid rate, rate control is first-line.
Metoprolol, a beta-blocker, is effective and rapid. Synchronized cardioversion (A) is reserved for
unstable patients. Amiodarone (B) is a rhythm control option but not first-line for rate control. TEE (D)
Page 2
,is indicated before cardioversion if duration >48 hours or unknown, but rate control is the immediate
priority.
6. A patient with chronic kidney disease stage 5 (not on dialysis) has the following lab results:
serum potassium 6.8 mEq/L, serum creatinine 5.2 mg/dL, BUN 80 mg/dL, serum bicarbonate 16
mEq/L, serum calcium 8.0 mg/dL, serum phosphate 6.5 mg/dL. ECG shows peaked T waves.
Which intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (SPS) 30 g orally
B. Administer intravenous calcium gluconate 10 mL over 2 minutes
C. Administer intravenous regular insulin 10 units with D50 50 mL
D. Prepare the patient for emergent hemodialysis
Answer: B
Rationale: The patient has life-threatening hyperkalemia with ECG changes (peaked T waves). First-line
treatment is intravenous calcium gluconate to stabilize the cardiac membrane and prevent dysrhythmias.
Insulin and glucose (C) shift potassium intracellularly but take longer to act. SPS (A) is a slow-acting
potassium binder. Hemodialysis (D) is definitive but not immediately available; calcium is the priority.
7. A patient with a history of peptic ulcer disease is admitted with melena and orthostatic
hypotension. Esophagogastroduodenoscopy reveals a bleeding duodenal ulcer with a visible vessel.
The ulcer is treated with epinephrine injection and bipolar coagulation. Post-procedure, the nurse
administers intravenous pantoprazole 80 mg bolus followed by 8 mg/hr continuous infusion. What
is the primary rationale for this high-dose proton pump inhibitor (PPI) regimen?
A. To neutralize gastric acid and promote platelet aggregation
B. To maintain intragastric pH >6 to stabilize the clot
C. To reduce gastric acid secretion and prevent rebleeding
D. To eradicate Helicobacter pylori if present
Answer: B
Rationale: After endoscopic hemostasis of a bleeding ulcer, high-dose PPI (bolus plus continuous
infusion) is used to maintain intragastric pH >6, which is necessary for platelet aggregation and clot
stability. This reduces the risk of rebleeding. Neutralization (A) is not the mechanism; PPIs suppress
acid secretion. Reducing acid (C) is true but the specific goal is pH >6. H. pylori eradication (D)
requires antibiotics, not PPI alone.
8. A patient with septic shock is receiving norepinephrine infusion at 15 mcg/min via a central line.
The mean arterial pressure (MAP) is 58 mm Hg. The nurse is about to administer a 500 mL
normal saline bolus per protocol. Which action should the nurse take?
A. Administer the fluid bolus and reassess MAP
B. Increase norepinephrine to 20 mcg/min and hold fluids
C. Start a second vasopressor such as vasopressin
D. Check a serum lactate level before giving fluids
Answer: A
Rationale: In septic shock, fluid resuscitation is a priority. The patient is on a moderate dose of
norepinephrine with persistent hypotension (MAP <65). The nurse should administer the fluid bolus as
prescribed and reassess. Increasing norepinephrine (B) without fluids may be less effective. Adding a
Page 3
, second vasopressor (C) may be considered if fluids and norepinephrine fail, but fluids come first.
Checking lactate (D) is important but should not delay fluid administration.
9. A patient with acute pancreatitis has the following labs: serum lipase 1200 U/L, amylase 800
U/L, WBC 18,000/mm3, glucose 200 mg/dL, calcium 7.5 mg/dL, LDH 350 U/L, AST 120 U/L, and
hematocrit 50%. The patient has a Ranson score of 4. Which complication is the patient at highest
risk for developing?
A. Acute respiratory distress syndrome
B. Pancreatic pseudocyst
C. Chronic pancreatitis
D. Pancreatic necrosis
Answer: D
Rationale: Ranson criteria predict severity of pancreatitis. A score of 4 indicates severe pancreatitis. The
patient has multiple risk factors for pancreatic necrosis (elevated LDH, AST, glucose, leukocytosis,
hypocalcemia). Necrosis is a major complication in severe acute pancreatitis. ARDS (A) can occur but is
less specific. Pseudocyst (B) typically develops weeks later. Chronic pancreatitis (C) is a long-term
outcome, not acute.
