HESI Medical-Surgical Nursing Exam Prep
2025-2026 | 11th Edition | Donna D. Ignatavicius, M.
Linda Workman, Cherie R. Rebar, Nicole M.
Heimgartne
1. A patient with septic shock develops acute respiratory distress syndrome (ARDS). The nurse
notes that the patient's PaO2 is 55 mm Hg on 100% FiO2, and the chest radiograph shows
bilateral infiltrates. Which ventilator strategy is most appropriate to reduce ventilator-induced
lung injury?
A. Low tidal volume (6 mL/kg predicted body weight) with plateau pressure <30 cm H2O
B. High tidal volume (10 mL/kg) with positive end-expiratory pressure (PEEP) of 5 cm H2O
C. Pressure-controlled ventilation with peak inspiratory pressure of 40 cm H2O
D. Inverse ratio ventilation with a 2:1 inspiratory-to-expiratory ratio
Answer: A
Rationale: Low tidal volume ventilation (6 mL/kg PBW) with plateau pressure <30 cm H2O is the
lung-protective strategy shown to reduce mortality in ARDS (ARDSNet trial). High tidal volumes
increase barotrauma; high peak pressures and inverse ratios are not first-line lung-protective strategies.
2. A patient with cirrhosis and ascites develops hepatic encephalopathy. The nurse administers
lactulose. Which laboratory value best indicates therapeutic effectiveness of lactulose therapy?
A. Serum ammonia level decreasing from 80 to 45 mcg/dL
B. Stool pH decreasing from 7.0 to 5.5
C. Serum bilirubin decreasing from 3.2 to 1.8 mg/dL
D. Prothrombin time decreasing from 18 to 14 seconds
Answer: B
Rationale: Lactulose works by acidifying the colon, trapping ammonium (NH4+) in the stool, and
reducing serum ammonia. The goal is to achieve 2-3 soft stools per day with a stool pH of 5.0-6.0; stool
pH is a direct measure of colonic acidification. Serum ammonia levels correlate poorly with clinical
improvement and are not the best indicator of lactulose effectiveness.
3. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium of 5.8 mEq/L.
Which combination of medications requires the most cautious monitoring to prevent
life-threatening hyperkalemia?
A. Lisinopril and spironolactone
B. Metoprolol and furosemide
C. Calcium acetate and sevelamer
D. Erythropoietin and iron sucrose
Page 1
,Answer: A
Rationale: Lisinopril (ACE inhibitor) decreases aldosterone, reducing potassium excretion;
spironolactone (potassium-sparing diuretic) antagonizes aldosterone. Combined, they dramatically
increase hyperkalemia risk, especially in CKD. Metoprolol has minimal effect; furosemide promotes
potassium loss. Calcium acetate and sevelamer are phosphate binders; erythropoietin and iron do not
raise potassium.
4. A patient with diabetic ketoacidosis (DKA) is receiving intravenous insulin at 0.1 units/kg/hour.
The nurse monitors serum glucose and potassium. After 2 hours, glucose has decreased from 650
to 450 mg/dL, but potassium is now 3.2 mEq/L (from 4.5). What is the priority nursing action?
A. Decrease the insulin infusion rate to 0.05 units/kg/hour
B. Administer 20 mEq of potassium chloride intravenously over 1 hour
C. Administer 50 mL of 50% dextrose intravenously
D. Continue the current insulin infusion and recheck potassium in 1 hour
Answer: B
Rationale: Insulin drives potassium into cells, causing hypokalemia. In DKA, potassium replacement is
critical when serum K+ <3.3 mEq/L to prevent cardiac dysrhythmias. Insulin should be held until
potassium is >3.3 mEq/L; decreasing the rate is insufficient. Dextrose is given when glucose drops too
rapidly (<250 mg/dL), not for hypokalemia.
5. A patient with acute pancreatitis has severe epigastric pain radiating to the back, nausea, and
vomiting. The nurse reviews the laboratory results: serum lipase 1200 U/L, WBC 18,000/mm3, and
calcium 7.2 mg/dL. Which assessment finding indicates a poor prognosis and requires immediate
notification of the healthcare provider?
A. Grey Turner sign
B. Positive Chvostek sign
C. Hypoactive bowel sounds
D. Temperature of 100.2°F (37.9°C)
Answer: B
Rationale: Hypocalcemia (Ca 7.2) in acute pancreatitis is a poor prognostic sign (Ranson criteria).
