HESI Medical Surgical RN Exam | 2026 Study Guide - 250
Questions
This exam assesses advanced understanding of cardiovascular pathophysiology, hemodynamics, pharmacological
management, and evidence-based nursing interventions for acute and chronic cardiac conditions. It mirrors the
rigor of Ivy League nursing programs and prepares students for the HESI RN exit exam. It contains 250
multiple-choice questions, each with four distractors and a fully worked rationale that explains why the keyed
answer is correct. Content is organized into 11 focused sections: Cardiovascular System, Respiratory System,
Gastrointestinal System, Neurological System, Renal and Urinary System, Endocrine System, Musculoskeletal
System, Integumentary System, Perioperative Care, Fluid and Electrolyte Balance, Oncology and Hematology.
Targeted learning outcomes include: Analyze hemodynamic parameters to differentiate types of shock; Evaluate
ECG findings and correlate with clinical management; Synthesize pathophysiology and pharmacotherapy for
heart failure and arrhythmias; Interpret diagnostic data to guide nursing interventions in cardiac emergencies.
Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that students can study with
confidence and self-correct as they work through the bank. Use it as a high-yield review immediately before the
exam, or as a structured practice tool during the unit - the rationales double as concise teaching notes. The
recommended writing time is 3 hours, with a passing score of 900/1200. Aligned with Meets AACN and CCNE
standards for baccalaureate nursing education standards and reflects the question style commonly seen on
Section 1: Cardiovascular System (Questions 1-23)
1 A patient with acute decompensated heart failure has a pulmonary artery
wedge pressure (PAWP) of 28 mm Hg and cardiac index of 1.8 L/min/m².
Which hemodynamic profile is most consistent with these values?
A) Warm and dry (normal perfusion, no congestion)
B) Warm and wet (normal perfusion, congestion)
C) Cold and dry (hypoperfusion, no congestion)
D) Cold and wet (hypoperfusion, congestion)
Answer: D
Rationale: A PAWP >18 mm Hg indicates pulmonary congestion; a cardiac
index <2.2 L/min/m² indicates hypoperfusion. This combination defines the
'cold and wet' profile (Forrester class IV), requiring inotropic support and
diuresis.
2 Which electrolyte abnormality most predisposes a patient to digoxin toxicity,
and what is the underlying mechanism?
A) Hyperkalemia; reduces renal clearance of digoxin
B) Hypokalemia; increases myocardial binding of digoxin to Na+/K+ ATPase
C) Hypercalcemia; enhances digoxin-induced afterdepolarizations
D) Hypomagnesemia; impairs digoxin metabolism in the liver
,Answer: B
Rationale: Hypokalemia increases the affinity of digoxin for the Na+/K+
ATPase pump, potentiating its toxic effects. Hyperkalemia actually decreases
binding, while hypomagnesemia and hypercalcemia can contribute but are not
the primary predisposing factor.
3 A patient with non-ST-elevation myocardial infarction (NSTEMI) has
elevated high-sensitivity troponin and recurrent chest pain despite medical
therapy. Which intervention is most appropriate to reduce ischemic risk
before percutaneous coronary intervention?
A) Administration of fibrinolytic therapy
B) Insertion of an intra-aortic balloon pump
C) Loading dose of ticagrelor and aspirin
D) Urgent coronary artery bypass grafting
Answer: C
Rationale: Dual antiplatelet therapy (aspirin + P2Y12 inhibitor like ticagrelor)
is recommended for NSTEMI to reduce thrombotic events. Fibrinolytics are
contraindicated in NSTEMI; IABP is reserved for cardiogenic shock; CABG is
not urgent unless anatomy dictates.
4 In a patient with atrial fibrillation and a CHADS-VASc score of 4, which
anticoagulation strategy is most appropriate, and what is the primary concern
with vitamin K antagonists?
