BSN HESI Medical-Surgical Exam Mastery 2026/2027 –
Elsevier Evolve / NCSBN Clinical Judgment Measurement
Model – Comprehensive Adult Health Nursing Competency
Assessment — 300 Questions
Section 1: Management of Care (Questions 1-38)
1 A charge nurse on a medical-surgical unit is assigning patient care to a team consisting of two registered nurses
(RNs), one licensed practical nurse (LPN), and one unlicensed assistive personnel (UAP). Which patient should
the charge nurse assign to the LPN?
A) A patient with pneumonia requiring frequent respiratory assessments and titration of oxygen
B) A patient with a new colostomy who needs stoma care education and demonstration
C) A patient with a urinary tract infection receiving IV antibiotics and a continuous bladder irrigation
D) A patient with a stage 3 pressure injury requiring wound debridement and complex dressing change
Answer: D
Rationale: LPNs are trained to perform wound care, including debridement and complex dressing changes, under the
supervision of an RN. Option A requires ongoing assessment and titration, which is an RN responsibility. Option B
involves patient education, which is an RN scope. Option C involves IV therapy and continuous bladder irrigation,
which are typically RN duties.
2 A nurse is caring for a patient with acute pancreatitis who has a nasogastric tube to low intermittent suction. The
patient complains of severe abdominal pain and nausea. The nurse notes that the suction is not functioning and
the drainage bag is empty. Which action should the nurse take first?
A) Reposition the nasogastric tube and check for placement
B) Irrigate the nasogastric tube with normal saline
C) Notify the healthcare provider of the malfunction
D) Assess the patient's bowel sounds and abdominal distention
Answer: A
Rationale: The first step is to ensure the NG tube is properly placed and functioning. Repositioning and checking
placement can resolve the issue quickly. Irrigating without confirming placement could cause harm. Notifying the
provider is delayed until after assessment. Assessing bowel sounds is important but secondary to restoring suction.
3 A nurse is preparing to administer a blood transfusion to a patient. Which of the following actions is most
important for the nurse to take to prevent a transfusion reaction?
A) Verify the patient's identity with two identifiers and check the blood product against the prescription
B) Obtain informed consent from the patient for the transfusion
C) Prime the blood administration tubing with normal saline and hang the blood within 30 minutes
D) Monitor vital signs every 15 minutes during the first hour of transfusion
Answer: A
Rationale: The most critical step to prevent a transfusion reaction is proper patient identification and verification of
the blood product. This ensures the right blood is given to the right patient. Informed consent is important but does
not prevent reactions. Priming and monitoring are essential but secondary to correct identification.
, 4 A nurse is delegating the collection of a clean-catch urine specimen to a UAP. The UAP has never performed
this procedure before. Which instruction should the nurse provide?
A) Instruct the patient to void a small amount into the toilet, then collect the midstream urine in the sterile cup
B) Have the patient void directly into the sterile cup after cleaning the perineal area with the provided wipe
C) Clean the perineal area with soap and water, then have the patient void into a clean bedpan and transfer to the
specimen cup
D) Use a straight catheter to obtain the specimen to ensure it is sterile
Answer: A
Rationale: For a clean-catch midstream specimen, the patient should start voiding, then collect the midstream
portion to avoid contamination from the distal urethra. Option B is incorrect because the initial stream should be
discarded. Option C introduces contamination risk. Option D is not delegation to a UAP and is invasive.
5 A patient with a history of heart failure is admitted with shortness of breath and bilateral lower extremity edema.
The nurse notes that the patient's weight has increased by 5 kg in 2 days. Which provider prescription should the
nurse question?
A) Furosemide 40 mg IV push now
B) Oxygen 2 L/min via nasal cannula to maintain SpO2 >92%
C) 0.9% normal saline at 100 mL/hour
D) Daily weights and strict intake and output monitoring
Answer: C
Rationale: The patient is fluid overloaded; administering 0.9% normal saline at 100 mL/hour would exacerbate the
condition. Furosemide is appropriate for diuresis. Oxygen and daily weights are standard. The nurse should
question the saline infusion.
6 A nurse is evaluating the effectiveness of a patient's pain management plan. The patient has a patient-controlled
analgesia (PCA) pump with morphine. The nurse notes that the patient is somnolent and has a respiratory rate of
8 breaths per minute. Which action should the nurse take first?