Positive Chvostek sign indicates tetany due to hypocalcemia, which can progress to life-threatening
laryngospasm or arrhythmias. Grey Turner sign indicates retroperitoneal hemorrhage but is not
immediate. Hypoactive bowel sounds are common; low-grade fever is expected.
6. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor
reading of 22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. The nurse prepares to
administer which intervention first?
A. Mannitol 0.5 g/kg intravenously
B. Propofol infusion for sedation
C. Hyperventilation to PaCO2 of 30 mm Hg
D. Elevate the head of bed to 30 degrees
Answer: D
Page 2
,Rationale: Elevating the head of bed improves venous outflow, reducing ICP and potentially increasing CPP. It is a simple,
noninvasive first-line intervention. Mannitol and propofol may be used if ICP remains elevated, but the head elevation should
be optimized first. Hyperventilation is reserved for acute ICP crisis due to risk of cerebral ischemia.
7. A patient with a history of heart failure with reduced ejection fraction (HFrEF) presents with
dyspnea, jugular venous distention, and 3+ pitting edema. The nurse reviews the medication list:
lisinopril, metoprolol, furosemide, and digoxin. Which laboratory value is most important to assess
before administering digoxin?
A. Serum potassium
B. Serum creatinine
C. Serum magnesium
D. Serum calcium
Answer: A
Rationale: Hypokalemia potentiates digoxin toxicity, leading to life-threatening dysrhythmias.
Furosemide causes potassium loss, increasing risk. While renal function (creatinine) affects digoxin
clearance, potassium is the most critical immediate concern. Magnesium and calcium also affect toxicity
but are less commonly altered acutely by furosemide.
8. A patient with acute kidney injury (AKI) due to acute tubular necrosis (ATN) has a urine output
of 200 mL over the past 24 hours. The serum creatinine is 4.2 mg/dL, BUN 80 mg/dL, and
potassium 5.6 mEq/L. Which finding is most indicative of the need for urgent hemodialysis?
A. Urine output 200 mL/24 hours
B. Serum creatinine 4.2 mg/dL
C. BUN 80 mg/dL
D. Potassium 5.6 mEq/L
Answer: D
Rationale: Life-threatening hyperkalemia (K+ >6.0 mEq/L or rapidly rising with ECG changes) is an
absolute indication for urgent dialysis. While oliguria, high creatinine, and high BUN are concerning,
they do not mandate immediate dialysis unless accompanied by refractory volume overload, severe
acidosis, or uremic symptoms. A K+ of 5.6 is borderline but trending upward; however, if ECG changes
are present, dialysis is indicated. The question implies urgency; hyperkalemia is the most immediately
dangerous.
9. A patient with a history of type 2 diabetes mellitus and chronic kidney disease (CKD) stage 3 is
prescribed metformin. The nurse reviews the patient's most recent laboratory results: eGFR 48
mL/min/1.73 m², serum creatinine 1.4 mg/dL, and hemoglobin A1c 8.2%. What is the nurse's best
action?
A. Administer metformin as prescribed, but monitor renal function every 3 months
B. Hold metformin and notify the provider because eGFR is below 60
C. Administer metformin with a reduced dose based on eGFR
D. Hold metformin and request a change to an insulin secretagogue
Answer: A
Page 3
, Rationale: Current FDA guidelines allow metformin use if eGFR is "e30; at eGFR 45-59, metformin can be continued with
monitoring every 3-6 months. The eGFR of 48 is above the threshold for contraindication. Dose reduction is not required
until eGFR <45. Insulin secretagogues increase hypoglycemia risk. Therefore, administering metformin with monitoring is
appropriate.
10. A patient with acute pancreatitis develops sudden onset of severe abdominal pain, hypotension,
and a palpable abdominal mass. A CT scan reveals a fluid collection in the lesser sac. Which
intervention should the nurse anticipate as the priority?
A. Administer intravenous albumin to increase oncotic pressure.
B. Prepare the patient for percutaneous catheter drainage.
C. Initiate total parenteral nutrition to rest the pancreas.
D. Administer a bolus of lactated Ringer's solution.
Answer: B
Rationale: The findings suggest a pancreatic pseudocyst or abscess, which requires drainage to prevent
rupture or infection. Percutaneous drainage is the least invasive and often first-line intervention.
