HESI RN CRITICAL CARE EXAMINATION
Critical Care RN HESI Exit Exam Preparation
2026/2027 Edition | Aligned with Elsevier HESI Critical Care Nursing Blueprint and NGN Clinical Judgment Framework
180 Multiple-Choice Questions with Comprehensive Rationales | Hemodynamics, Respiratory, Cardiovascular, Neurological,
Multisystem, Pharmacology, Ethics, and NGN Case Scenarios
Exam Duration: 180 Minutes | Passing Score: 70% (126/180) | Cognitive Levels: 25% Recall, 55% Application, 20% Analysis
Section 1: Hemodynamics and Shock States (Q1-Q30)
Q1: A patient in the ICU has the following hemodynamic parameters: HR 110, BP 85/50, CVP 2 mmHg, PAWP 6 mmHg,
CI 1.8 L/min/m2, SVR 1400 dynes/sec/cm-5. Which type of shock does this patient most likely have?
A. Hypovolemic shock [CORRECT] B. Cardiogenic shock
C. Septic shock D. Neurogenic shock
Correct Answer: A
Rationale: The patient presents with low CVP (2 mmHg), low PAWP (6 mmHg), low CI (1.8), and elevated SVR (1400), which is
characteristic of hypovolemic shock due to decreased preload. Cardiogenic shock would present with elevated PAWP and CVP. Septic
shock initially shows high CI with low SVR. Neurogenic shock presents with bradycardia and warm dry skin, not elevated SVR.
Q2: A nurse is reviewing hemodynamic data for a patient who weighs 70 kg and is 170 cm tall. The cardiac output is 5.6
L/min and the body surface area (BSA) is 1.8 m2. What is the patient's cardiac index?
A. 3.5 L/min/m2 B. 2.8 L/min/m2
C. 4.0 L/min/m2 D. 3.1 L/min/m2 [CORRECT]
Correct Answer: D
Rationale: Cardiac index is calculated by dividing cardiac output by body surface area: CI = CO / BSA = 5..8 = 3.1 L/min/m2. This
falls within the normal range of 2.5-4.0 L/min/m2. Option B (2.8) would result from an incorrect BSA of 2.0, option A (3.5) from CO of
6.3, and option C from CO of 7.2.
Q3: A patient's blood pressure is 100/60 mmHg and heart rate is 80 bpm. What is the mean arterial pressure (MAP)?
A. 80 mmHg B. 67 mmHg
C. 73 mmHg [CORRECT] D. 86 mmHg
Correct Answer: C
Rationale: MAP is calculated using the formula: MAP = DBP + 1/3(SBP - DBP) = 60 + 1/3(100 - 60) = 60 + 13.3 = 73.3 mmHg,
rounded to 73 mmHg. This is above the critical threshold of 65 mmHg, indicating adequate organ perfusion pressure. Option B uses an
incorrect formula, and options A and D are calculation errors.
Q4: Which hemodynamic parameter is most directly affected by a patient receiving a fluid bolus of 500 mL normal saline?
A. Heart rate (HR) B. Systemic vascular resistance (SVR)
C. Central venous pressure (CVP) D. Pulmonary vascular resistance (PVR)
[CORRECT]
Correct Answer: C
Rationale: A fluid bolus increases intravascular volume, which directly increases preload and raises central venous pressure (CVP). CVP
is measured in the right atrium and reflects right ventricular preload, making it the parameter most directly affected by volume
administration. SVR is influenced by vasoactive medications, not directly by fluid. PVR reflects pulmonary vascular tone. Heart rate may
change indirectly but is not the most directly affected parameter.
Q5: A patient has a PAWP of 18 mmHg, CI of 2.0 L/min/m2, and SVR of 1100 dynes/sec/cm-5. The nurse notes bilateral
crackles and JVD. Which intervention should the nurse anticipate?