A) Administer naloxone per protocol
B) Stop the PCA infusion and call the healthcare provider
C) Stimulate the patient and instruct to take deep breaths
D) Increase the lockout interval on the PCA pump
Answer: A
Rationale: The patient is experiencing respiratory depression from opioid overdose. Naloxone is the antidote and
should be administered immediately to reverse the effects. Stopping the infusion is important but secondary.
Stimulation and increasing lockout are insufficient.
7 A nurse is caring for a patient with a new diagnosis of type 2 diabetes mellitus. The patient is prescribed
metformin and insulin glargine. Which statement by the patient indicates a need for further teaching?
A) I will take my metformin with meals to avoid stomach upset
B) I will inject my insulin glargine at bedtime each night
C) I can skip my insulin if I skip a meal
D) I should monitor my blood glucose before meals and at bedtime
Answer: C
Rationale: Insulin glargine is a long-acting basal insulin and should be taken consistently, even if a meal is skipped,
to maintain baseline insulin levels. Skipping it can lead to hyperglycemia. The other statements are correct:
metformin with meals reduces GI side effects, glargine is typically given at bedtime, and monitoring is appropriate.
,8 A nurse is preparing a patient for discharge after a total hip arthroplasty. Which instruction is most important to
include to prevent dislocation?
A) Avoid crossing your legs or bending at the hip past 90 degrees
B) Use a raised toilet seat and avoid low chairs
C) Sleep with a pillow between your legs while lying on your back
D) Perform ankle pumps and quadriceps sets every hour while awake
Answer: A
Rationale: The most critical instruction to prevent dislocation is to avoid hip adduction and flexion beyond 90
degrees. Options B and C are also important but are specific examples of the general principle in A. Option D is for
preventing thromboembolism, not dislocation.
9 A nurse is assessing a patient with a chest tube connected to a water seal drainage system. The nurse notes
continuous bubbling in the water seal chamber. Which action should the nurse take?
A) Clamp the chest tube near the insertion site
B) Check the system for an air leak
C) Increase the suction pressure
D) Notify the healthcare provider immediately
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can
compromise lung re-expansion. The nurse should assess the entire system for leaks (tubing connections, dressing).
Clamping is dangerous and may cause tension pneumothorax. Increasing suction is not indicated. Notifying the
provider is appropriate after assessment.
10 A nurse is caring for a patient who is receiving a continuous IV infusion of heparin for deep vein thrombosis.
The patient's activated partial thromboplastin time (aPTT) is 120 seconds (therapeutic range 60-80 seconds).
Which action should the nurse take?
A) Increase the heparin infusion rate
B) Decrease the heparin infusion rate
C) Administer protamine sulfate
D) Continue the current infusion rate
Answer: B
Rationale: The aPTT is above the therapeutic range, indicating the patient is over-anticoagulated and at risk for
bleeding. The nurse should decrease the infusion rate per protocol. Increasing the rate would worsen the situation.
Protamine sulfate is the antidote but is reserved for severe bleeding or reversal. Continuing the current rate is
unsafe.
11 A nurse is leading a multidisciplinary team meeting to coordinate care for a patient with complex
comorbidities. A physician proposes a treatment plan that the nurse believes may be unsafe based on current
evidence. What is the most appropriate initial action by the nurse?
A) Document the disagreement in the medical record and implement the plan as ordered.
B) Respect the physician's authority and proceed with the treatment plan.
C) Voice concerns using the SBAR technique and request a team discussion of alternatives.
D) Refuse to implement the plan and escalate to the nursing supervisor immediately.
Answer: C
Rationale: The nurse's primary responsibility is patient safety, and SBAR
(Situation-Background-Assessment-Recommendation) is a structured communication tool that facilitates effective
advocacy and team collaboration. Option A undermines advocacy; option B disregards the nurse's duty to question
, unsafe orders; option D bypasses collaborative problem-solving.
12 A nurse is delegating tasks to an unlicensed assistive personnel (UAP) on a medical-surgical unit. Which task is
appropriate for the nurse to delegate?
A) Administering a scheduled oral anticoagulant to a stable patient.
B) Assessing the lung sounds of a patient with pneumonia.
C) Ambulating a patient who had a knee replacement 2 days ago.
D) Developing the plan of care for a newly admitted patient.
