HESI Med-Surg II Practice Exam (2025/2026) — 130
Advanced Medical-Surgical Nursing Questions with
Correct Answers & Detailed Rationales
A 69-year-old man with a history of COPD is admitted to the ICU with acute hypercapnic
respiratory failure. He is placed on BiPAP with IPAP 16 cm H₂O and EPAP 6 cm H₂O.
Which ABG result after 1 hour indicates effective ventilation?
A. pH 7.48, PaCO₂ 34 mm Hg
B. pH 7.36, PaCO₂ 50 mm Hg
C. pH 7.28, PaCO₂ 65 mm Hg
1. D. pH 7.32, PaCO₂ 58 mm Hg
Correct Answer: B
Rationale: The goal in hypercapnic failure is to return pH to ≥ 7.35 and PaCO₂ to the
patient’s baseline (often 45–55 mm Hg for COPD). pH 7.36/CO₂ 50 meets this target,
showing improved respiratory acidosis without over-correction. Option A shows
respiratory alkalosis, while C and D remain acidotic.
A client with a thoracic aortic aneurysm (5.2 cm) is scheduled for endovascular repair.
Which pre-operative finding must be reported immediately?
A. BP 158/92 mm Hg
B. HR 88 beats/min
C. Serum creatinine 1.9 mg/dL
2. D. Hgb 11 g/dL
Correct Answer: C
Rationale: A creatinine ≥ 1.5 mg/dL increases the risk of contrast-induced nephropathy
and may alter the plan for IV contrast. Hypertension should be controlled but is not an
immediate cancel criterion. Mild anemia and normal HR are acceptable.
,A client with DKA receives an insulin infusion at 0.1 units/kg/hr. After 3 hours, the blood
glucose drops from 550 mg/dL to 420 mg/dL. Which is the priority nursing action?
A. Decrease insulin rate by half
B. Add dextrose 5% to the IV
C. Continue current infusion and reassess in 1 hour
3. D. Give 25 g dextrose IV push
Correct Answer: C
Rationale: A drop of ~130 mg/dL over 3 hours (≈ 43 mg/dL/hr) is within the
recommended 50–75 mg/dL/hr range; no change is needed yet. Adding dextrose or
reducing insulin too early risks slowing ketone clearance. Dextrose bolus is unnecessary.
A client with acute pancreatitis has a Ranson score of 4 on admission. Which level of
care is most appropriate?
A. Medical floor with q4h vitals
B. Step-down unit with cardiac monitoring
C. ICU for close hemodynamic monitoring
4. D. Discharge with home health follow-up
Correct Answer: C
Rationale: Ranson ≥ 3 indicates severe pancreatitis with high risk for shock, ARDS, and
renal failure, requiring ICU-level monitoring. Floor care is insufficient; discharge is
unsafe.
A client with a cervical spinal-cord injury at C4 develops bradycardia (HR 38 beats/min)
and hypotension. Which intervention is priority?
A. Administer atropine 0.5 mg IV
B. Place in Trendelenburg position
C. Start dopamine infusion
5. D. Apply abdominal binder
Correct Answer: A
,Rationale: Neurogenic shock from loss of sympathetic tone causes vagal bradycardia;
atropine blocks vagal effects and increases HR. Trendelenburg worsens ICP, dopamine is
second-line, and binders help orthostatic hypotension later.
A client with acute liver failure has grade III encephalopathy and a serum ammonia of
210 mcg/dL. Which nutritional intervention is evidence-based?
A. Restrict protein to < 20 g/day
B. Provide 1.2–1.5 g/kg vegetable and dairy protein
C. NPO to reduce ammonia formation
6. D. Give branched-chain amino acids only TPN
Correct Answer: B
Rationale: Severe protein restriction causes muscle wasting and increases ammonia from
endogenous sources. Vegetable/dairy proteins are low in aromatic amino acids and
improve nitrogen balance. BCAA-enriched formulas are reserved for refractory cases.
A client with a pulmonary embolism is on a heparin infusion. aPTT is 110 seconds (target
60–80). Which adjustment is appropriate?