HESI RN Critical Care Examination 2026/2027 | Page 1
, A. Administer a 500 mL fluid bolus B. Increase PEEP to 15 cm H2O
C. Administer vasopressin D. Initiate dobutamine infusion [CORRECT]
Correct Answer: D
Rationale: This patient shows signs of cardiogenic shock with elevated PAWP (18 mmHg, upper limit normal), low CI (2.0), and
congestive symptoms (crackles, JVD). Dobutamine is a first-line inotrope for cardiogenic shock that increases contractility and cardiac
output without significantly increasing afterload. A fluid bolus would worsen pulmonary congestion. Vasopressin is used for septic or
distributive shock. Increasing PEEP is a respiratory intervention, not the primary treatment for the underlying cardiac dysfunction.
Q6: A 62-year-old patient 3 days post-MI develops cool, clammy skin, oliguria, and altered mental status. Hemodynamics
reveal: HR 118, BP 78/50, CVP 14 mmHg, PAWP 22 mmHg, CI 1.6 L/min/m2, SVR 1500 dynes/sec/cm-5. Which
medication should the nurse prepare to administer first?
A. Dobutamine drip [CORRECT] B. Nitroglycerin drip
C. Nitroprusside drip D. Dopamine drip
Correct Answer: A
Rationale: This patient is in cardiogenic shock with low CI (1.6), elevated PAWP (22), and elevated SVR (1500). Dobutamine is the
first-line inotrope because it increases cardiac output through positive inotropy and mild vasodilation, improving both CO and reducing
afterload. Nitroglycerin is contraindicated with SBP < 90 mmHg. Dopamine at high doses increases SVR, further stressing the heart.
Nitroprusside would dangerously lower BP in this hypotensive patient.
Q7: A patient in cardiogenic shock has an intra-aortic balloon pump (IABP) placed. The nurse understands that the IABP
inflates during which phase of the cardiac cycle?
A. During systole to reduce afterload B. During isovolumetric contraction to increase
stroke volume
C. During diastole to increase coronary D. During atrial contraction to improve preload
perfusion [CORRECT]
Correct Answer: C
Rationale: The IABP inflates during diastole, which displaces blood from the aorta back toward the coronary arteries, increasing
coronary perfusion pressure and improving oxygen delivery to the ischemic myocardium. It deflates just before systole, reducing afterload
and decreasing myocardial oxygen demand. Inflation during systole would increase afterload and worsen cardiac function. The other
options describe physiologic phases that do not correspond to IABP timing.
Q8: A patient with severe heart failure is started on milrinone. The nurse should monitor for which most common adverse
effect?
A. Hypotension [CORRECT] B. Hypertension
C. Hyperkalemia D. Bradycardia
Correct Answer: A
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that increases contractility and causes vasodilation, commonly leading to
hypotension. Unlike dobutamine, milrinone's effects are not dependent on beta-receptors, making it useful in patients on beta-blockers, but
its vasodilatory properties make hypotension the most frequent side effect requiring close blood pressure monitoring. Hypertension and
bradycardia are opposite of expected effects. Hyperkalemia is not associated with milrinone.
Q9: A nurse is caring for a patient in cardiogenic shock with SBP of 82 mmHg. The physician orders sublingual
nitroglycerin. What is the nurse's best action?
A. Hold the nitroglycerin and contact the B. Administer the nitroglycerin as ordered
physician [CORRECT]
C. Request an order for IV nitroglycerin instead D. Administer half the dose and reassess in 5
minutes
Correct Answer: A
Rationale: Nitroglycerin should not be administered when SBP is below 90 mmHg because it causes vasodilation and can precipitate
severe, life-threatening hypotension in an already hemodynamically compromised patient. The nurse must hold the medication and contact
the physician for an alternative order. Administering even half the dose is unsafe. Requesting IV nitroglycerin would be even more
HESI RN Critical Care Examination 2026/2027 | Page 2
,dangerous as it causes more profound vasodilation.
