Evolve Elsevier HESI Med-Surg Practice Exam
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
A 68-year-old client is admitted with acute decompensated heart failure. The nurse notes
bilateral crackles, oxygen saturation 86%, and BP 160/90 mmHg. Which prescribed
intervention should the nurse implement FIRST?
A. Administer IV furosemide 40 mg
B. Obtain chest X-ray
C. Start oxygen at 2 L via nasal cannula
1. D. Insert Foley catheter
Correct Answer: C
Rationale: The client is hypoxemic (SpO₂ 86%) and in acute respiratory distress; oxygen
is the immediate priority to prevent tissue hypoxia and cardiac decompensation. Once
oxygenation improves, rapid-acting diuretics can be given to reduce pulmonary
congestion. Chest X-ray and Foley are important but not life-saving in the first minutes.
Remember the ABCs—airway and breathing come before circulation interventions like
diuresis.
The nurse is caring for a client 4 hours post-CABG. The mediastinal chest tube suddenly
drains 250 mL of bright-red blood. Which action is MOST appropriate?
A. Milk the chest tube toward the collection chamber
B. Increase suction to −30 cm H₂O
C. Notify the surgeon immediately
2. D. Document and reassess in 15 minutes
Correct Answer: C
Rationale: Acute bleeding >100 mL/hr or sudden bright-red output suggests surgical
hemorrhage; immediate surgical notification is required for possible mediastinal
exploration. Milking may dislodge clots but will not stop arterial bleeding. Increasing
,suction can damage tissue and is contraindicated. Delaying notification risks
hypovolemic shock and cardiac tamponade.
A client with DKA is receiving an insulin infusion at 0.1 units/kg/hr. Which laboratory
value is the BEST indicator that the insulin dose is effective?
A. pH 7.30
B. Serum bicarbonate 18 mEq/L
C. Serum glucose 250 mg/dL
3. D. Anion gap 10 mEq/L
Correct Answer: D
Rationale: Closure of the anion gap (normal 8–12 mEq/L) reflects cessation of ketone
production and is the primary endpoint of insulin therapy, regardless of glucose level.
Glucose falls faster than ketones; continuing insulin until gap closes prevents early
relapse. pH and bicarbonate improve later and are less sensitive markers of real-time
insulin effect.
The nurse is assessing a client with Guillain-Barré syndrome. Which finding requires
IMMEDIATE intervention?
A. Bilateral lower-extremity weakness 4/5
B. Decreased deep tendon reflexes
C. Respiratory rate 28/min, vital capacity 12 mL/kg
4. D. Tingling in fingers and toes
Correct Answer: C
Rationale: Vital capacity <15 mL/kg or RR >30 signals impending respiratory failure;
prompt intubation may be needed. Progressive weakness and areflexia are expected;
sensory symptoms alone are not emergent. Frequent pulmonary assessment (negative
inspiratory force, VC) is critical because respiratory muscles can fatigue rapidly.
A client with pancreatitis reports severe abdominal pain 8/10 and is NPO. The nurse
notes HR 110, BP 100/50, urine output 20 mL/hr. Which order is PRIORITY?
A. Administer morphine 4 mg IV
B. Start LR 500 mL bolus
,C. Insert NG tube to low suction
5. D. Obtain serum lipase
Correct Answer: B
Rationale: Hypotension and oliguria indicate hypovolemic shock from third-spacing;
isotonic fluid resuscitation is priority to restore perfusion. Pain control is important but
must follow hemodynamic stability. NG decompression is used for ileus, not
hypovolemia. Lab draws do not supersede life-saving fluids.
A client with a pulmonary embolism is on a heparin infusion. aPTT is 90 seconds
(control 30). The nurse should anticipate which prescription?
A. Decrease heparin rate by 2 units/kg/hr
B. Stop heparin for 2 hours then resume
C. Give protamine sulfate 10 mg IV
6. D. No change; therapeutic range
Correct Answer: A
Rationale: aPTT >80 seconds (≥2.7 × control) increases bleeding risk; reducing the
infusion rate is first-line. Brief interruption is reserved for clinically significant bleeding.
Protamine reverses heparin but is used only for major hemorrhage. The upper therapeutic
limit is usually 70 seconds.
A client with a T4 spinal cord injury develops flushing and a pounding headache. BP is
220/110. Which action is FIRST?
