Evolve Elsevier HESI Med-Surg Practice Exam
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
1. A 68-year-old client is admitted with acute decompensated heart failure. The nurse
notes bilateral crackles, oxygen saturation 86 % on room air, and BP 160/90 mm
Hg. Which prescribed intervention should the nurse implement first?
A. Administer furosemide 40 mg IV push
B. Apply high-flow oxygen via non-rebreather
C. Obtain a 12-lead ECG
D. Restrict oral fluids to 1 500 mL/day
Correct Answer: B
Rationale: Hypoxemia is an immediate life-threatening problem; oxygenation must be
optimized before any other action. High-flow oxygen quickly improves saturation and
tissue oxygen delivery. Furosemide is important but follows oxygenation. ECG provides
data but is not urgent if monitor shows sinus rhythm. Fluid restriction is long-term
management, not emergent.
2. The nurse is caring for a client 8 hours post-CABG. Chest tube drainage has
decreased from 75 mL/h to 10 mL/h over the past 3 hours, but mediastinal
widening is noted on chest x-ray and BP drops to 88/50 mm Hg. What is the
priority nursing action?
A. Milk the chest tube to remove clots
B. Prepare for emergency mediastinal exploration
C. Increase dopamine infusion
D. Administer protamine sulfate
,Correct Answer: B
Rationale: Sudden drop in drainage with hemodynamic collapse and mediastinal
widening suggests cardiac tamponade—surgical emergency. Milking is ineffective
against organized clot. Inotropes may transiently support BP but do not relieve
tamponade. Protamine reverses heparin but bleeding here is mechanical, not
coagulopathic.
3. A client with DKA receives an insulin infusion at 0.1 units/kg/hr. Which
laboratory value is the best indicator that the insulin dose is effective?
A. pH 7.32
B. Serum glucose 250 mg/dL
C. Serum bicarbonate 18 mEq/L
D. Anion gap 10 mEq/L
Correct Answer: D
Rationale: Resolution of ketogenesis closes the anion gap—direct evidence insulin is
suppressing lipolysis and acid production. Glucose falls faster than ketones; pH and
bicarbonate lag. A normal gap (8–12) signals readiness to transition to subcutaneous
insulin. Other values improve but are indirect.
4. A client with COPD has a PaCO₂ of 58 mm Hg and is receiving 4 L/min nasal
cannula. The nurse notes a decreasing level of consciousness. Which action is
most appropriate?
A. Increase O₂ to 6 L/min
B. Obtain ABGs in 1 hour
C. Switch to Venturi mask at 24 %
D. Encourage use of incentive spirometer
Correct Answer: C
,Rationale: COPD clients depend on hypoxic drive; high-flow O₂ can worsen hypercapnia
and narcosis. Venturi mask delivers precise low FiO₂ (24 %) to maintain SpO₂ 88–92 %
without suppressing drive. Increasing flow further obtunds ventilation. Delaying ABGs
risks respiratory arrest. Incentive spirometry is ineffective for hypercapnia.
5. A client with acute pancreatitis complains of severe epigastric pain and is
receiving morphine PCA. Which assessment finding warrants immediate
intervention?
A. Pain rating 6/10 30 min after dosing
B. Serum amylase 800 units/dL
C. Grey Turner sign
D. Temperature 37.8 °C
Correct Answer: C
Rationale: Grey Turner sign (flank ecchymosis) indicates retroperitoneal
bleeding—severe necrotizing pancreatitis requiring urgent surgical/ICU management.
Persistent pain is expected early. Elevated amylase confirms diagnosis but is not acute
emergency. Low-grade fever is common due to inflammation.
6. The nurse is managing a client with Guillain-Barré syndrome who can barely lift
his legs off the bed. Which priority intervention should be included in the plan of
care?
A. Schedule active ROM qid
B. Initiate high-protein diet
C. Monitor respiratory vital capacity q4h
D. Administer low-molecular-weight heparin
Correct Answer: C
, Rationale: Ascending weakness can paralyze respiratory muscles; serial VC predicts need
for intubation (VC < 20 mL/kg). Active ROM is contraindicated in acute phase due to
fatigue. Diet is supportive, not priority. DVT prophylaxis is important but secondary to
airway.
7. A client with a pulmonary embolism is started on a heparin infusion. The PTT is
42 seconds (control 30) after 6 hours. The protocol indicates a bolus of 80 units/kg
and increase infusion by 4 units/kg/hr. Before implementing, what does the nurse
check?
A. Platelet count
B. PT/INR
C. Hemoglobin
D. Activated clotting time
Correct Answer: A
Rationale: Heparin-induced thrombocytopenia (HIT) can develop within hours if prior
exposure; platelets must be checked before escalating heparin. Other labs assess bleeding
but do not influence immediate heparin dosing. ACT is used in interventional settings,
not routine monitoring.
8. A client with a subdural hematoma becomes restless and develops a sudden
bradycardia (48 bpm). His pupils are 6 mm and sluggish. Which action is priority?