Q10: A patient with cardiogenic shock is receiving dobutamine at 10 mcg/kg/min. The nurse notes the heart rate has
increased from 90 to 128 bpm and the patient reports palpitations. What is the priority nursing action?
A. Administer a beta-blocker IV push B. Stop the infusion and prepare for
cardioversion
C. Document the findings and continue D. Slow the infusion rate and notify the
monitoring provider [CORRECT]
Correct Answer: D
Rationale: Dobutamine is a beta-1 agonist that increases heart rate as a dose-related side effect. Tachycardia increases myocardial
oxygen demand and can worsen ischemia in cardiogenic shock. The priority is to slow the infusion rate to reduce the tachycardic effect
and notify the provider for further orders. A beta-blocker would be contraindicated as it would counteract the inotropic support.
Cardioversion is not indicated for sinus tachycardia. Simply documenting without intervening is unsafe.
Q11: Which combination of hemodynamic findings is most consistent with cardiogenic shock?
A. Low CVP, low PAWP, high CI, low SVR B. High CVP, high PAWP, low CI, high SVR
[CORRECT]
C. Low CVP, low PAWP, low CI, high SVR D. High CVP, low PAWP, low CI, low SVR
Correct Answer: B
Rationale: Cardiogenic shock results from pump failure, leading to elevated filling pressures (high CVP and high PAWP) due to blood
backing up, decreased cardiac output (low CI), and compensatory vasoconstriction (high SVR). Low CVP and PAWP with high SVR
suggest hypovolemic shock. High CI with low SVR is seen in early septic shock. The combination in option D does not fit any single shock
state pattern.
Q12: A 28-year-old patient arrives to the ED after a motor vehicle collision. BP 78/40, HR 135, CVP 1 mmHg, PAWP 4
mmHg. The patient's skin is cool and pale with delayed capillary refill. Which fluid should the nurse prepare to administer
first?
A. Packed red blood cells B. Lactated Ringer's 30 mL/kg [CORRECT]
C. 0.9% normal saline 500 mL over 4 hours D. 5% albumin
Correct Answer: B
Rationale: This patient has signs of hypovolemic shock with very low CVP (1) and PAWP (4), indicating severe volume depletion. Current
guidelines recommend an initial crystalloid bolus of 30 mL/kg for hypovolemic shock, and lactated Ringer's is preferred over normal
saline as it causes less hyperchloremic acidosis. Packed RBCs may be needed later but crystalloids are given first. Albumin is more
expensive without clear superiority. Four hours is too slow for a patient in active shock.
Q13: A patient with massive GI bleeding has received 2 L of lactated Ringer's. BP is now 88/54, HR 110, urine output 15
mL/hr. Hemoglobin is 6.8 g/dL. What is the priority intervention?
A. Administer vasopressin 0.03 units/min B. Administer another liter of lactated Ringer's
C. Begin transfusion of packed red blood D. Start a norepinephrine drip
cells [CORRECT]
Correct Answer: C
Rationale: Despite fluid resuscitation, this patient remains hypotensive with tachycardia, oliguria, and critically low hemoglobin (6.8
g/dL), indicating ongoing hemorrhage requiring blood product replacement. Crystalloids alone cannot restore oxygen-carrying capacity.
Further crystalloid will dilute clotting factors and worsen coagulopathy. Vasopressors are not first-line for hemorrhagic shock and would
further compromise tissue perfusion. Vasopressin is used for distributive shock.
Q14: A nurse is monitoring a patient with hypovolemic shock. Which assessment finding indicates that fluid resuscitation is
effective?
A. Heart rate decreases from 120 to 95 bpm B. MAP decreases from 70 to 60 mmHg
[CORRECT]
C. CVP increases from 2 to 18 mmHg D. Urine output decreases from 30 to 15 mL/hr
HESI RN Critical Care Examination 2026/2027 | Page 3
, Correct Answer: A
Rationale: A decreasing heart rate from 120 to 95 bpm indicates improving intravascular volume and reduced compensatory sympathetic
response, suggesting effective fluid resuscitation. CVP increasing to 18 mmHg would suggest fluid overload and possible right heart
failure. Decreasing urine output and decreasing MAP indicate worsening perfusion and inadequate resuscitation. The goal is to restore
adequate organ perfusion reflected by HR < 100, MAP > 65, and urine output > 0.5 mL/kg/hr.
