BSN 246 HESI Practice Exam Questions And Answers 2026/2027
- 233 Questions and Answers Already Graded A+ Premium
Exam Tested And Verified
Subject Area Medical-Surgical Nursing (HESI Comprehensive Review)
Description This exam assesses advanced clinical reasoning and application of evidence-based
nursing interventions for complex adult health conditions. Content aligns with
HESI exit exam competencies and AACN baccalaureate essentials.
Expected Grade A+
Total Questions 233
Duration 3 hours
Learning Outcomes 1. Apply pathophysiological principles to prioritize nursing care
2. Interpret diagnostic data and hemodynamic parameters
3. Evaluate pharmacologic and non-pharmacologic interventions
4. Demonstrate safety and quality improvement in acute care settings
Accreditation Accredited by CCNE and aligned with NCLEX-RN test plan
Page 1
,1. A patient with chronic systolic heart failure reports weight gain and
orthopnea. On assessment, the nurse notes jugular venous distention and an S3
gallop. Which additional finding most consistently indicates worsening fluid
overload?
A. Inspiratory crackles that clear with coughing
B. 1+ pitting edema in lower extremities
C. Hepatojugular reflex of 4 cm
D. B-type natriuretic peptide (BNP) level of 350 pg/mL
Answer: C. Hepatojugular reflex of 4 cm
A hepatojugular reflex >3 cm is a reliable sign of elevated right atrial pressure in
heart failure. S3 gallop and JVD indicate left and right heart failure. Crackles
that clear with coughing are auscultation artifacts, not persistent pulmonary
congestion. BNP of 350 pg/mL is moderately elevated but may be confounded by
renal function or age.
2. A patient with stage 4 chronic kidney disease (eGFR 25 mL/min) requires
antibiotic therapy for a urinary tract infection. The nurse knows that which
antibiotic is contraindicated due to risk of peripheral neuropathy?
A. Ceftriaxone
B. Nitrofurantoin
C. Ciprofloxacin
D. Amoxicillin
Answer: B. Nitrofurantoin
Nitrofurantoin is contraindicated when eGFR <30 mL/min because it
accumulates and increases risk of peripheral neuropathy; also, it does not achieve
therapeutic urine concentrations. Ceftriaxone is hepatically cleared.
Ciprofloxacin requires dose reduction but is not contraindicated. Amoxicillin is
generally safe.
Page 2
,3. A diabetic patient presents with DKA: blood glucose 580 mg/dL, pH 7.1,
bicarbonate 10 mEq/L. After initial fluid resuscitation with normal saline,
which laboratory change indicates appropriate volume repletion?
A. Increase in serum sodium to 155 mEq/L
B. Decrease in serum potassium to 3.0 mEq/L
C. Decrease in serum creatinine from 2.5 to 1.8 mg/dL
D. Increase in anion gap to 30
Answer: C. Decrease in serum creatinine from 2.5 to 1.8 mg/dL
Volume depletion in DKA causes prerenal azotemia; with adequate fluids,
creatinine decreases as renal perfusion improves. Hypernatremia suggests
unreplaced free water loss. Hypokalemia occurs from insulin therapy, not
volume. Increasing anion gap indicates worsening acidosis.
4. A patient arrives 2 hours after sudden onset of left-sided weakness. CT scan
shows no hemorrhage. The nurse reviews the history for tPA eligibility. Which
finding contraindicates tPA administration?
A. History of controlled hypertension with BP 158/92
B. Use of oral anticoagulants with INR 1.2
C. Recent myocardial infarction within 3 months
D. Blood glucose of 45 mg/dL
Answer: D. Blood glucose of 45 mg/dL
Hypoglycemia can mimic stroke and must be excluded before tPA (AHA: blood
glucose <50 mg/dL is contraindicated). Uncontrolled hypertension is relative, but
BP <185/110 is acceptable. INR 1.2 is not elevated. Recent MI within 3 months is
a relative contraindication, not absolute.
Page 3
, 5. A patient taking morphine 10 mg IV every 4 hours for chronic pain is to be
switched to oral hydromorphone. Using equianalgesic conversion, which oral
hydromorphone dose is approximately equivalent?
A. 4 mg every 4 hours
B. 8 mg every 6 hours
C. 2 mg every 4 hours
D. 6 mg every 4 hours
Answer: D. 6 mg every 4 hours
IV morphine 10 mg q4h 30 mg oral morphine q4h (1:3 ratio). Oral morphine to
oral hydromorphone ratio is 5:1, so 30 mg oral morphine 6 mg oral
hydromorphone. Thus 6 mg q4h is correct. Lower doses (4 mg, 2 mg) are
subtherapeutic; 8 mg q6h (32 mg/day) is also low.
6. A patient undergoing total knee arthroplasty has a history of
heparin-induced thrombocytopenia (HIT). Which pharmacologic prophylaxis
for venous thromboembolism should the nurse question?
A. Fondaparinux
B. Enoxaparin
C. Rivaroxaban
D. Warfarin
Answer: B. Enoxaparin
Enoxaparin is a low molecular weight heparin with high cross-reactivity to HIT
antibodies and is contraindicated. Fondaparinux is a synthetic pentasaccharide
with minimal cross-reactivity and is often used. Rivaroxaban and warfarin are
non-heparin anticoagulants and safe alternatives.