A. Stop infusion for 1 hour and restart at 80 % dose
B. Continue current rate
C. Increase rate by 2 units/kg/hr
7. D. Administer protamine sulfate
Correct Answer: A
Rationale: Supratherapeutic aPTT increases bleeding risk; holding the infusion briefly
and reducing the dose brings levels back into range. Protamine is reserved for major
bleeding. Increasing the rate would worsen over-anticoagulation.
A client with a SAH post-coiling develops hyponatremia (Na 128 mEq/L) and increased
urine output. Which condition is suspected?
A. SIADH
B. Cerebral salt wasting
C. Diabetes insipidus
, 8. D. Dilutional hyponatremia from fluid overload
Correct Answer: B
Rationale: Cerebral salt wasting (CSW) causes renal sodium loss, hyponatremia, and
hypovolemia after SAH. SIADH is also common but presents with euvolemia and low
urine output. DI causes hypernatremia, and dilutional hyponatremia is not associated with
high urine sodium.
A client with a serum K⁺ of 6.8 mEq/L shows peaked T waves on the cardiac monitor.
Which medication is given first?
A. 10 % calcium gluconate 10 mL IV over 2 min
B. Regular insulin 10 units + 25 g dextrose IV
C. Albuterol 20 mg nebulizer
9. D. Sodium polystyrene sulfonate 30 g PO
Correct Answer: A
Rationale: Calcium gluconate stabilizes cardiac membranes within minutes and is
life-saving in hyperkalemic ECG changes. Insulin/dextrose and albuterol shift potassium
intracellularly over 15–30 min, while kayexalate removes potassium slowly.
A client with septic shock has a central venous pressure (CVP) of 4 mm Hg and MAP 58
mm Hg after 2 L of crystalloid. Which intervention is next per the Surviving Sepsis
Bundle?
A. Give another 1000 mL bolus
B. Start norepinephrine infusion
C. Obtain echocardiogram
10. D. Start dobutamine 5 mcg/kg/min
Correct Answer: B
Rationale: After 30 mL/kg crystalloid, if MAP < 65 mm Hg, vasopressors are started to
restore perfusion. Additional fluid may be given but vasopressors should not be delayed.
Echo and dobutamine are used if cardiac dysfunction is suspected later.
Advanced Medical-Surgical Nursing Questions with
Correct Answers & Detailed Rationales
A 69-year-old man with a history of COPD is admitted to the ICU with acute hypercapnic
respiratory failure. He is placed on BiPAP with IPAP 16 cm H₂O and EPAP 6 cm H₂O.
Which ABG result after 1 hour indicates effective ventilation?
A. pH 7.48, PaCO₂ 34 mm Hg
B. pH 7.36, PaCO₂ 50 mm Hg
C. pH 7.28, PaCO₂ 65 mm Hg
1. D. pH 7.32, PaCO₂ 58 mm Hg
Correct Answer: B
Rationale: The goal in hypercapnic failure is to return pH to ≥ 7.35 and PaCO₂ to the
patient’s baseline (often 45–55 mm Hg for COPD). pH 7.36/CO₂ 50 meets this target,
showing improved respiratory acidosis without over-correction. Option A shows
respiratory alkalosis, while C and D remain acidotic.
A client with a thoracic aortic aneurysm (5.2 cm) is scheduled for endovascular repair.
Which pre-operative finding must be reported immediately?
A. BP 158/92 mm Hg
B. HR 88 beats/min
C. Serum creatinine 1.9 mg/dL
2. D. Hgb 11 g/dL
Correct Answer: C
Rationale: A creatinine ≥ 1.5 mg/dL increases the risk of contrast-induced nephropathy
and may alter the plan for IV contrast. Hypertension should be controlled but is not an
immediate cancel criterion. Mild anemia and normal HR are acceptable.
,A client with DKA receives an insulin infusion at 0.1 units/kg/hr. After 3 hours, the blood
glucose drops from 550 mg/dL to 420 mg/dL. Which is the priority nursing action?
A. Decrease insulin rate by half
B. Add dextrose 5% to the IV
C. Continue current infusion and reassess in 1 hour
3. D. Give 25 g dextrose IV push
Correct Answer: C
Rationale: A drop of ~130 mg/dL over 3 hours (≈ 43 mg/dL/hr) is within the
recommended 50–75 mg/dL/hr range; no change is needed yet. Adding dextrose or
reducing insulin too early risks slowing ketone clearance. Dextrose bolus is unnecessary.