Q15: A patient with severe burns covering 40% total body surface area is in hypovolemic shock. The nurse understands that
the primary mechanism of hypovolemia in burn patients during the first 24 hours is:
A. Fluid shift from intravascular to B. Hemorrhage from damaged capillaries
interstitial space [CORRECT]
C. Third-spacing of fluid into the peritoneal D. Increased insensible water loss through the
cavity wound
Correct Answer: A
Rationale: During the first 24 hours after a major burn, increased capillary permeability causes massive fluid and protein shifts from the
intravascular space into the interstitial space (edema), resulting in hypovolemic shock. This is not hemorrhage but rather a transudative
process. While insensible losses increase, they are not the primary mechanism of hypovolemia. Third-spacing into the peritoneal cavity is
not characteristic of burn shock.
Q16: Which set of hemodynamic values is most consistent with hypovolemic shock?
A. CVP 14 mmHg, PAWP 20 mmHg, CI 1.8 B. CVP 8 mmHg, PAWP 10 mmHg, CI 3.8
L/min/m2 L/min/m2
C. CVP 2 mmHg, PAWP 5 mmHg, CI 1.5 D. CVP 3 mmHg, PAWP 8 mmHg, CI 5.5
L/min/m2 [CORRECT] L/min/m2
Correct Answer: C
Rationale: Hypovolemic shock is characterized by decreased intravascular volume, resulting in low filling pressures (CVP 2, PAWP 5)
and low cardiac output (CI 1.5). Option A shows elevated filling pressures consistent with cardiogenic shock. Option B shows normal
pressures with high output, which is not consistent with any shock state. Option D shows low CVP but normal PAWP with very high CI,
which is inconsistent with hypovolemia.
Q17: A 55-year-old patient with a urinary tract infection develops fever (103.2°F), HR 125, BP 82/48, warm and flushed
skin, CVP 4 mmHg, CI 4.5 L/min/m2, SVR 650 dynes/sec/cm-5. Which stage of septic shock is this patient experiencing?
A. Late hypodynamic phase B. Refractory phase
C. Early hyperdynamic phase [CORRECT] D. Compensated phase
Correct Answer: C
Rationale: This patient is in the early hyperdynamic (warm) phase of septic shock, characterized by high cardiac output (CI 4.5), low SVR
(650) due to profound vasodilation, warm and flushed skin from peripheral vasodilation, and tachycardia. The late hypodynamic phase
would show low CI and high SVR with cool, clammy skin. 'Compensated phase' is not standard septic shock terminology. The refractory
phase implies unresponsiveness to treatment.
Q18: A patient in septic shock has a MAP of 52 mmHg after receiving a 30 mL/kg crystalloid bolus. Which vasopressor
should the nurse anticipate as the first-line agent?
A. Norepinephrine [CORRECT] B. Dopamine
C. Vasopressin D. Epinephrine
Correct Answer: A
Rationale: Surviving Sepsis Campaign guidelines recommend norepinephrine as the first-line vasopressor for septic shock to maintain a
MAP of 65 mmHg or greater. Norepinephrine has potent alpha-1 and moderate beta-1 effects, effectively increasing MAP through
vasoconstriction while maintaining some inotropic support. Dopamine is associated with higher arrhythmia rates. Epinephrine causes
excessive tachycardia and lactic acidosis. Vasopressin is used as a second-line agent or adjunct.
Q19: A patient presents to the ED with suspected septic shock. Blood cultures have been drawn. How soon should the nurse
administer the first dose of broad-spectrum antibiotics?