Page 4
- 233 Questions and Answers Already Graded A+ Premium
Exam Tested And Verified
Subject Area Medical-Surgical Nursing (HESI Comprehensive Review)
Description This exam assesses advanced clinical reasoning and application of evidence-based
nursing interventions for complex adult health conditions. Content aligns with
HESI exit exam competencies and AACN baccalaureate essentials.
Expected Grade A+
Total Questions 233
Duration 3 hours
Learning Outcomes 1. Apply pathophysiological principles to prioritize nursing care
2. Interpret diagnostic data and hemodynamic parameters
3. Evaluate pharmacologic and non-pharmacologic interventions
4. Demonstrate safety and quality improvement in acute care settings
Accreditation Accredited by CCNE and aligned with NCLEX-RN test plan
Page 1
,1. A patient with chronic systolic heart failure reports weight gain and
orthopnea. On assessment, the nurse notes jugular venous distention and an S3
gallop. Which additional finding most consistently indicates worsening fluid
overload?
A. Inspiratory crackles that clear with coughing
B. 1+ pitting edema in lower extremities
C. Hepatojugular reflex of 4 cm
D. B-type natriuretic peptide (BNP) level of 350 pg/mL
Answer: C. Hepatojugular reflex of 4 cm
A hepatojugular reflex >3 cm is a reliable sign of elevated right atrial pressure in
heart failure. S3 gallop and JVD indicate left and right heart failure. Crackles
that clear with coughing are auscultation artifacts, not persistent pulmonary
congestion. BNP of 350 pg/mL is moderately elevated but may be confounded by
renal function or age.
2. A patient with stage 4 chronic kidney disease (eGFR 25 mL/min) requires
antibiotic therapy for a urinary tract infection. The nurse knows that which
antibiotic is contraindicated due to risk of peripheral neuropathy?
A. Ceftriaxone
B. Nitrofurantoin
C. Ciprofloxacin
D. Amoxicillin
Answer: B. Nitrofurantoin
Nitrofurantoin is contraindicated when eGFR <30 mL/min because it
accumulates and increases risk of peripheral neuropathy; also, it does not achieve
therapeutic urine concentrations. Ceftriaxone is hepatically cleared.
Ciprofloxacin requires dose reduction but is not contraindicated. Amoxicillin is
generally safe.
Page 2
,3. A diabetic patient presents with DKA: blood glucose 580 mg/dL, pH 7.1,
bicarbonate 10 mEq/L. After initial fluid resuscitation with normal saline,
which laboratory change indicates appropriate volume repletion?
A. Increase in serum sodium to 155 mEq/L
B. Decrease in serum potassium to 3.0 mEq/L
C. Decrease in serum creatinine from 2.5 to 1.8 mg/dL
D. Increase in anion gap to 30
Answer: C. Decrease in serum creatinine from 2.5 to 1.8 mg/dL
Volume depletion in DKA causes prerenal azotemia; with adequate fluids,
creatinine decreases as renal perfusion improves. Hypernatremia suggests
unreplaced free water loss. Hypokalemia occurs from insulin therapy, not
volume. Increasing anion gap indicates worsening acidosis.
4. A patient arrives 2 hours after sudden onset of left-sided weakness. CT scan
shows no hemorrhage. The nurse reviews the history for tPA eligibility. Which
finding contraindicates tPA administration?
A. History of controlled hypertension with BP 158/92
B. Use of oral anticoagulants with INR 1.2
C. Recent myocardial infarction within 3 months
D. Blood glucose of 45 mg/dL
Answer: D. Blood glucose of 45 mg/dL
Hypoglycemia can mimic stroke and must be excluded before tPA (AHA: blood
glucose <50 mg/dL is contraindicated). Uncontrolled hypertension is relative, but
BP <185/110 is acceptable. INR 1.2 is not elevated. Recent MI within 3 months is
a relative contraindication, not absolute.
Page 3
, 5. A patient taking morphine 10 mg IV every 4 hours for chronic pain is to be
switched to oral hydromorphone. Using equianalgesic conversion, which oral
hydromorphone dose is approximately equivalent?
A. 4 mg every 4 hours
B. 8 mg every 6 hours
C. 2 mg every 4 hours
D. 6 mg every 4 hours
Answer: D. 6 mg every 4 hours
IV morphine 10 mg q4h 30 mg oral morphine q4h (1:3 ratio). Oral morphine to
oral hydromorphone ratio is 5:1, so 30 mg oral morphine 6 mg oral
hydromorphone. Thus 6 mg q4h is correct. Lower doses (4 mg, 2 mg) are
subtherapeutic; 8 mg q6h (32 mg/day) is also low.
6. A patient undergoing total knee arthroplasty has a history of
heparin-induced thrombocytopenia (HIT). Which pharmacologic prophylaxis
for venous thromboembolism should the nurse question?
A. Fondaparinux
B. Enoxaparin
C. Rivaroxaban
D. Warfarin
Answer: B. Enoxaparin
Enoxaparin is a low molecular weight heparin with high cross-reactivity to HIT
antibodies and is contraindicated. Fondaparinux is a synthetic pentasaccharide
with minimal cross-reactivity and is often used. Rivaroxaban and warfarin are
non-heparin anticoagulants and safe alternatives.
Page 4