A client with acute pancreatitis has a Ranson score of 4 on admission. Which level of
care is most appropriate?
A. Medical floor with q4h vitals
B. Step-down unit with cardiac monitoring
C. ICU for close hemodynamic monitoring
4. D. Discharge with home health follow-up
Correct Answer: C
Rationale: Ranson ≥ 3 indicates severe pancreatitis with high risk for shock, ARDS, and
renal failure, requiring ICU-level monitoring. Floor care is insufficient; discharge is
unsafe.
A client with a cervical spinal-cord injury at C4 develops bradycardia (HR 38 beats/min)
and hypotension. Which intervention is priority?
A. Administer atropine 0.5 mg IV
B. Place in Trendelenburg position
C. Start dopamine infusion
5. D. Apply abdominal binder
Correct Answer: A
,Rationale: Neurogenic shock from loss of sympathetic tone causes vagal bradycardia;
atropine blocks vagal effects and increases HR. Trendelenburg worsens ICP, dopamine is
second-line, and binders help orthostatic hypotension later.
A client with acute liver failure has grade III encephalopathy and a serum ammonia of
210 mcg/dL. Which nutritional intervention is evidence-based?
A. Restrict protein to < 20 g/day
B. Provide 1.2–1.5 g/kg vegetable and dairy protein
C. NPO to reduce ammonia formation
6. D. Give branched-chain amino acids only TPN
Correct Answer: B
Rationale: Severe protein restriction causes muscle wasting and increases ammonia from
endogenous sources. Vegetable/dairy proteins are low in aromatic amino acids and
improve nitrogen balance. BCAA-enriched formulas are reserved for refractory cases.
A client with a pulmonary embolism is on a heparin infusion. aPTT is 110 seconds (target
60–80). Which adjustment is appropriate?
A. Stop infusion for 1 hour and restart at 80 % dose
B. Continue current rate
C. Increase rate by 2 units/kg/hr
7. D. Administer protamine sulfate
Correct Answer: A
Rationale: Supratherapeutic aPTT increases bleeding risk; holding the infusion briefly
and reducing the dose brings levels back into range. Protamine is reserved for major
bleeding. Increasing the rate would worsen over-anticoagulation.
A client with a SAH post-coiling develops hyponatremia (Na 128 mEq/L) and increased
urine output. Which condition is suspected?
A. SIADH
B. Cerebral salt wasting
C. Diabetes insipidus
, 8. D. Dilutional hyponatremia from fluid overload
Correct Answer: B
Rationale: Cerebral salt wasting (CSW) causes renal sodium loss, hyponatremia, and
hypovolemia after SAH. SIADH is also common but presents with euvolemia and low
urine output. DI causes hypernatremia, and dilutional hyponatremia is not associated with
high urine sodium.
A client with a serum K⁺ of 6.8 mEq/L shows peaked T waves on the cardiac monitor.
Which medication is given first?
A. 10 % calcium gluconate 10 mL IV over 2 min
B. Regular insulin 10 units + 25 g dextrose IV
C. Albuterol 20 mg nebulizer
9. D. Sodium polystyrene sulfonate 30 g PO
Correct Answer: A
Rationale: Calcium gluconate stabilizes cardiac membranes within minutes and is
life-saving in hyperkalemic ECG changes. Insulin/dextrose and albuterol shift potassium
intracellularly over 15–30 min, while kayexalate removes potassium slowly.
A client with septic shock has a central venous pressure (CVP) of 4 mm Hg and MAP 58
mm Hg after 2 L of crystalloid. Which intervention is next per the Surviving Sepsis
Bundle?
A. Give another 1000 mL bolus
B. Start norepinephrine infusion
C. Obtain echocardiogram
10. D. Start dobutamine 5 mcg/kg/min
Correct Answer: B
Rationale: After 30 mL/kg crystalloid, if MAP < 65 mm Hg, vasopressors are started to
restore perfusion. Additional fluid may be given but vasopressors should not be delayed.
Echo and dobutamine are used if cardiac dysfunction is suspected later.