HESI RN Critical Care Examination 2026/2027 | Page 4
Critical Care RN HESI Exit Exam Preparation
2026/2027 Edition | Aligned with Elsevier HESI Critical Care Nursing Blueprint and NGN Clinical Judgment Framework
180 Multiple-Choice Questions with Comprehensive Rationales | Hemodynamics, Respiratory, Cardiovascular, Neurological,
Multisystem, Pharmacology, Ethics, and NGN Case Scenarios
Exam Duration: 180 Minutes | Passing Score: 70% (126/180) | Cognitive Levels: 25% Recall, 55% Application, 20% Analysis
Section 1: Hemodynamics and Shock States (Q1-Q30)
Q1: A patient in the ICU has the following hemodynamic parameters: HR 110, BP 85/50, CVP 2 mmHg, PAWP 6 mmHg,
CI 1.8 L/min/m2, SVR 1400 dynes/sec/cm-5. Which type of shock does this patient most likely have?
A. Hypovolemic shock [CORRECT] B. Cardiogenic shock
C. Septic shock D. Neurogenic shock
Correct Answer: A
Rationale: The patient presents with low CVP (2 mmHg), low PAWP (6 mmHg), low CI (1.8), and elevated SVR (1400), which is
characteristic of hypovolemic shock due to decreased preload. Cardiogenic shock would present with elevated PAWP and CVP. Septic
shock initially shows high CI with low SVR. Neurogenic shock presents with bradycardia and warm dry skin, not elevated SVR.
Q2: A nurse is reviewing hemodynamic data for a patient who weighs 70 kg and is 170 cm tall. The cardiac output is 5.6
L/min and the body surface area (BSA) is 1.8 m2. What is the patient's cardiac index?
A. 3.5 L/min/m2 B. 2.8 L/min/m2
C. 4.0 L/min/m2 D. 3.1 L/min/m2 [CORRECT]
Correct Answer: D
Rationale: Cardiac index is calculated by dividing cardiac output by body surface area: CI = CO / BSA = 5..8 = 3.1 L/min/m2. This
falls within the normal range of 2.5-4.0 L/min/m2. Option B (2.8) would result from an incorrect BSA of 2.0, option A (3.5) from CO of
6.3, and option C from CO of 7.2.
Q3: A patient's blood pressure is 100/60 mmHg and heart rate is 80 bpm. What is the mean arterial pressure (MAP)?
A. 80 mmHg B. 67 mmHg
C. 73 mmHg [CORRECT] D. 86 mmHg
Correct Answer: C
Rationale: MAP is calculated using the formula: MAP = DBP + 1/3(SBP - DBP) = 60 + 1/3(100 - 60) = 60 + 13.3 = 73.3 mmHg,
rounded to 73 mmHg. This is above the critical threshold of 65 mmHg, indicating adequate organ perfusion pressure. Option B uses an
incorrect formula, and options A and D are calculation errors.
Q4: Which hemodynamic parameter is most directly affected by a patient receiving a fluid bolus of 500 mL normal saline?
A. Heart rate (HR) B. Systemic vascular resistance (SVR)
C. Central venous pressure (CVP) D. Pulmonary vascular resistance (PVR)
[CORRECT]
Correct Answer: C
Rationale: A fluid bolus increases intravascular volume, which directly increases preload and raises central venous pressure (CVP). CVP
is measured in the right atrium and reflects right ventricular preload, making it the parameter most directly affected by volume
administration. SVR is influenced by vasoactive medications, not directly by fluid. PVR reflects pulmonary vascular tone. Heart rate may
change indirectly but is not the most directly affected parameter.
Q5: A patient has a PAWP of 18 mmHg, CI of 2.0 L/min/m2, and SVR of 1100 dynes/sec/cm-5. The nurse notes bilateral
crackles and JVD. Which intervention should the nurse anticipate?