10. A patient is receiving a continuous infusion of unfractionated heparin for acute pulmonary
embolism. The aPTT is 90 seconds (therapeutic range 60-80 seconds). The nurse notes the patient
has new-onset hemoptysis and a drop in hemoglobin from 12.5 to 10.0 g/dL over 4 hours. What is
the nurse's priority action?
A. Decrease the heparin infusion rate by 50%
B. Stop the heparin infusion and administer protamine sulfate
C. Obtain a stat chest X-ray and CT pulmonary angiogram
D. Administer vitamin K 10 mg intravenously
Answer: B
Rationale: The patient has a supratherapeutic aPTT and signs of major bleeding (hemoptysis, dropping
hemoglobin). Heparin should be stopped immediately, and protamine sulfate given to reverse
anticoagulation. Decreasing the rate (A) is insufficient. Chest X-ray and CT (C) may be done after
stabilization. Vitamin K (D) reverses warfarin, not heparin.
11. A patient with acute decompensated heart failure is receiving intravenous furosemide at 10
mg/hour. The nurse notes a drop in urine output from 100 mL/hour to 30 mL/hour over the past 2
hours, and the patient's blood pressure is 88/52 mm Hg. The serum creatinine has risen from 1.0
mg/dL to 1.8 mg/dL. Which intervention should the nurse prioritize?
A. Increase the furosemide infusion rate to 20 mg/hour to improve urine output.
B. Administer a 500 mL bolus of 0.9% normal saline over 30 minutes.
C. Hold the furosemide infusion and notify the healthcare provider immediately.
D. Obtain a stat serum potassium level and prepare for dialysis.
Answer: C
Rationale: The patient is showing signs of prerenal acute kidney injury (AKI) due to hypoperfusion from
over-diuresis and hypotension. Continuing furosemide would worsen renal function. Holding the
infusion and notifying the provider allows for reassessment and possible fluid resuscitation or
Page 4
Nursing Questions, 2026 HESI Exit Med surg Exam
Prep (Guarantee Pass)
1. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled mechanical
ventilation with FiO2 0.8, PEEP 14 cm H2O, and tidal volume 6 mL/kg ideal body weight. Arterial
blood gas shows pH 7.25, PaCO2 50 mm Hg, PaO2 65 mm Hg, HCO3- 22 mEq/L. Which
intervention should the nurse anticipate to improve oxygenation while minimizing
ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg to improve ventilation
B. Increase PEEP to 18 cm H2O and perform a recruitment maneuver
C. Decrease FiO2 to 0.6 to reduce oxygen toxicity
D. Switch to pressure-controlled ventilation with inverse ratio
Answer: B
Rationale: In ARDS, increasing PEEP recruits alveoli, improves oxygenation, and allows reduction of
FiO2, reducing oxygen toxicity. Recruitment maneuvers help open collapsed alveoli. Increasing tidal
volume (A) risks volutrauma. Decreasing FiO2 (C) without improving oxygenation is unsafe.
Pressure-controlled inverse ratio ventilation (D) may be considered but is not first-line and can cause
hemodynamic compromise; increasing PEEP is more direct.
2. A patient with cirrhosis and ascites develops sudden onset of confusion, asterixis, and a musty
odor on the breath. Vital signs: BP 90/60 mm Hg, HR 110 bpm, temperature 37.2°C. Serum
ammonia is 120 mcg/dL (normal 15-45). Which intervention should the nurse implement first?
A. Administer lactulose 30 mL orally
B. Start a normal saline bolus at 500 mL/hr
C. Prepare for paracentesis to relieve ascites
D. Administer intravenous ceftriaxone 1 g
Answer: A
Rationale: The patient is experiencing hepatic encephalopathy, as evidenced by confusion, asterixis, fetor
hepaticus, and elevated ammonia. Lactulose reduces serum ammonia by acidifying the colon and
promoting excretion. This is the priority intervention. IV fluids (B) may be needed but are not first-line
for encephalopathy. Paracentesis (C) does not address encephalopathy. Ceftriaxone (D) is for
spontaneous bacterial peritonitis, not indicated here without signs of infection.
Page 1
,3. A patient with type 2 diabetes mellitus is admitted with hyperglycemic hyperosmolar state
(HHS). Serum glucose 680 mg/dL, serum sodium 148 mEq/L (corrected 152), BUN 42 mg/dL,
creatinine 1.8 mg/dL, serum osmolality 340 mOsm/kg. The patient is awake and oriented. The
nurse starts 0.9% normal saline at 1 L/hr. After 2 liters, reassessment shows glucose 550 mg/dL,
sodium 146 mEq/L, osmolality 320 mOsm/kg. What is the nurse's next best action?
