BSN 266 HESI Med-Surg Exam Prep | NGN Case Scenarios
+ Rationales (2026/2027)
Medical-Surgical Nursing Clinical Judgment Prep | Key Domains: Recognition of Patient
Decompensation, Analysis of Complex Clinical Data, Prioritization of Interventions in Crisis,
Delegation & Supervision in a Team, Management of Technological Dependencies (Vents,
Drains, Drips), and Interprofessional Communication for Safe Handoffs | Expert-Aligned
Structure | NGN Case Scenario Prep Format
Introduction
This structured BSN 266 HESI Medical-Surgical Exam Prep for 2026/2027 provides a focused set of
Next Generation NCLEX-style case scenarios with correct answers and rationales. It is designed to
hone clinical judgment skills specifically for the high-stakes HESI exam, emphasizing the rapid
processing of information, identification of the "worst first" problem, and implementation of
time-sensitive interventions to prevent adverse outcomes in medical-surgical patients.
Prep Structure:
• NGN Case Scenario Prep Bank: (60 UNFOLDING SCENARIOS)
Answer Format
All correct priority actions and clinical decisions must appear in bold and cyan blue, accompanied
by concise rationales explaining the immediate threat to physiological stability (e.g., airway,
breathing, circulation), the interpretation of trending data (e.g., dropping blood pressure, rising
lactate), the appropriate delegation of tasks to LPNs/UAPs, the critical element to communicate
during an SBAR handoff, and why delayed or alternative actions would result in patient harm.
Case 1: Post-Op Respiratory Distress
A 68-year-old male, 2 hours post–abdominal surgery under general anesthesia, has SpO₂ 88% on 2 L
NC, RR 28/min, and is drowsy. He received morphine 4 mg IV 30 minutes ago.
,What is the priority action?
A. Administer another 2 mg morphine for pain
B. Increase oxygen to 6 L NC and stimulate the patient to take deep breaths
C. Place in supine position
D. Document findings and continue to monitor
Recognize Cues: Hypoxia (SpO₂ 88%) and tachypnea in a drowsy post-op patient indicate opioid-induced
respiratory depression. Increasing oxygen and stimulation promote ventilation; giving more
morphine would worsen depression. High Fowler’s position (not supine) aids lung expansion.
Immediate intervention is required—monitoring alone risks respiratory arrest.
Case 2: Sepsis with Rising Lactate
A 72-year-old female with UTI has BP 88/50 mmHg, HR 118 bpm, and lactate 4.2 mmol/L (up from
2.8 two hours ago). Urine output is 15 mL/hr.
What is the priority intervention?
A. Administer antipyretic for fever
B. Initiate 30 mL/kg crystalloid fluid bolus immediately
C. Obtain a urine culture
D. Start oral antibiotics
,Analyze Cues: Rising lactate indicates worsening tissue hypoperfusion in septic shock. Per Surviving
Sepsis guidelines, 30 mL/kg fluid resuscitation within the first hour is critical to restore
perfusion and prevent multi-organ failure. Cultures and antibiotics are essential but secondary to
hemodynamic stabilization.
Case 3: Delegation of Post-Op Care
A nurse is caring for four patients. One is 4 hours post-op colectomy with a nasogastric tube to low
intermittent suction, Jackson-Pratt drain, and PCA pump.
Which task can be safely delegated to a UAP?
A. Assess bowel sounds and NG tube output
B. Adjust PCA pump settings
C. Assist the patient with oral hygiene
D. Evaluate pain level and administer PRN medication
Generate Solutions: Oral hygiene is a non-invasive, routine hygiene task within the UAP’s scope.
Assessment, medication administration (including PCA), and evaluation require licensed nursing
judgment and cannot be delegated. Delegation must follow the “Five Rights” to ensure patient safety.
Case 4: Ventilator Alarm – High Pressure
A patient on mechanical ventilation suddenly has a high-pressure alarm. The nurse observes
increased work of breathing and decreased chest rise.
What is the priority action?
A. Silence the alarm to reduce anxiety
, B. Suction the endotracheal tube for possible mucus plug
C. Increase the FiO₂ to 100%
D. Disconnect the patient from the ventilator
Take Action: High-pressure alarms often indicate airway obstruction (e.g., mucus plug, bronchospasm).
Suctioning clears secretions; bronchodilators may follow if wheezing persists. Disconnecting the
ventilator causes apnea; increasing FiO₂ does not address the obstruction; silencing the alarm ignores
the emergency.
Case 5: SBAR Handoff Communication
A nurse is transferring care of a patient with new-onset atrial fibrillation (HR 130, BP 100/60) to
the oncoming nurse.
What is the most critical "A" (Assessment) data to communicate?
A. Patient’s dietary preferences
B. Hemodynamic stability: BP, HR, and presence of chest pain or dyspnea
C. Last dose of pain medication
D. Family visiting hours
Evaluate Outcomes: In unstable AFib, the priority is assessing for signs of decompensation. SBAR
requires concise, relevant clinical data; hemodynamic status determines urgency of intervention
(e.g., cardioversion vs. rate control). Non-urgent information can be shared later.