HESI RN Critical Care Examination 2026/2027 | Page 1
, A. Administer a 500 mL fluid bolus B. Increase PEEP to 15 cm H2O
C. Administer vasopressin D. Initiate dobutamine infusion [CORRECT]
Correct Answer: D
Rationale: This patient shows signs of cardiogenic shock with elevated PAWP (18 mmHg, upper limit normal), low CI (2.0), and
congestive symptoms (crackles, JVD). Dobutamine is a first-line inotrope for cardiogenic shock that increases contractility and cardiac
output without significantly increasing afterload. A fluid bolus would worsen pulmonary congestion. Vasopressin is used for septic or
distributive shock. Increasing PEEP is a respiratory intervention, not the primary treatment for the underlying cardiac dysfunction.
Q6: A 62-year-old patient 3 days post-MI develops cool, clammy skin, oliguria, and altered mental status. Hemodynamics
reveal: HR 118, BP 78/50, CVP 14 mmHg, PAWP 22 mmHg, CI 1.6 L/min/m2, SVR 1500 dynes/sec/cm-5. Which
medication should the nurse prepare to administer first?
A. Dobutamine drip [CORRECT] B. Nitroglycerin drip
C. Nitroprusside drip D. Dopamine drip
Correct Answer: A
Rationale: This patient is in cardiogenic shock with low CI (1.6), elevated PAWP (22), and elevated SVR (1500). Dobutamine is the
first-line inotrope because it increases cardiac output through positive inotropy and mild vasodilation, improving both CO and reducing
afterload. Nitroglycerin is contraindicated with SBP < 90 mmHg. Dopamine at high doses increases SVR, further stressing the heart.
Nitroprusside would dangerously lower BP in this hypotensive patient.
Q7: A patient in cardiogenic shock has an intra-aortic balloon pump (IABP) placed. The nurse understands that the IABP
inflates during which phase of the cardiac cycle?
A. During systole to reduce afterload B. During isovolumetric contraction to increase
stroke volume
C. During diastole to increase coronary D. During atrial contraction to improve preload
perfusion [CORRECT]
Correct Answer: C
Rationale: The IABP inflates during diastole, which displaces blood from the aorta back toward the coronary arteries, increasing
coronary perfusion pressure and improving oxygen delivery to the ischemic myocardium. It deflates just before systole, reducing afterload
and decreasing myocardial oxygen demand. Inflation during systole would increase afterload and worsen cardiac function. The other
options describe physiologic phases that do not correspond to IABP timing.
Q8: A patient with severe heart failure is started on milrinone. The nurse should monitor for which most common adverse
effect?
A. Hypotension [CORRECT] B. Hypertension
C. Hyperkalemia D. Bradycardia
Correct Answer: A
Rationale: Milrinone is a phosphodiesterase-3 inhibitor that increases contractility and causes vasodilation, commonly leading to
hypotension. Unlike dobutamine, milrinone's effects are not dependent on beta-receptors, making it useful in patients on beta-blockers, but
its vasodilatory properties make hypotension the most frequent side effect requiring close blood pressure monitoring. Hypertension and
bradycardia are opposite of expected effects. Hyperkalemia is not associated with milrinone.
Q9: A nurse is caring for a patient in cardiogenic shock with SBP of 82 mmHg. The physician orders sublingual
nitroglycerin. What is the nurse's best action?
A. Hold the nitroglycerin and contact the B. Administer the nitroglycerin as ordered
physician [CORRECT]
C. Request an order for IV nitroglycerin instead D. Administer half the dose and reassess in 5
minutes
Correct Answer: A
Rationale: Nitroglycerin should not be administered when SBP is below 90 mmHg because it causes vasodilation and can precipitate
severe, life-threatening hypotension in an already hemodynamically compromised patient. The nurse must hold the medication and contact
the physician for an alternative order. Administering even half the dose is unsafe. Requesting IV nitroglycerin would be even more
HESI RN Critical Care Examination 2026/2027 | Page 2
,dangerous as it causes more profound vasodilation.