Answer: C
Rationale: Ambulation of a stable postoperative patient is a routine task that can be delegated to UAP after proper
training. Administering medications (A) and assessment (B) require nursing judgment; developing the plan of care
(D) is a nursing responsibility.
13 A nurse is caring for a patient who requires a blood transfusion. The patient's religious beliefs prohibit blood
products, but the patient is unconscious and unable to communicate. The patient's spouse requests the
transfusion. What is the nurse's best action?
A) Proceed with the transfusion based on the spouse's consent.
B) Delay the transfusion until the patient can be consulted.
C) Seek a court order to override the patient's presumed wishes.
D) Respect the patient's autonomy and withhold the transfusion.
Answer: D
Rationale: Patient autonomy and advance directives must be honored. In the absence of an advance directive, the
patient's known religious beliefs should guide care. The nurse should advocate for the patient's previously stated
wishes, even if the spouse disagrees.
14 A nurse manager is evaluating the use of a critical pathway for patients with heart failure. The pathway
includes daily weights, strict intake/output, and ACE inhibitor titration. Which outcome indicates effective care
coordination?
A) Reduction in length of stay by 1 day compared to the previous year.
B) Decreased incidence of hospital-acquired infections.
C) Increased patient satisfaction scores on discharge surveys.
D) Higher rate of ACE inhibitor prescriptions at discharge.
Answer: A
Rationale: Critical pathways aim to standardize care and reduce variability, leading to improved efficiency and
reduced length of stay. While other options are positive, length of stay is a direct measure of care coordination and
pathway effectiveness.
15 A nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A) A patient with a history of diabetes who has a blood glucose of 60 mg/dL and is diaphoretic.
B) A patient with pneumonia who has a temperature of 38.5°C and a productive cough.
C) A patient with a hip fracture who is reporting pain of 6/10 after receiving analgesia.
D) A patient with a urinary tract infection who has cloudy urine and mild flank pain.
Answer: A
Rationale: Hypoglycemia with diaphoresis indicates a potential medical emergency (e.g., severe hypoglycemia)
requiring immediate intervention to prevent neurological damage. The other patients are stable or have non-urgent
issues.
Elsevier Evolve / NCSBN Clinical Judgment Measurement
Model – Comprehensive Adult Health Nursing Competency
Assessment — 300 Questions
Section 1: Management of Care (Questions 1-38)
1 A charge nurse on a medical-surgical unit is assigning patient care to a team consisting of two registered nurses
(RNs), one licensed practical nurse (LPN), and one unlicensed assistive personnel (UAP). Which patient should
the charge nurse assign to the LPN?
A) A patient with pneumonia requiring frequent respiratory assessments and titration of oxygen
B) A patient with a new colostomy who needs stoma care education and demonstration
C) A patient with a urinary tract infection receiving IV antibiotics and a continuous bladder irrigation
D) A patient with a stage 3 pressure injury requiring wound debridement and complex dressing change
Answer: D
Rationale: LPNs are trained to perform wound care, including debridement and complex dressing changes, under the
supervision of an RN. Option A requires ongoing assessment and titration, which is an RN responsibility. Option B
involves patient education, which is an RN scope. Option C involves IV therapy and continuous bladder irrigation,
which are typically RN duties.
2 A nurse is caring for a patient with acute pancreatitis who has a nasogastric tube to low intermittent suction. The
patient complains of severe abdominal pain and nausea. The nurse notes that the suction is not functioning and
the drainage bag is empty. Which action should the nurse take first?
A) Reposition the nasogastric tube and check for placement
B) Irrigate the nasogastric tube with normal saline
C) Notify the healthcare provider of the malfunction
D) Assess the patient's bowel sounds and abdominal distention
Answer: A
Rationale: The first step is to ensure the NG tube is properly placed and functioning. Repositioning and checking
placement can resolve the issue quickly. Irrigating without confirming placement could cause harm. Notifying the
provider is delayed until after assessment. Assessing bowel sounds is important but secondary to restoring suction.
3 A nurse is preparing to administer a blood transfusion to a patient. Which of the following actions is most
important for the nurse to take to prevent a transfusion reaction?