Case 6: Chest Tube Management
+ Rationales (2026/2027)
Medical-Surgical Nursing Clinical Judgment Prep | Key Domains: Recognition of Patient
Decompensation, Analysis of Complex Clinical Data, Prioritization of Interventions in Crisis,
Delegation & Supervision in a Team, Management of Technological Dependencies (Vents,
Drains, Drips), and Interprofessional Communication for Safe Handoffs | Expert-Aligned
Structure | NGN Case Scenario Prep Format
Introduction
This structured BSN 266 HESI Medical-Surgical Exam Prep for 2026/2027 provides a focused set of
Next Generation NCLEX-style case scenarios with correct answers and rationales. It is designed to
hone clinical judgment skills specifically for the high-stakes HESI exam, emphasizing the rapid
processing of information, identification of the "worst first" problem, and implementation of
time-sensitive interventions to prevent adverse outcomes in medical-surgical patients.
Prep Structure:
• NGN Case Scenario Prep Bank: (60 UNFOLDING SCENARIOS)
Answer Format
All correct priority actions and clinical decisions must appear in bold and cyan blue, accompanied
by concise rationales explaining the immediate threat to physiological stability (e.g., airway,
breathing, circulation), the interpretation of trending data (e.g., dropping blood pressure, rising
lactate), the appropriate delegation of tasks to LPNs/UAPs, the critical element to communicate
during an SBAR handoff, and why delayed or alternative actions would result in patient harm.
Case 1: Post-Op Respiratory Distress
A 68-year-old male, 2 hours post–abdominal surgery under general anesthesia, has SpO₂ 88% on 2 L
NC, RR 28/min, and is drowsy. He received morphine 4 mg IV 30 minutes ago.
,What is the priority action?
A. Administer another 2 mg morphine for pain
B. Increase oxygen to 6 L NC and stimulate the patient to take deep breaths
C. Place in supine position
D. Document findings and continue to monitor
Recognize Cues: Hypoxia (SpO₂ 88%) and tachypnea in a drowsy post-op patient indicate opioid-induced
respiratory depression. Increasing oxygen and stimulation promote ventilation; giving more
morphine would worsen depression. High Fowler’s position (not supine) aids lung expansion.
Immediate intervention is required—monitoring alone risks respiratory arrest.
Case 2: Sepsis with Rising Lactate
A 72-year-old female with UTI has BP 88/50 mmHg, HR 118 bpm, and lactate 4.2 mmol/L (up from
2.8 two hours ago). Urine output is 15 mL/hr.
What is the priority intervention?
A. Administer antipyretic for fever
B. Initiate 30 mL/kg crystalloid fluid bolus immediately
C. Obtain a urine culture
D. Start oral antibiotics
,Analyze Cues: Rising lactate indicates worsening tissue hypoperfusion in septic shock. Per Surviving
Sepsis guidelines, 30 mL/kg fluid resuscitation within the first hour is critical to restore
perfusion and prevent multi-organ failure. Cultures and antibiotics are essential but secondary to
hemodynamic stabilization.
Case 3: Delegation of Post-Op Care
A nurse is caring for four patients. One is 4 hours post-op colectomy with a nasogastric tube to low
intermittent suction, Jackson-Pratt drain, and PCA pump.
Which task can be safely delegated to a UAP?
A. Assess bowel sounds and NG tube output
B. Adjust PCA pump settings
C. Assist the patient with oral hygiene
D. Evaluate pain level and administer PRN medication
Generate Solutions: Oral hygiene is a non-invasive, routine hygiene task within the UAP’s scope.
Assessment, medication administration (including PCA), and evaluation require licensed nursing
judgment and cannot be delegated. Delegation must follow the “Five Rights” to ensure patient safety.
Case 4: Ventilator Alarm – High Pressure
A patient on mechanical ventilation suddenly has a high-pressure alarm. The nurse observes
increased work of breathing and decreased chest rise.
What is the priority action?
A. Silence the alarm to reduce anxiety
, B. Suction the endotracheal tube for possible mucus plug
C. Increase the FiO₂ to 100%
D. Disconnect the patient from the ventilator
Take Action: High-pressure alarms often indicate airway obstruction (e.g., mucus plug, bronchospasm).
Suctioning clears secretions; bronchodilators may follow if wheezing persists. Disconnecting the
ventilator causes apnea; increasing FiO₂ does not address the obstruction; silencing the alarm ignores
the emergency.
Case 5: SBAR Handoff Communication
A nurse is transferring care of a patient with new-onset atrial fibrillation (HR 130, BP 100/60) to
the oncoming nurse.
What is the most critical "A" (Assessment) data to communicate?
A. Patient’s dietary preferences
B. Hemodynamic stability: BP, HR, and presence of chest pain or dyspnea
C. Last dose of pain medication
D. Family visiting hours
Evaluate Outcomes: In unstable AFib, the priority is assessing for signs of decompensation. SBAR
requires concise, relevant clinical data; hemodynamic status determines urgency of intervention
(e.g., cardioversion vs. rate control). Non-urgent information can be shared later.
Case 6: Chest Tube Management