Q10: A patient with cardiogenic shock is receiving dobutamine at 10 mcg/kg/min. The nurse notes the heart rate has
increased from 90 to 128 bpm and the patient reports palpitations. What is the priority nursing action?
A. Administer a beta-blocker IV push B. Stop the infusion and prepare for
cardioversion
C. Document the findings and continue D. Slow the infusion rate and notify the
monitoring provider [CORRECT]
Correct Answer: D
Rationale: Dobutamine is a beta-1 agonist that increases heart rate as a dose-related side effect. Tachycardia increases myocardial
oxygen demand and can worsen ischemia in cardiogenic shock. The priority is to slow the infusion rate to reduce the tachycardic effect
and notify the provider for further orders. A beta-blocker would be contraindicated as it would counteract the inotropic support.
Cardioversion is not indicated for sinus tachycardia. Simply documenting without intervening is unsafe.
Q11: Which combination of hemodynamic findings is most consistent with cardiogenic shock?
A. Low CVP, low PAWP, high CI, low SVR B. High CVP, high PAWP, low CI, high SVR
[CORRECT]
C. Low CVP, low PAWP, low CI, high SVR D. High CVP, low PAWP, low CI, low SVR
Correct Answer: B
Rationale: Cardiogenic shock results from pump failure, leading to elevated filling pressures (high CVP and high PAWP) due to blood
backing up, decreased cardiac output (low CI), and compensatory vasoconstriction (high SVR). Low CVP and PAWP with high SVR
suggest hypovolemic shock. High CI with low SVR is seen in early septic shock. The combination in option D does not fit any single shock
state pattern.
Q12: A 28-year-old patient arrives to the ED after a motor vehicle collision. BP 78/40, HR 135, CVP 1 mmHg, PAWP 4
mmHg. The patient's skin is cool and pale with delayed capillary refill. Which fluid should the nurse prepare to administer
first?
A. Packed red blood cells B. Lactated Ringer's 30 mL/kg [CORRECT]
C. 0.9% normal saline 500 mL over 4 hours D. 5% albumin
Correct Answer: B
Rationale: This patient has signs of hypovolemic shock with very low CVP (1) and PAWP (4), indicating severe volume depletion. Current
guidelines recommend an initial crystalloid bolus of 30 mL/kg for hypovolemic shock, and lactated Ringer's is preferred over normal
saline as it causes less hyperchloremic acidosis. Packed RBCs may be needed later but crystalloids are given first. Albumin is more
expensive without clear superiority. Four hours is too slow for a patient in active shock.
Q13: A patient with massive GI bleeding has received 2 L of lactated Ringer's. BP is now 88/54, HR 110, urine output 15
mL/hr. Hemoglobin is 6.8 g/dL. What is the priority intervention?
A. Administer vasopressin 0.03 units/min B. Administer another liter of lactated Ringer's
C. Begin transfusion of packed red blood D. Start a norepinephrine drip
cells [CORRECT]
Correct Answer: C
Rationale: Despite fluid resuscitation, this patient remains hypotensive with tachycardia, oliguria, and critically low hemoglobin (6.8
g/dL), indicating ongoing hemorrhage requiring blood product replacement. Crystalloids alone cannot restore oxygen-carrying capacity.
Further crystalloid will dilute clotting factors and worsen coagulopathy. Vasopressors are not first-line for hemorrhagic shock and would
further compromise tissue perfusion. Vasopressin is used for distributive shock.
Q14: A nurse is monitoring a patient with hypovolemic shock. Which assessment finding indicates that fluid resuscitation is
effective?
A. Heart rate decreases from 120 to 95 bpm B. MAP decreases from 70 to 60 mmHg
[CORRECT]
C. CVP increases from 2 to 18 mmHg D. Urine output decreases from 30 to 15 mL/hr
HESI RN Critical Care Examination 2026/2027 | Page 3
, Correct Answer: A
Rationale: A decreasing heart rate from 120 to 95 bpm indicates improving intravascular volume and reduced compensatory sympathetic
response, suggesting effective fluid resuscitation. CVP increasing to 18 mmHg would suggest fluid overload and possible right heart
failure. Decreasing urine output and decreasing MAP indicate worsening perfusion and inadequate resuscitation. The goal is to restore
adequate organ perfusion reflected by HR < 100, MAP > 65, and urine output > 0.5 mL/kg/hr.