A) Verify the patient's identity with two identifiers and check the blood product against the prescription
B) Obtain informed consent from the patient for the transfusion
C) Prime the blood administration tubing with normal saline and hang the blood within 30 minutes
D) Monitor vital signs every 15 minutes during the first hour of transfusion
Answer: A
Rationale: The most critical step to prevent a transfusion reaction is proper patient identification and verification of
the blood product. This ensures the right blood is given to the right patient. Informed consent is important but does
not prevent reactions. Priming and monitoring are essential but secondary to correct identification.
, 4 A nurse is delegating the collection of a clean-catch urine specimen to a UAP. The UAP has never performed
this procedure before. Which instruction should the nurse provide?
A) Instruct the patient to void a small amount into the toilet, then collect the midstream urine in the sterile cup
B) Have the patient void directly into the sterile cup after cleaning the perineal area with the provided wipe
C) Clean the perineal area with soap and water, then have the patient void into a clean bedpan and transfer to the
specimen cup
D) Use a straight catheter to obtain the specimen to ensure it is sterile
Answer: A
Rationale: For a clean-catch midstream specimen, the patient should start voiding, then collect the midstream
portion to avoid contamination from the distal urethra. Option B is incorrect because the initial stream should be
discarded. Option C introduces contamination risk. Option D is not delegation to a UAP and is invasive.
5 A patient with a history of heart failure is admitted with shortness of breath and bilateral lower extremity edema.
The nurse notes that the patient's weight has increased by 5 kg in 2 days. Which provider prescription should the
nurse question?
A) Furosemide 40 mg IV push now
B) Oxygen 2 L/min via nasal cannula to maintain SpO2 >92%
C) 0.9% normal saline at 100 mL/hour
D) Daily weights and strict intake and output monitoring
Answer: C
Rationale: The patient is fluid overloaded; administering 0.9% normal saline at 100 mL/hour would exacerbate the
condition. Furosemide is appropriate for diuresis. Oxygen and daily weights are standard. The nurse should
question the saline infusion.
6 A nurse is evaluating the effectiveness of a patient's pain management plan. The patient has a patient-controlled
analgesia (PCA) pump with morphine. The nurse notes that the patient is somnolent and has a respiratory rate of
8 breaths per minute. Which action should the nurse take first?
A) Administer naloxone per protocol
B) Stop the PCA infusion and call the healthcare provider
C) Stimulate the patient and instruct to take deep breaths
D) Increase the lockout interval on the PCA pump
Answer: A
Rationale: The patient is experiencing respiratory depression from opioid overdose. Naloxone is the antidote and
should be administered immediately to reverse the effects. Stopping the infusion is important but secondary.
Stimulation and increasing lockout are insufficient.
7 A nurse is caring for a patient with a new diagnosis of type 2 diabetes mellitus. The patient is prescribed
metformin and insulin glargine. Which statement by the patient indicates a need for further teaching?
A) I will take my metformin with meals to avoid stomach upset
B) I will inject my insulin glargine at bedtime each night
C) I can skip my insulin if I skip a meal
D) I should monitor my blood glucose before meals and at bedtime
Answer: C
Rationale: Insulin glargine is a long-acting basal insulin and should be taken consistently, even if a meal is skipped,
to maintain baseline insulin levels. Skipping it can lead to hyperglycemia. The other statements are correct:
metformin with meals reduces GI side effects, glargine is typically given at bedtime, and monitoring is appropriate.
,8 A nurse is preparing a patient for discharge after a total hip arthroplasty. Which instruction is most important to
include to prevent dislocation?
A) Avoid crossing your legs or bending at the hip past 90 degrees
B) Use a raised toilet seat and avoid low chairs
C) Sleep with a pillow between your legs while lying on your back
D) Perform ankle pumps and quadriceps sets every hour while awake
Answer: A
Rationale: The most critical instruction to prevent dislocation is to avoid hip adduction and flexion beyond 90
degrees. Options B and C are also important but are specific examples of the general principle in A. Option D is for
preventing thromboembolism, not dislocation.
9 A nurse is assessing a patient with a chest tube connected to a water seal drainage system. The nurse notes
continuous bubbling in the water seal chamber. Which action should the nurse take?
A) Clamp the chest tube near the insertion site
B) Check the system for an air leak
C) Increase the suction pressure
D) Notify the healthcare provider immediately
Answer: B
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can
compromise lung re-expansion. The nurse should assess the entire system for leaks (tubing connections, dressing).