A. Administer IV morphine for restlessness
B. Hyperventilate client at 20 breaths/min
C. Prepare for emergency craniotomy
D. Give atropine 0.5 mg IV
Correct Answer: C
(2025/2026) — 150 High-Level Nursing Questions,
Correct Answers & Full Rationales
1. A 68-year-old client is admitted with acute decompensated heart failure. The nurse
notes bilateral crackles, oxygen saturation 86 % on room air, and BP 160/90 mm
Hg. Which prescribed intervention should the nurse implement first?
A. Administer furosemide 40 mg IV push
B. Apply high-flow oxygen via non-rebreather
C. Obtain a 12-lead ECG
D. Restrict oral fluids to 1 500 mL/day
Correct Answer: B
Rationale: Hypoxemia is an immediate life-threatening problem; oxygenation must be
optimized before any other action. High-flow oxygen quickly improves saturation and
tissue oxygen delivery. Furosemide is important but follows oxygenation. ECG provides
data but is not urgent if monitor shows sinus rhythm. Fluid restriction is long-term
management, not emergent.
2. The nurse is caring for a client 8 hours post-CABG. Chest tube drainage has
decreased from 75 mL/h to 10 mL/h over the past 3 hours, but mediastinal
widening is noted on chest x-ray and BP drops to 88/50 mm Hg. What is the
priority nursing action?
A. Milk the chest tube to remove clots
B. Prepare for emergency mediastinal exploration
C. Increase dopamine infusion
D. Administer protamine sulfate
,Correct Answer: B
Rationale: Sudden drop in drainage with hemodynamic collapse and mediastinal
widening suggests cardiac tamponade—surgical emergency. Milking is ineffective
against organized clot. Inotropes may transiently support BP but do not relieve
tamponade. Protamine reverses heparin but bleeding here is mechanical, not
coagulopathic.
3. A client with DKA receives an insulin infusion at 0.1 units/kg/hr. Which
laboratory value is the best indicator that the insulin dose is effective?
A. pH 7.32
B. Serum glucose 250 mg/dL
C. Serum bicarbonate 18 mEq/L
D. Anion gap 10 mEq/L
Correct Answer: D
Rationale: Resolution of ketogenesis closes the anion gap—direct evidence insulin is
suppressing lipolysis and acid production. Glucose falls faster than ketones; pH and
bicarbonate lag. A normal gap (8–12) signals readiness to transition to subcutaneous
insulin. Other values improve but are indirect.
4. A client with COPD has a PaCO₂ of 58 mm Hg and is receiving 4 L/min nasal
cannula. The nurse notes a decreasing level of consciousness. Which action is
most appropriate?
A. Increase O₂ to 6 L/min
B. Obtain ABGs in 1 hour
C. Switch to Venturi mask at 24 %
D. Encourage use of incentive spirometer
Correct Answer: C
,Rationale: COPD clients depend on hypoxic drive; high-flow O₂ can worsen hypercapnia
and narcosis. Venturi mask delivers precise low FiO₂ (24 %) to maintain SpO₂ 88–92 %
without suppressing drive. Increasing flow further obtunds ventilation. Delaying ABGs
risks respiratory arrest. Incentive spirometry is ineffective for hypercapnia.
5. A client with acute pancreatitis complains of severe epigastric pain and is
receiving morphine PCA. Which assessment finding warrants immediate
intervention?
A. Pain rating 6/10 30 min after dosing
B. Serum amylase 800 units/dL
C. Grey Turner sign
D. Temperature 37.8 °C
Correct Answer: C
Rationale: Grey Turner sign (flank ecchymosis) indicates retroperitoneal
bleeding—severe necrotizing pancreatitis requiring urgent surgical/ICU management.
Persistent pain is expected early. Elevated amylase confirms diagnosis but is not acute
emergency. Low-grade fever is common due to inflammation.
6. The nurse is managing a client with Guillain-Barré syndrome who can barely lift
his legs off the bed. Which priority intervention should be included in the plan of
care?
A. Schedule active ROM qid
B. Initiate high-protein diet
C. Monitor respiratory vital capacity q4h
D. Administer low-molecular-weight heparin
Correct Answer: C
, Rationale: Ascending weakness can paralyze respiratory muscles; serial VC predicts need
for intubation (VC < 20 mL/kg). Active ROM is contraindicated in acute phase due to
fatigue. Diet is supportive, not priority. DVT prophylaxis is important but secondary to
airway.
7. A client with a pulmonary embolism is started on a heparin infusion. The PTT is
42 seconds (control 30) after 6 hours. The protocol indicates a bolus of 80 units/kg
and increase infusion by 4 units/kg/hr. Before implementing, what does the nurse
check?
A. Platelet count
B. PT/INR
C. Hemoglobin
D. Activated clotting time
Correct Answer: A
Rationale: Heparin-induced thrombocytopenia (HIT) can develop within hours if prior
exposure; platelets must be checked before escalating heparin. Other labs assess bleeding
but do not influence immediate heparin dosing. ACT is used in interventional settings,
not routine monitoring.
8. A client with a subdural hematoma becomes restless and develops a sudden
bradycardia (48 bpm). His pupils are 6 mm and sluggish. Which action is priority?
A. Administer IV morphine for restlessness
B. Hyperventilate client at 20 breaths/min
C. Prepare for emergency craniotomy
D. Give atropine 0.5 mg IV
Correct Answer: C