A. Continue 0.9% normal saline at 1 L/hr
B. Switch to 0.45% normal saline at 250 mL/hr
C. Start intravenous regular insulin at 0.1 units/kg bolus then 0.1 units/kg/hr
D. Administer sodium bicarbonate 50 mEq IV push
Answer: B
Rationale: In HHS, initial fluid resuscitation with 0.9% NS corrects hypovolemia. After hemodynamic
stability and falling glucose, the corrected sodium is elevated (hypernatremia), indicating free water
deficit. Switching to 0.45% NS provides free water to correct hypernatremia. Continuing 0.9% NS (A)
risks worsening hypernatremia. Insulin (C) is typically started after fluid resuscitation when glucose
stops falling, but here glucose is still dropping; insulin may be considered but fluid correction takes
priority to avoid rapid osmotic shifts. Sodium bicarbonate (D) is not indicated without severe acidosis
(pH <7.0).
4. A patient with a history of heart failure (HFrEF, LVEF 30%) is admitted with acute
decompensation. The nurse notes jugular venous distention, bilateral crackles up to the
mid-scapulae, and 3+ pitting edema to the knees. Vital signs: BP 142/88 mm Hg, HR 98 bpm, RR
22, SpO2 91% on room air. Which prescription should the nurse question?
A. Furosemide 40 mg IV push now
B. Metoprolol succinate 50 mg PO daily
C. Nitroglycerin 0.4 mg sublingual every 5 minutes for chest pain
D. Oxygen 2 L nasal cannula to maintain SpO2 >92%
Answer: B
Rationale: In acute decompensated heart failure, beta-blockers like metoprolol succinate are typically
held until the patient is euvolemic and hemodynamically stable, as they can reduce cardiac contractility
and worsen acute failure. Furosemide (A) is appropriate for diuresis. Nitroglycerin (C) is used for
angina; there is no indication of chest pain, but the prescription is not inherently wrong. Oxygen (D) is
appropriate for hypoxemia. Holding the beta-blocker is the priority.
5. A patient in the intensive care unit develops new-onset atrial fibrillation with rapid ventricular
response (HR 150 bpm). The patient is hemodynamically stable, BP 110/70 mm Hg, and denies
chest pain. Which intervention should the nurse prepare for first?
A. Synchronized cardioversion at 100 J
B. Intravenous amiodarone bolus and infusion
C. Intravenous metoprolol 5 mg over 2 minutes
D. Transesophageal echocardiogram to rule out clot
Answer: C
Rationale: For hemodynamically stable atrial fibrillation with rapid rate, rate control is first-line.
Metoprolol, a beta-blocker, is effective and rapid. Synchronized cardioversion (A) is reserved for
unstable patients. Amiodarone (B) is a rhythm control option but not first-line for rate control. TEE (D)
Page 2
,is indicated before cardioversion if duration >48 hours or unknown, but rate control is the immediate
priority.
6. A patient with chronic kidney disease stage 5 (not on dialysis) has the following lab results:
serum potassium 6.8 mEq/L, serum creatinine 5.2 mg/dL, BUN 80 mg/dL, serum bicarbonate 16
mEq/L, serum calcium 8.0 mg/dL, serum phosphate 6.5 mg/dL. ECG shows peaked T waves.
Which intervention should the nurse implement first?
A. Administer sodium polystyrene sulfonate (SPS) 30 g orally
B. Administer intravenous calcium gluconate 10 mL over 2 minutes
C. Administer intravenous regular insulin 10 units with D50 50 mL
D. Prepare the patient for emergent hemodialysis
Answer: B
Rationale: The patient has life-threatening hyperkalemia with ECG changes (peaked T waves). First-line
treatment is intravenous calcium gluconate to stabilize the cardiac membrane and prevent dysrhythmias.
Insulin and glucose (C) shift potassium intracellularly but take longer to act. SPS (A) is a slow-acting
potassium binder. Hemodialysis (D) is definitive but not immediately available; calcium is the priority.
7. A patient with a history of peptic ulcer disease is admitted with melena and orthostatic
hypotension. Esophagogastroduodenoscopy reveals a bleeding duodenal ulcer with a visible vessel.
The ulcer is treated with epinephrine injection and bipolar coagulation. Post-procedure, the nurse
administers intravenous pantoprazole 80 mg bolus followed by 8 mg/hr continuous infusion. What
is the primary rationale for this high-dose proton pump inhibitor (PPI) regimen?