A) Apixaban; narrow therapeutic window requiring frequent INR monitoring
B) Warfarin; unpredictable dose response due to dietary vitamin K interaction
C) Rivaroxaban; increased risk of gastrointestinal bleeding in renal
impairment
D) Dabigatran; requires dose adjustment for hepatic impairment
Answer: A
Rationale: Apixaban is a direct oral anticoagulant with fixed dosing and no INR
monitoring. Warfarin's narrow therapeutic window and food/drug interactions
necessitate frequent monitoring. Rivaroxaban and dabigatran have renal
clearance concerns but not hepatic.
5 A patient with hypertrophic cardiomyopathy experiences syncope during
exercise. The most likely cause is:
,A) Dynamic left ventricular outflow tract obstruction exacerbated by
increased contractility
B) Paradoxical embolus from a patent foramen ovale
C) Vasovagal response due to increased vagal tone during exertion
D) Torsades de pointes from prolonged QT interval
Answer: A
Rationale: In hypertrophic cardiomyopathy, exercise increases heart rate and
contractility, reducing ventricular volume and worsening left ventricular
outflow tract obstruction. This decreases cardiac output, causing syncope. The
other options are less common causes.
6 A patient with severe aortic stenosis (valve area 0.7 cm²) is scheduled for
valve replacement. Which finding would most likely delay surgery and
require further evaluation?
A) Left ventricular ejection fraction of 35%
B) Mean transvalvular gradient of 50 mm Hg
C) Moderate mitral regurgitation on echocardiography
D) Severe pulmonary hypertension with right ventricular dysfunction
Answer: D
Rationale: Severe pulmonary hypertension and right ventricular dysfunction
significantly increase perioperative mortality; optimizing right heart function
preoperatively may be indicated. Reduced LVEF and moderate MR are
common in severe AS and not contraindications. A high gradient confirms
severity.
7 Which of the following best explains why a patient with chronic heart failure
may have an elevated BNP level but a normal ejection fraction?
A) BNP is solely released from the left ventricle in response to pressure
overload
B) Heart failure with preserved ejection fraction often involves diastolic
dysfunction and elevated filling pressures
C) BNP is cleared more slowly in patients with liver congestion
D) Elevated BNP in this setting indicates concomitant atrial fibrillation
Answer: B
Rationale: In heart failure with preserved ejection fraction (HFpEF), impaired
relaxation and increased stiffness lead to elevated left ventricular end-diastolic
, pressure, stimulating BNP release. BNP is also released from atria; clearance is
not significantly altered. Atrial fibrillation can elevate BNP but is not the
primary explanation.
8 A patient presents with acute chest pain, ECG showing ST elevation in leads
II, III, and aVF, and elevated troponin. Which artery is most likely occluded?
A) Left anterior descending artery
B) Left circumflex artery
C) Right coronary artery
D) Left main coronary artery
Answer: C
Rationale: ST elevation in the inferior leads (II, III, aVF) indicates occlusion of
the right coronary artery (RCA) in 80-90% of cases. The left anterior
descending supplies anterior wall; left circumflex supplies lateral wall; left
main occlusion would cause widespread ST changes.
9 A patient with chronic stable angina develops new-onset dyspnea on exertion
and orthopnea. Which complication of coronary artery disease is most
likely?
A) Papillary muscle rupture causing acute mitral regurgitation
B) Left ventricular aneurysm formation with thrombus
C) Ischemic cardiomyopathy with systolic heart failure
D) Ventricular septal defect following silent infarction
Answer: C
Rationale: Chronic ischemia can lead to progressive myocardial dysfunction
and heart failure, manifesting as dyspnea and orthopnea. Papillary muscle
rupture and VSD are acute complications of MI. LV aneurysm typically
presents with persistent ST elevation or embolic events.
10 Which of the following is the most appropriate initial intervention for a
patient with unstable supraventricular tachycardia (heart rate 220 bpm) and
blood pressure 80/50 mm Hg?
