Evolve Elsevier HESI Med-Surg Practice Exam
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
1. A 68-year-old with a history of heart failure is admitted with acute shortness of
breath and bilateral crackles. The nurse notes a new-onset irregularly irregular
heart rhythm with a rate of 150 bpm. Which assessment finding warrants
immediate intervention?
A. Oxygen saturation 88 % on 6 L nasal cannula
B. BP 90/60 mmHg
C. Respiratory rate 28/min
D. Fine crackles posterior bases
Correct Answer: B
Rationale: A systolic BP < 90 mmHg indicates cardiogenic shock and inadequate
perfusion, requiring immediate cardioversion or rate control. While hypoxemia and
tachypnea are concerning, they are expected in acute HF; priority is perfusion. Crackles
reflect pulmonary congestion but not imminent collapse.
2. Four hours after a coronary artery bypass graft, the patient’s mediastinal chest tube
output spikes from 75 mL/h to 250 mL/h of bright-red blood. The first nursing
action is to:
A. Increase suction on the chest drainage system
B. Notify the surgeon immediately
C. Administer protamine per protocol
D. Check PT/INR and aPTT
Correct Answer: B
Rationale: Sudden increase in bright-red output > 100 mL/h for 2–3 h suggests surgical
bleeding; rapid surgical re-exploration may be required. Increasing suction will not
,control arterial bleed. Protamine reverses heparin but is secondary; labs confirm but delay
intervention.
3. A patient with COPD is receiving 4 L O₂ via nasal cannula. ABG results: pH 7.28,
PaCO₂ 68 mmHg, HCO₃ 34 mEq/L, PaO₂ 58 mmHg. The nurse should:
A. Increase O₂ to 6 L to raise PaO₂ above 60
B. Keep current O₂ and encourage pursed-lip breathing
C. Switch to non-rebreather at 10 L
D. Prepare for immediate intubation
Correct Answer: B
Rationale: The patient has compensated respiratory acidosis; increasing O₂ may blunt
hypoxic drive and worsen hypercarbia. Current PaO₂ is near acceptable for COPD.
Pursed-lip breathing prolongs expiration, reduces air trapping. Intubation is premature
without mental-status change or severe acidosis.
4. A client with DKA receives an insulin bolus and is now on 0.1 units/kg/h infusion.
After 2 h, blood glucose drops from 480 mg/dL to 320 mg/dL. The nurse expects
which change in the next 2 h?
A. Serum potassium will fall
B. Serum pH will worsen
C. Serum osmolality will rise
D. Urine output will decrease
Correct Answer: A
Rationale: Insulin drives potassium intracellularly; hypokalemia is common as glucose
and acidosis improve. pH should improve with ketone clearance; osmolality falls as
glucose drops; osmotic diuresis continues until glucose < 250 mg/dL, so output remains
high.
5. A patient with acute pancreatitis complains of severe epigastric pain radiating to
the back. Which nursing intervention is priority?
, A. Administer morphine 4 mg IV
B. Apply high-flow O₂ by mask
C. Keep NPO and start NG suction
D. Measure abdominal girth q4h
Correct Answer: C
Rationale: Bowel rest (NPO) and decompression reduce pancreatic stimulation and pain.
Pain control is important but second to limiting stimulation. O₂ is not routine unless
hypoxic. Measuring girth monitors ascites but does not relieve pain.
6. A client with a subarachnoid hemorrhage develops sudden bradycardia (HR 38)
and elevated BP (210/110). Which complication is suspected?
A. Neurogenic shock
B. Cushing’s triad from increased ICP
C. Pulmonary embolism
D. Vagal reaction to suctioning
Correct Answer: B
Rationale: Elevated BP with bradycardia and irregular respirations (not listed) form
Cushing’s triad, indicating brain-stem compression from rising ICP. Neurogenic shock
presents with hypotension and bradycardia. PE causes tachycardia and hypoxemia.
7. A patient with Guillain-Barré syndrome experiences dyspnea while lying flat.
SpO₂ 89 %, RR 32, accessory muscle use. The nurse should prepare for:
A. Plasmapheresis
B. Endotracheal intubation
C. IVIG infusion
D. High-dose steroids
Correct Answer: B
, Rationale: Respiratory muscle weakness leading to hypoventilation is an emergency;
intubation precedes definitive therapy. Plasmapheresis and IVIG treat the disease but do
not immediately secure airway. Steroids are ineffective in GBS.
8. A post-thyroidectomy patient reports tingling around the mouth and fingertips.
Which lab value should be checked stat?
A. Calcium
B. Magnesium
C. Potassium
D. Sodium
Correct Answer: A
Rationale: Tingling is early sign of hypocalcemia from accidental parathyroid removal.
Chvostek/Trousseau may follow. Calcium should be checked immediately; low Ca is
treated with calcium gluconate and calcitriol.
9. A patient with chronic kidney disease (stage 4) is started on sevelamer. The nurse
teaches that this drug works by:
A. Increasing calcium absorption
B. Binding dietary phosphate in the gut
C. Enhancing renal phosphate excretion
D. Stimulating parathyroid hormone
Correct Answer: B
Rationale: Sevelamer is a non-calcium phosphate binder that complexes dietary
phosphate, reducing hyperphosphatemia and secondary hyperparathyroidism. It does not
affect calcium absorption, renal function, or PTH secretion.