Albumin is not indicated; fluid resuscitation is important but not the priority once a collection is
identified. TPN is supportive but not emergent.
11. A patient with chronic heart failure (HFrEF) on guideline-directed medical therapy (GDMT)
with sacubitril/valsartan, metoprolol succinate, and spironolactone develops symptomatic
hypotension and a serum potassium of 5.6 mEq/L. Which medication adjustment is most
appropriate?
A. Discontinue spironolactone and reduce sacubitril/valsartan dose.
B. Increase metoprolol succinate dose to counteract hypotension.
C. Add a loop diuretic and continue all current medications.
D. Replace sacubitril/valsartan with an ACE inhibitor.
Answer: A
Rationale: Hyperkalemia (K+ 5.6) with spironolactone requires discontinuation of the mineralocorticoid
receptor antagonist. Sacubitril/valsartan can also contribute to hypotension and hyperkalemia; dose
reduction is appropriate. Increasing beta-blocker would worsen hypotension. Adding a loop diuretic
may help but does not address the hyperkalemia risk. Switching to an ACE inhibitor does not resolve the
hyperkalemia and may cause angioedema.
12. A patient with cirrhosis and ascites is started on a course of oral ciprofloxacin. Which
mechanism best explains the rationale for this prophylactic therapy?
A. Reduction of intestinal bacterial overgrowth to prevent spontaneous bacterial peritonitis.
B. Direct antibacterial action against ascitic fluid pathogens.
C. Inhibition of renal vasoconstriction to improve renal perfusion.
D. Suppression of hepatic fibrogenesis by modulating gut microbiota.
Answer: A
Rationale: Fluoroquinolones like ciprofloxacin are used for prophylaxis of spontaneous bacterial
peritonitis (SBP) in cirrhotic patients with ascites. They work by reducing gram-negative bacterial load
in the gut, decreasing translocation and subsequent infection of ascitic fluid. They do not act directly on
ascitic fluid, nor do they affect renal perfusion or fibrogenesis.
Page 4
2025-2026 | 11th Edition | Donna D. Ignatavicius, M.
Linda Workman, Cherie R. Rebar, Nicole M.
Heimgartne
1. A patient with septic shock develops acute respiratory distress syndrome (ARDS). The nurse
notes that the patient's PaO2 is 55 mm Hg on 100% FiO2, and the chest radiograph shows
bilateral infiltrates. Which ventilator strategy is most appropriate to reduce ventilator-induced
lung injury?
A. Low tidal volume (6 mL/kg predicted body weight) with plateau pressure <30 cm H2O
B. High tidal volume (10 mL/kg) with positive end-expiratory pressure (PEEP) of 5 cm H2O
C. Pressure-controlled ventilation with peak inspiratory pressure of 40 cm H2O
D. Inverse ratio ventilation with a 2:1 inspiratory-to-expiratory ratio
Answer: A
Rationale: Low tidal volume ventilation (6 mL/kg PBW) with plateau pressure <30 cm H2O is the
lung-protective strategy shown to reduce mortality in ARDS (ARDSNet trial). High tidal volumes
increase barotrauma; high peak pressures and inverse ratios are not first-line lung-protective strategies.
2. A patient with cirrhosis and ascites develops hepatic encephalopathy. The nurse administers
lactulose. Which laboratory value best indicates therapeutic effectiveness of lactulose therapy?
A. Serum ammonia level decreasing from 80 to 45 mcg/dL
B. Stool pH decreasing from 7.0 to 5.5
C. Serum bilirubin decreasing from 3.2 to 1.8 mg/dL
D. Prothrombin time decreasing from 18 to 14 seconds
Answer: B
Rationale: Lactulose works by acidifying the colon, trapping ammonium (NH4+) in the stool, and
reducing serum ammonia. The goal is to achieve 2-3 soft stools per day with a stool pH of 5.0-6.0; stool
pH is a direct measure of colonic acidification. Serum ammonia levels correlate poorly with clinical
improvement and are not the best indicator of lactulose effectiveness.
3. A patient with chronic kidney disease (CKD) stage 4 has a serum potassium of 5.8 mEq/L.
Which combination of medications requires the most cautious monitoring to prevent
life-threatening hyperkalemia?