A) Administration of adenosine 6 mg rapid IV push
B) Synchronized cardioversion at 100 J biphasic
C) IV amiodarone 150 mg over 10 minutes
D) Valsalva maneuver with postural modification
Questions
This exam assesses advanced understanding of cardiovascular pathophysiology, hemodynamics, pharmacological
management, and evidence-based nursing interventions for acute and chronic cardiac conditions. It mirrors the
rigor of Ivy League nursing programs and prepares students for the HESI RN exit exam. It contains 250
multiple-choice questions, each with four distractors and a fully worked rationale that explains why the keyed
answer is correct. Content is organized into 11 focused sections: Cardiovascular System, Respiratory System,
Gastrointestinal System, Neurological System, Renal and Urinary System, Endocrine System, Musculoskeletal
System, Integumentary System, Perioperative Care, Fluid and Electrolyte Balance, Oncology and Hematology.
Targeted learning outcomes include: Analyze hemodynamic parameters to differentiate types of shock; Evaluate
ECG findings and correlate with clinical management; Synthesize pathophysiology and pharmacotherapy for
heart failure and arrhythmias; Interpret diagnostic data to guide nursing interventions in cardiac emergencies.
Every item has been reviewed for clinical accuracy, current guidelines, and clarity so that students can study with
confidence and self-correct as they work through the bank. Use it as a high-yield review immediately before the
exam, or as a structured practice tool during the unit - the rationales double as concise teaching notes. The
recommended writing time is 3 hours, with a passing score of 900/1200. Aligned with Meets AACN and CCNE
standards for baccalaureate nursing education standards and reflects the question style commonly seen on
Section 1: Cardiovascular System (Questions 1-23)
1 A patient with acute decompensated heart failure has a pulmonary artery
wedge pressure (PAWP) of 28 mm Hg and cardiac index of 1.8 L/min/m².
Which hemodynamic profile is most consistent with these values?
A) Warm and dry (normal perfusion, no congestion)
B) Warm and wet (normal perfusion, congestion)
C) Cold and dry (hypoperfusion, no congestion)
D) Cold and wet (hypoperfusion, congestion)
Answer: D
Rationale: A PAWP >18 mm Hg indicates pulmonary congestion; a cardiac
index <2.2 L/min/m² indicates hypoperfusion. This combination defines the
'cold and wet' profile (Forrester class IV), requiring inotropic support and
diuresis.
2 Which electrolyte abnormality most predisposes a patient to digoxin toxicity,
and what is the underlying mechanism?
A) Hyperkalemia; reduces renal clearance of digoxin
B) Hypokalemia; increases myocardial binding of digoxin to Na+/K+ ATPase
C) Hypercalcemia; enhances digoxin-induced afterdepolarizations
D) Hypomagnesemia; impairs digoxin metabolism in the liver
,Answer: B
Rationale: Hypokalemia increases the affinity of digoxin for the Na+/K+
ATPase pump, potentiating its toxic effects. Hyperkalemia actually decreases
binding, while hypomagnesemia and hypercalcemia can contribute but are not
the primary predisposing factor.
3 A patient with non-ST-elevation myocardial infarction (NSTEMI) has
elevated high-sensitivity troponin and recurrent chest pain despite medical
therapy. Which intervention is most appropriate to reduce ischemic risk
before percutaneous coronary intervention?
A) Administration of fibrinolytic therapy
B) Insertion of an intra-aortic balloon pump
C) Loading dose of ticagrelor and aspirin
D) Urgent coronary artery bypass grafting
Answer: C
Rationale: Dual antiplatelet therapy (aspirin + P2Y12 inhibitor like ticagrelor)
is recommended for NSTEMI to reduce thrombotic events. Fibrinolytics are
contraindicated in NSTEMI; IABP is reserved for cardiogenic shock; CABG is
not urgent unless anatomy dictates.
4 In a patient with atrial fibrillation and a CHADS-VASc score of 4, which
anticoagulation strategy is most appropriate, and what is the primary concern
with vitamin K antagonists?