A. Sit patient upright and loosen clothing
B. Administer sublingual nifedipine
C. Catheterize to check for bladder distention
7. D. Call code blue
Correct Answer: A
Rationale: Autonomic dysreflexia is a medical emergency; upright posture lowers
cerebral perfusion pressure and stimulus search begins immediately. Sublingual
nifedipine may be used but only after positioning. Bladder distention is the most common
trigger and should be relieved promptly, but airway/positioning precede pharmacology.
, A client with cirrhosis has a massive hematemesis. Which intervention should the nurse
prepare for FIRST?
A. Insert a Sengstaken-Blakemore tube
B. Start two large-bore IV lines
C. Administer vitamin K 10 mg IV
8. D. Insert NG tube for lavage
Correct Answer: B
Rationale: Rapid volume resuscitation is critical in variceal hemorrhage; two 16-gauge
IVs allow simultaneous fluids and blood products. Balloon tamponade is used only when
endoscopy fails. Vitamin K takes 6–12 hours to correct coagulopathy. NG lavage does not
control bleeding and may increase variceal pressure.
A client with diabetic gastroparesis reports nausea and early satiety. Which dietary
modification is BEST?
A. Six small low-fat meals daily
B. High-fiber breakfast
C. Large evening meal
9. D. Carbonated beverages with meals
Correct Answer: A
Rationale: Small, frequent, low-fat meals reduce gastric load and improve emptying. Fat
delays motility; fiber and large meals worsen distention. Carbonation increases gastric
pressure and nausea. Metoclopramide may be added but diet is first-line.
A client with acute kidney injury (oliguric phase) has K⁺ 6.2 mEq/L, peaked T waves, HR
52. Which medication is given FIRST?
A. Calcium gluconate 1 g IV
B. Regular insulin 10 units + 25 g dextrose IV
C. Albuterol 10 mg nebulized
10. D. Sodium polystyrene sulfonate 30 g PO
Correct Answer: A
Rationale: Membrane-stabilizing calcium reverses cardiotoxicity within 1–3 minutes and
is given before any other drug when ECG changes exist. Insulin/dextrose and albuterol
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
A 68-year-old client is admitted with acute decompensated heart failure. The nurse notes
bilateral crackles, oxygen saturation 86%, and BP 160/90 mmHg. Which prescribed
intervention should the nurse implement FIRST?
A. Administer IV furosemide 40 mg
B. Obtain chest X-ray
C. Start oxygen at 2 L via nasal cannula
1. D. Insert Foley catheter
Correct Answer: C
Rationale: The client is hypoxemic (SpO₂ 86%) and in acute respiratory distress; oxygen
is the immediate priority to prevent tissue hypoxia and cardiac decompensation. Once
oxygenation improves, rapid-acting diuretics can be given to reduce pulmonary
congestion. Chest X-ray and Foley are important but not life-saving in the first minutes.
Remember the ABCs—airway and breathing come before circulation interventions like
diuresis.
The nurse is caring for a client 4 hours post-CABG. The mediastinal chest tube suddenly
drains 250 mL of bright-red blood. Which action is MOST appropriate?
A. Milk the chest tube toward the collection chamber
B. Increase suction to −30 cm H₂O
C. Notify the surgeon immediately
2. D. Document and reassess in 15 minutes
Correct Answer: C
Rationale: Acute bleeding >100 mL/hr or sudden bright-red output suggests surgical
hemorrhage; immediate surgical notification is required for possible mediastinal
exploration. Milking may dislodge clots but will not stop arterial bleeding. Increasing
,suction can damage tissue and is contraindicated. Delaying notification risks
hypovolemic shock and cardiac tamponade.
A client with DKA is receiving an insulin infusion at 0.1 units/kg/hr. Which laboratory
value is the BEST indicator that the insulin dose is effective?
A. pH 7.30
B. Serum bicarbonate 18 mEq/L
C. Serum glucose 250 mg/dL
3. D. Anion gap 10 mEq/L
Correct Answer: D
Rationale: Closure of the anion gap (normal 8–12 mEq/L) reflects cessation of ketone
production and is the primary endpoint of insulin therapy, regardless of glucose level.