A. Lisinopril and spironolactone
B. Metoprolol and furosemide
C. Calcium acetate and sevelamer
D. Erythropoietin and iron sucrose
Page 1
,Answer: A
Rationale: Lisinopril (ACE inhibitor) decreases aldosterone, reducing potassium excretion;
spironolactone (potassium-sparing diuretic) antagonizes aldosterone. Combined, they dramatically
increase hyperkalemia risk, especially in CKD. Metoprolol has minimal effect; furosemide promotes
potassium loss. Calcium acetate and sevelamer are phosphate binders; erythropoietin and iron do not
raise potassium.
4. A patient with diabetic ketoacidosis (DKA) is receiving intravenous insulin at 0.1 units/kg/hour.
The nurse monitors serum glucose and potassium. After 2 hours, glucose has decreased from 650
to 450 mg/dL, but potassium is now 3.2 mEq/L (from 4.5). What is the priority nursing action?
A. Decrease the insulin infusion rate to 0.05 units/kg/hour
B. Administer 20 mEq of potassium chloride intravenously over 1 hour
C. Administer 50 mL of 50% dextrose intravenously
D. Continue the current insulin infusion and recheck potassium in 1 hour
Answer: B
Rationale: Insulin drives potassium into cells, causing hypokalemia. In DKA, potassium replacement is
critical when serum K+ <3.3 mEq/L to prevent cardiac dysrhythmias. Insulin should be held until
potassium is >3.3 mEq/L; decreasing the rate is insufficient. Dextrose is given when glucose drops too
rapidly (<250 mg/dL), not for hypokalemia.
5. A patient with acute pancreatitis has severe epigastric pain radiating to the back, nausea, and
vomiting. The nurse reviews the laboratory results: serum lipase 1200 U/L, WBC 18,000/mm3, and
calcium 7.2 mg/dL. Which assessment finding indicates a poor prognosis and requires immediate
notification of the healthcare provider?
A. Grey Turner sign
B. Positive Chvostek sign
C. Hypoactive bowel sounds
D. Temperature of 100.2°F (37.9°C)
Answer: B
Rationale: Hypocalcemia (Ca 7.2) in acute pancreatitis is a poor prognostic sign (Ranson criteria).
Positive Chvostek sign indicates tetany due to hypocalcemia, which can progress to life-threatening
laryngospasm or arrhythmias. Grey Turner sign indicates retroperitoneal hemorrhage but is not
immediate. Hypoactive bowel sounds are common; low-grade fever is expected.
6. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) monitor
reading of 22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. The nurse prepares to
administer which intervention first?
A. Mannitol 0.5 g/kg intravenously
B. Propofol infusion for sedation
C. Hyperventilation to PaCO2 of 30 mm Hg
D. Elevate the head of bed to 30 degrees
Answer: D
Page 2
,Rationale: Elevating the head of bed improves venous outflow, reducing ICP and potentially increasing CPP. It is a simple,
noninvasive first-line intervention. Mannitol and propofol may be used if ICP remains elevated, but the head elevation should
be optimized first. Hyperventilation is reserved for acute ICP crisis due to risk of cerebral ischemia.
7. A patient with a history of heart failure with reduced ejection fraction (HFrEF) presents with
dyspnea, jugular venous distention, and 3+ pitting edema. The nurse reviews the medication list:
lisinopril, metoprolol, furosemide, and digoxin. Which laboratory value is most important to assess
before administering digoxin?
A. Serum potassium
B. Serum creatinine
C. Serum magnesium
D. Serum calcium
Answer: A
Rationale: Hypokalemia potentiates digoxin toxicity, leading to life-threatening dysrhythmias.
Furosemide causes potassium loss, increasing risk. While renal function (creatinine) affects digoxin
clearance, potassium is the most critical immediate concern. Magnesium and calcium also affect toxicity
but are less commonly altered acutely by furosemide.
8. A patient with acute kidney injury (AKI) due to acute tubular necrosis (ATN) has a urine output
of 200 mL over the past 24 hours. The serum creatinine is 4.2 mg/dL, BUN 80 mg/dL, and
potassium 5.6 mEq/L. Which finding is most indicative of the need for urgent hemodialysis?