A) Apixaban; narrow therapeutic window requiring frequent INR monitoring
B) Warfarin; unpredictable dose response due to dietary vitamin K interaction
C) Rivaroxaban; increased risk of gastrointestinal bleeding in renal
impairment
D) Dabigatran; requires dose adjustment for hepatic impairment
Answer: A
Rationale: Apixaban is a direct oral anticoagulant with fixed dosing and no INR
monitoring. Warfarin's narrow therapeutic window and food/drug interactions
necessitate frequent monitoring. Rivaroxaban and dabigatran have renal
clearance concerns but not hepatic.
5 A patient with hypertrophic cardiomyopathy experiences syncope during
exercise. The most likely cause is:
,A) Dynamic left ventricular outflow tract obstruction exacerbated by
increased contractility
B) Paradoxical embolus from a patent foramen ovale
C) Vasovagal response due to increased vagal tone during exertion
D) Torsades de pointes from prolonged QT interval
Answer: A
Rationale: In hypertrophic cardiomyopathy, exercise increases heart rate and
contractility, reducing ventricular volume and worsening left ventricular
outflow tract obstruction. This decreases cardiac output, causing syncope. The
other options are less common causes.
6 A patient with severe aortic stenosis (valve area 0.7 cm²) is scheduled for
valve replacement. Which finding would most likely delay surgery and
require further evaluation?
A) Left ventricular ejection fraction of 35%
B) Mean transvalvular gradient of 50 mm Hg
C) Moderate mitral regurgitation on echocardiography
D) Severe pulmonary hypertension with right ventricular dysfunction
Answer: D
Rationale: Severe pulmonary hypertension and right ventricular dysfunction
significantly increase perioperative mortality; optimizing right heart function
preoperatively may be indicated. Reduced LVEF and moderate MR are
common in severe AS and not contraindications. A high gradient confirms
severity.
7 Which of the following best explains why a patient with chronic heart failure
may have an elevated BNP level but a normal ejection fraction?
A) BNP is solely released from the left ventricle in response to pressure
overload
B) Heart failure with preserved ejection fraction often involves diastolic
dysfunction and elevated filling pressures
C) BNP is cleared more slowly in patients with liver congestion
D) Elevated BNP in this setting indicates concomitant atrial fibrillation
Answer: B
Rationale: In heart failure with preserved ejection fraction (HFpEF), impaired
relaxation and increased stiffness lead to elevated left ventricular end-diastolic
, pressure, stimulating BNP release. BNP is also released from atria; clearance is
not significantly altered. Atrial fibrillation can elevate BNP but is not the
primary explanation.
8 A patient presents with acute chest pain, ECG showing ST elevation in leads
II, III, and aVF, and elevated troponin. Which artery is most likely occluded?
A) Left anterior descending artery
B) Left circumflex artery
C) Right coronary artery
D) Left main coronary artery
Answer: C
Rationale: ST elevation in the inferior leads (II, III, aVF) indicates occlusion of
the right coronary artery (RCA) in 80-90% of cases. The left anterior
descending supplies anterior wall; left circumflex supplies lateral wall; left
main occlusion would cause widespread ST changes.
9 A patient with chronic stable angina develops new-onset dyspnea on exertion
and orthopnea. Which complication of coronary artery disease is most
likely?
A) Papillary muscle rupture causing acute mitral regurgitation
B) Left ventricular aneurysm formation with thrombus
C) Ischemic cardiomyopathy with systolic heart failure
D) Ventricular septal defect following silent infarction
Answer: C
Rationale: Chronic ischemia can lead to progressive myocardial dysfunction
and heart failure, manifesting as dyspnea and orthopnea. Papillary muscle
rupture and VSD are acute complications of MI. LV aneurysm typically
presents with persistent ST elevation or embolic events.
10 Which of the following is the most appropriate initial intervention for a
patient with unstable supraventricular tachycardia (heart rate 220 bpm) and
blood pressure 80/50 mm Hg?
A) Administration of adenosine 6 mg rapid IV push
B) Synchronized cardioversion at 100 J biphasic
C) IV amiodarone 150 mg over 10 minutes
D) Valsalva maneuver with postural modification