Q15: A patient with severe burns covering 40% total body surface area is in hypovolemic shock. The nurse understands that
the primary mechanism of hypovolemia in burn patients during the first 24 hours is:
A. Fluid shift from intravascular to B. Hemorrhage from damaged capillaries
interstitial space [CORRECT]
C. Third-spacing of fluid into the peritoneal D. Increased insensible water loss through the
cavity wound
Correct Answer: A
Rationale: During the first 24 hours after a major burn, increased capillary permeability causes massive fluid and protein shifts from the
intravascular space into the interstitial space (edema), resulting in hypovolemic shock. This is not hemorrhage but rather a transudative
process. While insensible losses increase, they are not the primary mechanism of hypovolemia. Third-spacing into the peritoneal cavity is
not characteristic of burn shock.
Q16: Which set of hemodynamic values is most consistent with hypovolemic shock?
A. CVP 14 mmHg, PAWP 20 mmHg, CI 1.8 B. CVP 8 mmHg, PAWP 10 mmHg, CI 3.8
L/min/m2 L/min/m2
C. CVP 2 mmHg, PAWP 5 mmHg, CI 1.5 D. CVP 3 mmHg, PAWP 8 mmHg, CI 5.5
L/min/m2 [CORRECT] L/min/m2
Correct Answer: C
Rationale: Hypovolemic shock is characterized by decreased intravascular volume, resulting in low filling pressures (CVP 2, PAWP 5)
and low cardiac output (CI 1.5). Option A shows elevated filling pressures consistent with cardiogenic shock. Option B shows normal
pressures with high output, which is not consistent with any shock state. Option D shows low CVP but normal PAWP with very high CI,
which is inconsistent with hypovolemia.
Q17: A 55-year-old patient with a urinary tract infection develops fever (103.2°F), HR 125, BP 82/48, warm and flushed
skin, CVP 4 mmHg, CI 4.5 L/min/m2, SVR 650 dynes/sec/cm-5. Which stage of septic shock is this patient experiencing?
A. Late hypodynamic phase B. Refractory phase
C. Early hyperdynamic phase [CORRECT] D. Compensated phase
Correct Answer: C
Rationale: This patient is in the early hyperdynamic (warm) phase of septic shock, characterized by high cardiac output (CI 4.5), low SVR
(650) due to profound vasodilation, warm and flushed skin from peripheral vasodilation, and tachycardia. The late hypodynamic phase
would show low CI and high SVR with cool, clammy skin. 'Compensated phase' is not standard septic shock terminology. The refractory
phase implies unresponsiveness to treatment.
Q18: A patient in septic shock has a MAP of 52 mmHg after receiving a 30 mL/kg crystalloid bolus. Which vasopressor
should the nurse anticipate as the first-line agent?
A. Norepinephrine [CORRECT] B. Dopamine
C. Vasopressin D. Epinephrine
Correct Answer: A
Rationale: Surviving Sepsis Campaign guidelines recommend norepinephrine as the first-line vasopressor for septic shock to maintain a
MAP of 65 mmHg or greater. Norepinephrine has potent alpha-1 and moderate beta-1 effects, effectively increasing MAP through
vasoconstriction while maintaining some inotropic support. Dopamine is associated with higher arrhythmia rates. Epinephrine causes
excessive tachycardia and lactic acidosis. Vasopressin is used as a second-line agent or adjunct.
Q19: A patient presents to the ED with suspected septic shock. Blood cultures have been drawn. How soon should the nurse
administer the first dose of broad-spectrum antibiotics?
HESI RN Critical Care Examination 2026/2027 | Page 4