Glucose falls faster than ketones; continuing insulin until gap closes prevents early
relapse. pH and bicarbonate improve later and are less sensitive markers of real-time
insulin effect.
The nurse is assessing a client with Guillain-Barré syndrome. Which finding requires
IMMEDIATE intervention?
A. Bilateral lower-extremity weakness 4/5
B. Decreased deep tendon reflexes
C. Respiratory rate 28/min, vital capacity 12 mL/kg
4. D. Tingling in fingers and toes
Correct Answer: C
Rationale: Vital capacity <15 mL/kg or RR >30 signals impending respiratory failure;
prompt intubation may be needed. Progressive weakness and areflexia are expected;
sensory symptoms alone are not emergent. Frequent pulmonary assessment (negative
inspiratory force, VC) is critical because respiratory muscles can fatigue rapidly.
A client with pancreatitis reports severe abdominal pain 8/10 and is NPO. The nurse
notes HR 110, BP 100/50, urine output 20 mL/hr. Which order is PRIORITY?
A. Administer morphine 4 mg IV
B. Start LR 500 mL bolus
,C. Insert NG tube to low suction
5. D. Obtain serum lipase
Correct Answer: B
Rationale: Hypotension and oliguria indicate hypovolemic shock from third-spacing;
isotonic fluid resuscitation is priority to restore perfusion. Pain control is important but
must follow hemodynamic stability. NG decompression is used for ileus, not
hypovolemia. Lab draws do not supersede life-saving fluids.
A client with a pulmonary embolism is on a heparin infusion. aPTT is 90 seconds
(control 30). The nurse should anticipate which prescription?
A. Decrease heparin rate by 2 units/kg/hr
B. Stop heparin for 2 hours then resume
C. Give protamine sulfate 10 mg IV
6. D. No change; therapeutic range
Correct Answer: A
Rationale: aPTT >80 seconds (≥2.7 × control) increases bleeding risk; reducing the
infusion rate is first-line. Brief interruption is reserved for clinically significant bleeding.
Protamine reverses heparin but is used only for major hemorrhage. The upper therapeutic
limit is usually 70 seconds.
A client with a T4 spinal cord injury develops flushing and a pounding headache. BP is
220/110. Which action is FIRST?
A. Sit patient upright and loosen clothing
B. Administer sublingual nifedipine
C. Catheterize to check for bladder distention
7. D. Call code blue
Correct Answer: A
Rationale: Autonomic dysreflexia is a medical emergency; upright posture lowers
cerebral perfusion pressure and stimulus search begins immediately. Sublingual
nifedipine may be used but only after positioning. Bladder distention is the most common
trigger and should be relieved promptly, but airway/positioning precede pharmacology.
, A client with cirrhosis has a massive hematemesis. Which intervention should the nurse
prepare for FIRST?
A. Insert a Sengstaken-Blakemore tube
B. Start two large-bore IV lines
C. Administer vitamin K 10 mg IV
8. D. Insert NG tube for lavage
Correct Answer: B
Rationale: Rapid volume resuscitation is critical in variceal hemorrhage; two 16-gauge
IVs allow simultaneous fluids and blood products. Balloon tamponade is used only when
endoscopy fails. Vitamin K takes 6–12 hours to correct coagulopathy. NG lavage does not
control bleeding and may increase variceal pressure.
A client with diabetic gastroparesis reports nausea and early satiety. Which dietary
modification is BEST?
A. Six small low-fat meals daily
B. High-fiber breakfast
C. Large evening meal
9. D. Carbonated beverages with meals
Correct Answer: A
Rationale: Small, frequent, low-fat meals reduce gastric load and improve emptying. Fat
delays motility; fiber and large meals worsen distention. Carbonation increases gastric
pressure and nausea. Metoclopramide may be added but diet is first-line.
A client with acute kidney injury (oliguric phase) has K⁺ 6.2 mEq/L, peaked T waves, HR
52. Which medication is given FIRST?
A. Calcium gluconate 1 g IV
B. Regular insulin 10 units + 25 g dextrose IV
C. Albuterol 10 mg nebulized
10. D. Sodium polystyrene sulfonate 30 g PO
Correct Answer: A
Rationale: Membrane-stabilizing calcium reverses cardiotoxicity within 1–3 minutes and
is given before any other drug when ECG changes exist. Insulin/dextrose and albuterol