A. To neutralize gastric acid and promote platelet aggregation
B. To maintain intragastric pH >6 to stabilize the clot
C. To reduce gastric acid secretion and prevent rebleeding
D. To eradicate Helicobacter pylori if present
Answer: B
Rationale: After endoscopic hemostasis of a bleeding ulcer, high-dose PPI (bolus plus continuous
infusion) is used to maintain intragastric pH >6, which is necessary for platelet aggregation and clot
stability. This reduces the risk of rebleeding. Neutralization (A) is not the mechanism; PPIs suppress
acid secretion. Reducing acid (C) is true but the specific goal is pH >6. H. pylori eradication (D)
requires antibiotics, not PPI alone.
8. A patient with septic shock is receiving norepinephrine infusion at 15 mcg/min via a central line.
The mean arterial pressure (MAP) is 58 mm Hg. The nurse is about to administer a 500 mL
normal saline bolus per protocol. Which action should the nurse take?
A. Administer the fluid bolus and reassess MAP
B. Increase norepinephrine to 20 mcg/min and hold fluids
C. Start a second vasopressor such as vasopressin
D. Check a serum lactate level before giving fluids
Answer: A
Rationale: In septic shock, fluid resuscitation is a priority. The patient is on a moderate dose of
norepinephrine with persistent hypotension (MAP <65). The nurse should administer the fluid bolus as
prescribed and reassess. Increasing norepinephrine (B) without fluids may be less effective. Adding a
Page 3
, second vasopressor (C) may be considered if fluids and norepinephrine fail, but fluids come first.
Checking lactate (D) is important but should not delay fluid administration.
9. A patient with acute pancreatitis has the following labs: serum lipase 1200 U/L, amylase 800
U/L, WBC 18,000/mm3, glucose 200 mg/dL, calcium 7.5 mg/dL, LDH 350 U/L, AST 120 U/L, and
hematocrit 50%. The patient has a Ranson score of 4. Which complication is the patient at highest
risk for developing?
A. Acute respiratory distress syndrome
B. Pancreatic pseudocyst
C. Chronic pancreatitis
D. Pancreatic necrosis
Answer: D
Rationale: Ranson criteria predict severity of pancreatitis. A score of 4 indicates severe pancreatitis. The
patient has multiple risk factors for pancreatic necrosis (elevated LDH, AST, glucose, leukocytosis,
hypocalcemia). Necrosis is a major complication in severe acute pancreatitis. ARDS (A) can occur but is
less specific. Pseudocyst (B) typically develops weeks later. Chronic pancreatitis (C) is a long-term
outcome, not acute.
10. A patient is receiving a continuous infusion of unfractionated heparin for acute pulmonary
embolism. The aPTT is 90 seconds (therapeutic range 60-80 seconds). The nurse notes the patient
has new-onset hemoptysis and a drop in hemoglobin from 12.5 to 10.0 g/dL over 4 hours. What is
the nurse's priority action?
A. Decrease the heparin infusion rate by 50%
B. Stop the heparin infusion and administer protamine sulfate
C. Obtain a stat chest X-ray and CT pulmonary angiogram
D. Administer vitamin K 10 mg intravenously
Answer: B
Rationale: The patient has a supratherapeutic aPTT and signs of major bleeding (hemoptysis, dropping
hemoglobin). Heparin should be stopped immediately, and protamine sulfate given to reverse
anticoagulation. Decreasing the rate (A) is insufficient. Chest X-ray and CT (C) may be done after
stabilization. Vitamin K (D) reverses warfarin, not heparin.
11. A patient with acute decompensated heart failure is receiving intravenous furosemide at 10
mg/hour. The nurse notes a drop in urine output from 100 mL/hour to 30 mL/hour over the past 2
hours, and the patient's blood pressure is 88/52 mm Hg. The serum creatinine has risen from 1.0
mg/dL to 1.8 mg/dL. Which intervention should the nurse prioritize?
A. Increase the furosemide infusion rate to 20 mg/hour to improve urine output.
B. Administer a 500 mL bolus of 0.9% normal saline over 30 minutes.
C. Hold the furosemide infusion and notify the healthcare provider immediately.
D. Obtain a stat serum potassium level and prepare for dialysis.
Answer: C
Rationale: The patient is showing signs of prerenal acute kidney injury (AKI) due to hypoperfusion from
over-diuresis and hypotension. Continuing furosemide would worsen renal function. Holding the
infusion and notifying the provider allows for reassessment and possible fluid resuscitation or
Page 4