Clamping is dangerous and may cause tension pneumothorax. Increasing suction is not indicated. Notifying the
provider is appropriate after assessment.
10 A nurse is caring for a patient who is receiving a continuous IV infusion of heparin for deep vein thrombosis.
The patient's activated partial thromboplastin time (aPTT) is 120 seconds (therapeutic range 60-80 seconds).
Which action should the nurse take?
A) Increase the heparin infusion rate
B) Decrease the heparin infusion rate
C) Administer protamine sulfate
D) Continue the current infusion rate
Answer: B
Rationale: The aPTT is above the therapeutic range, indicating the patient is over-anticoagulated and at risk for
bleeding. The nurse should decrease the infusion rate per protocol. Increasing the rate would worsen the situation.
Protamine sulfate is the antidote but is reserved for severe bleeding or reversal. Continuing the current rate is
unsafe.
11 A nurse is leading a multidisciplinary team meeting to coordinate care for a patient with complex
comorbidities. A physician proposes a treatment plan that the nurse believes may be unsafe based on current
evidence. What is the most appropriate initial action by the nurse?
A) Document the disagreement in the medical record and implement the plan as ordered.
B) Respect the physician's authority and proceed with the treatment plan.
C) Voice concerns using the SBAR technique and request a team discussion of alternatives.
D) Refuse to implement the plan and escalate to the nursing supervisor immediately.
Answer: C
Rationale: The nurse's primary responsibility is patient safety, and SBAR
(Situation-Background-Assessment-Recommendation) is a structured communication tool that facilitates effective
advocacy and team collaboration. Option A undermines advocacy; option B disregards the nurse's duty to question
, unsafe orders; option D bypasses collaborative problem-solving.
12 A nurse is delegating tasks to an unlicensed assistive personnel (UAP) on a medical-surgical unit. Which task is
appropriate for the nurse to delegate?
A) Administering a scheduled oral anticoagulant to a stable patient.
B) Assessing the lung sounds of a patient with pneumonia.
C) Ambulating a patient who had a knee replacement 2 days ago.
D) Developing the plan of care for a newly admitted patient.
Answer: C
Rationale: Ambulation of a stable postoperative patient is a routine task that can be delegated to UAP after proper
training. Administering medications (A) and assessment (B) require nursing judgment; developing the plan of care
(D) is a nursing responsibility.
13 A nurse is caring for a patient who requires a blood transfusion. The patient's religious beliefs prohibit blood
products, but the patient is unconscious and unable to communicate. The patient's spouse requests the
transfusion. What is the nurse's best action?
A) Proceed with the transfusion based on the spouse's consent.
B) Delay the transfusion until the patient can be consulted.
C) Seek a court order to override the patient's presumed wishes.
D) Respect the patient's autonomy and withhold the transfusion.
Answer: D
Rationale: Patient autonomy and advance directives must be honored. In the absence of an advance directive, the
patient's known religious beliefs should guide care. The nurse should advocate for the patient's previously stated
wishes, even if the spouse disagrees.
14 A nurse manager is evaluating the use of a critical pathway for patients with heart failure. The pathway
includes daily weights, strict intake/output, and ACE inhibitor titration. Which outcome indicates effective care
coordination?
A) Reduction in length of stay by 1 day compared to the previous year.
B) Decreased incidence of hospital-acquired infections.
C) Increased patient satisfaction scores on discharge surveys.
D) Higher rate of ACE inhibitor prescriptions at discharge.
Answer: A
Rationale: Critical pathways aim to standardize care and reduce variability, leading to improved efficiency and
reduced length of stay. While other options are positive, length of stay is a direct measure of care coordination and
pathway effectiveness.
15 A nurse is prioritizing care for four patients. Which patient should the nurse assess first?
A) A patient with a history of diabetes who has a blood glucose of 60 mg/dL and is diaphoretic.
B) A patient with pneumonia who has a temperature of 38.5°C and a productive cough.
C) A patient with a hip fracture who is reporting pain of 6/10 after receiving analgesia.
D) A patient with a urinary tract infection who has cloudy urine and mild flank pain.
Answer: A
Rationale: Hypoglycemia with diaphoresis indicates a potential medical emergency (e.g., severe hypoglycemia)
requiring immediate intervention to prevent neurological damage. The other patients are stable or have non-urgent
issues.