A. Urine output 200 mL/24 hours
B. Serum creatinine 4.2 mg/dL
C. BUN 80 mg/dL
D. Potassium 5.6 mEq/L
Answer: D
Rationale: Life-threatening hyperkalemia (K+ >6.0 mEq/L or rapidly rising with ECG changes) is an
absolute indication for urgent dialysis. While oliguria, high creatinine, and high BUN are concerning,
they do not mandate immediate dialysis unless accompanied by refractory volume overload, severe
acidosis, or uremic symptoms. A K+ of 5.6 is borderline but trending upward; however, if ECG changes
are present, dialysis is indicated. The question implies urgency; hyperkalemia is the most immediately
dangerous.
9. A patient with a history of type 2 diabetes mellitus and chronic kidney disease (CKD) stage 3 is
prescribed metformin. The nurse reviews the patient's most recent laboratory results: eGFR 48
mL/min/1.73 m², serum creatinine 1.4 mg/dL, and hemoglobin A1c 8.2%. What is the nurse's best
action?
A. Administer metformin as prescribed, but monitor renal function every 3 months
B. Hold metformin and notify the provider because eGFR is below 60
C. Administer metformin with a reduced dose based on eGFR
D. Hold metformin and request a change to an insulin secretagogue
Answer: A
Page 3
, Rationale: Current FDA guidelines allow metformin use if eGFR is "e30; at eGFR 45-59, metformin can be continued with
monitoring every 3-6 months. The eGFR of 48 is above the threshold for contraindication. Dose reduction is not required
until eGFR <45. Insulin secretagogues increase hypoglycemia risk. Therefore, administering metformin with monitoring is
appropriate.
10. A patient with acute pancreatitis develops sudden onset of severe abdominal pain, hypotension,
and a palpable abdominal mass. A CT scan reveals a fluid collection in the lesser sac. Which
intervention should the nurse anticipate as the priority?
A. Administer intravenous albumin to increase oncotic pressure.
B. Prepare the patient for percutaneous catheter drainage.
C. Initiate total parenteral nutrition to rest the pancreas.
D. Administer a bolus of lactated Ringer's solution.
Answer: B
Rationale: The findings suggest a pancreatic pseudocyst or abscess, which requires drainage to prevent
rupture or infection. Percutaneous drainage is the least invasive and often first-line intervention.
Albumin is not indicated; fluid resuscitation is important but not the priority once a collection is
identified. TPN is supportive but not emergent.
11. A patient with chronic heart failure (HFrEF) on guideline-directed medical therapy (GDMT)
with sacubitril/valsartan, metoprolol succinate, and spironolactone develops symptomatic
hypotension and a serum potassium of 5.6 mEq/L. Which medication adjustment is most
appropriate?
A. Discontinue spironolactone and reduce sacubitril/valsartan dose.
B. Increase metoprolol succinate dose to counteract hypotension.
C. Add a loop diuretic and continue all current medications.
D. Replace sacubitril/valsartan with an ACE inhibitor.
Answer: A
Rationale: Hyperkalemia (K+ 5.6) with spironolactone requires discontinuation of the mineralocorticoid
receptor antagonist. Sacubitril/valsartan can also contribute to hypotension and hyperkalemia; dose
reduction is appropriate. Increasing beta-blocker would worsen hypotension. Adding a loop diuretic
may help but does not address the hyperkalemia risk. Switching to an ACE inhibitor does not resolve the
hyperkalemia and may cause angioedema.
12. A patient with cirrhosis and ascites is started on a course of oral ciprofloxacin. Which
mechanism best explains the rationale for this prophylactic therapy?
A. Reduction of intestinal bacterial overgrowth to prevent spontaneous bacterial peritonitis.
B. Direct antibacterial action against ascitic fluid pathogens.
C. Inhibition of renal vasoconstriction to improve renal perfusion.
D. Suppression of hepatic fibrogenesis by modulating gut microbiota.
Answer: A
Rationale: Fluoroquinolones like ciprofloxacin are used for prophylaxis of spontaneous bacterial
peritonitis (SBP) in cirrhotic patients with ascites. They work by reducing gram-negative bacterial load
in the gut, decreasing translocation and subsequent infection of ascitic fluid. They do not act directly on
ascitic fluid, nor do they affect renal perfusion or fibrogenesis.
Page 4