10. A trauma client with a pelvic fracture receives 6 units of PRBCs and develops
tachycardia, jugular venous distension, and muffled heart sounds. The nurse
recognizes:
A. Tension pneumothorax
B. Cardiac tamponade
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
1. A 68-year-old with a history of heart failure is admitted with acute shortness of
breath and bilateral crackles. The nurse notes a new-onset irregularly irregular
heart rhythm with a rate of 150 bpm. Which assessment finding warrants
immediate intervention?
A. Oxygen saturation 88 % on 6 L nasal cannula
B. BP 90/60 mmHg
C. Respiratory rate 28/min
D. Fine crackles posterior bases
Correct Answer: B
Rationale: A systolic BP < 90 mmHg indicates cardiogenic shock and inadequate
perfusion, requiring immediate cardioversion or rate control. While hypoxemia and
tachypnea are concerning, they are expected in acute HF; priority is perfusion. Crackles
reflect pulmonary congestion but not imminent collapse.
2. Four hours after a coronary artery bypass graft, the patient’s mediastinal chest tube
output spikes from 75 mL/h to 250 mL/h of bright-red blood. The first nursing
action is to:
A. Increase suction on the chest drainage system
B. Notify the surgeon immediately
C. Administer protamine per protocol
D. Check PT/INR and aPTT
Correct Answer: B
Rationale: Sudden increase in bright-red output > 100 mL/h for 2–3 h suggests surgical
bleeding; rapid surgical re-exploration may be required. Increasing suction will not
,control arterial bleed. Protamine reverses heparin but is secondary; labs confirm but delay
intervention.
3. A patient with COPD is receiving 4 L O₂ via nasal cannula. ABG results: pH 7.28,
PaCO₂ 68 mmHg, HCO₃ 34 mEq/L, PaO₂ 58 mmHg. The nurse should:
A. Increase O₂ to 6 L to raise PaO₂ above 60
B. Keep current O₂ and encourage pursed-lip breathing
C. Switch to non-rebreather at 10 L
D. Prepare for immediate intubation
Correct Answer: B
Rationale: The patient has compensated respiratory acidosis; increasing O₂ may blunt
hypoxic drive and worsen hypercarbia. Current PaO₂ is near acceptable for COPD.
Pursed-lip breathing prolongs expiration, reduces air trapping. Intubation is premature
without mental-status change or severe acidosis.
4. A client with DKA receives an insulin bolus and is now on 0.1 units/kg/h infusion.
After 2 h, blood glucose drops from 480 mg/dL to 320 mg/dL. The nurse expects
which change in the next 2 h?
A. Serum potassium will fall
B. Serum pH will worsen
C. Serum osmolality will rise
D. Urine output will decrease
Correct Answer: A
Rationale: Insulin drives potassium intracellularly; hypokalemia is common as glucose
and acidosis improve. pH should improve with ketone clearance; osmolality falls as
glucose drops; osmotic diuresis continues until glucose < 250 mg/dL, so output remains
high.
5. A patient with acute pancreatitis complains of severe epigastric pain radiating to
the back. Which nursing intervention is priority?
, A. Administer morphine 4 mg IV
B. Apply high-flow O₂ by mask
C. Keep NPO and start NG suction
D. Measure abdominal girth q4h
Correct Answer: C
Rationale: Bowel rest (NPO) and decompression reduce pancreatic stimulation and pain.
Pain control is important but second to limiting stimulation. O₂ is not routine unless
hypoxic. Measuring girth monitors ascites but does not relieve pain.
6. A client with a subarachnoid hemorrhage develops sudden bradycardia (HR 38)
and elevated BP (210/110). Which complication is suspected?
A. Neurogenic shock
B. Cushing’s triad from increased ICP
C. Pulmonary embolism
D. Vagal reaction to suctioning
Correct Answer: B
Rationale: Elevated BP with bradycardia and irregular respirations (not listed) form
Cushing’s triad, indicating brain-stem compression from rising ICP. Neurogenic shock
presents with hypotension and bradycardia. PE causes tachycardia and hypoxemia.
7. A patient with Guillain-Barré syndrome experiences dyspnea while lying flat.
SpO₂ 89 %, RR 32, accessory muscle use. The nurse should prepare for:
A. Plasmapheresis
B. Endotracheal intubation
C. IVIG infusion
D. High-dose steroids
Correct Answer: B
, Rationale: Respiratory muscle weakness leading to hypoventilation is an emergency;
intubation precedes definitive therapy. Plasmapheresis and IVIG treat the disease but do
not immediately secure airway. Steroids are ineffective in GBS.
8. A post-thyroidectomy patient reports tingling around the mouth and fingertips.
Which lab value should be checked stat?
A. Calcium
B. Magnesium
C. Potassium
D. Sodium
Correct Answer: A
Rationale: Tingling is early sign of hypocalcemia from accidental parathyroid removal.
Chvostek/Trousseau may follow. Calcium should be checked immediately; low Ca is
treated with calcium gluconate and calcitriol.
9. A patient with chronic kidney disease (stage 4) is started on sevelamer. The nurse
teaches that this drug works by:
A. Increasing calcium absorption
B. Binding dietary phosphate in the gut
C. Enhancing renal phosphate excretion
D. Stimulating parathyroid hormone
Correct Answer: B
Rationale: Sevelamer is a non-calcium phosphate binder that complexes dietary
phosphate, reducing hyperphosphatemia and secondary hyperparathyroidism. It does not
affect calcium absorption, renal function, or PTH secretion.
10. A trauma client with a pelvic fracture receives 6 units of PRBCs and develops
tachycardia, jugular venous distension, and muffled heart sounds. The nurse
recognizes:
A. Tension pneumothorax
B. Cardiac tamponade
