1
EVOLVE ELSEVIER HESI
MED SURG EXAM
2025/2026,100 NCLEX-Style
Items with Answers &
Rationales
1. A 68-year-old with heart failure is receiving digoxin 0.25 mg PO daily.
Which morning serum result requires the nurse to hold the dose?
A. K+ 3.8 mEq/L
B. Mg2+ 1.9 mg/dL
C. Ca2+ 9.2 mg/dL
D. Digoxin level 2.8 ng/mL
Answer: D
Rationale: Therapeutic digoxin range 0.5–0.8 ng/mL (0.8–2.0 ng/mL in some
labs). >2 ng/mL → toxicity; hold dose and notify provider.
2. Two hours after starting a unit of packed RBCs, a client reports flank pain
and chills. What is the nurse’s first action?
A. Stop the transfusion
B. Take temperature
C. Send remaining blood to lab
D. Start normal saline at KVO
Answer: A
Rationale: Acute hemolytic reaction—stop infusion immediately to limit antigen–
antibody response, then maintain IV access.
, 2
3. A COPD client on 2 L nasal cannula has an SpO₂ of 98%. The client is
somnolent with a headache. Which action is priority?
A. Increase O₂ to 4 L
B. Obtain ABGs
C. Decrease O₂ to 1 L
D. Request ABGs then intubate
Answer: C
Rationale: High risk for CO₂ narcosis; hypoxic drive is blunted—reduce O₂,
monitor for respiratory acidosis.
4. Post thyroidectomy, the client develops stridor 30 min after extubation.
What should the nurse grab first?
A. Tracheostomy set
B. IV calcium gluconate
C. Oral airway
D. 100% O₂ mask
Answer: A
Rationale: Stridor = airway obstruction from edema or hematoma; keep
tracheostomy tray at bedside per policy.
5. Which urine output for a 70 kg adult should trigger acute kidney injury
“alert” criteria?
A. 35 mL/hr
B. 25 mL/hr
C. 15 mL/hr
D. 50 mL/hr
Answer: C
Rationale: <0.5 mL/kg/hr for 6 h = oliguria; 15 mL/hr = ~0.2 mL/kg/hr → AKI
stage 1.
, 3
6. A client with DKA receives an insulin drip. Which value best indicates the
insulin is effective?
A. K+ drops from 4.0 to 3.2 mEq/L
B. Glucose falls from 450 to 250 mg/dL
C. HCO₃ rises from 14 to 18 mEq/L
D. pH increases from 7.20 to 7.32
Answer: D
Rationale: Rising pH shows reversal of ketoacidosis, the primary goal; glucose
falls first but acidosis correction is key.
7. The nurse notes these VS for a client 4 h post-open AAA repair: BP 86/50,
HR 120, urine 20 mL/hr, abdomen firm. What should the nurse suspect?
A. Acute urinary retention
B. Hemorrhagic shock
C. Paralytic ileus
D. Cardiogenic shock
Answer: B
Rationale: Hypotension + tachycardia + oliguria + firm abdomen = possible graft
leak/retroperitoneal bleed—emergency.
8. A client with cirrhosis has a large-volume paracentesis (6 L removed). For
which complication should the nurse monitor?
A. Hypernatremia
B. Hypoglycemia
C. Paracentesis-induced circulatory dysfunction (PICD)
D. Hyperkalemia
Answer: C
Rationale: Rapid fluid shift → decreased effective circulating volume → PICD,
azotemia, hypotension.
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9. Which assessment finding supports acute rejection of a renal transplant
(happened 10 days ago)?
A. 2-lb weight loss
B. Decreased serum creatinine
C. Pain at incision site
D. Temperature 38.2 °C, graft tenderness, Cr ↑25%
Answer: D
Rationale: Classic acute rejection: fever, graft pain/swelling, rising creatinine,
decreased urine.
10.A client with MS receives oxybutynin 5 mg PO BID. Which side effect
should the nurse teach the client to expect?
A. Urinary frequency
B. Dry mouth
C. Diarrhea
D. Sedation
Answer: B
Rationale: Anticholinergic → dry mouth, constipation, blurred vision.
11.A client with MG is in crisis and receives pyridostigmine 60 mg PO. One
hour later the client complains of increased weakness. What should the nurse
suspect?
A. Under-medication
B. Cholinergic crisis
C. Myasthenic crisis
D. Steroid-induced myopathy
Answer: B
Rationale: Overdose of anticholinesterase → cholinergic crisis (muscle
fasciculations then weakness); hold drug, prepare edrophonium test.
EVOLVE ELSEVIER HESI
MED SURG EXAM
2025/2026,100 NCLEX-Style
Items with Answers &
Rationales
1. A 68-year-old with heart failure is receiving digoxin 0.25 mg PO daily.
Which morning serum result requires the nurse to hold the dose?
A. K+ 3.8 mEq/L
B. Mg2+ 1.9 mg/dL
C. Ca2+ 9.2 mg/dL
D. Digoxin level 2.8 ng/mL
Answer: D
Rationale: Therapeutic digoxin range 0.5–0.8 ng/mL (0.8–2.0 ng/mL in some
labs). >2 ng/mL → toxicity; hold dose and notify provider.
2. Two hours after starting a unit of packed RBCs, a client reports flank pain
and chills. What is the nurse’s first action?
A. Stop the transfusion
B. Take temperature
C. Send remaining blood to lab
D. Start normal saline at KVO
Answer: A
Rationale: Acute hemolytic reaction—stop infusion immediately to limit antigen–
antibody response, then maintain IV access.
, 2
3. A COPD client on 2 L nasal cannula has an SpO₂ of 98%. The client is
somnolent with a headache. Which action is priority?
A. Increase O₂ to 4 L
B. Obtain ABGs
C. Decrease O₂ to 1 L
D. Request ABGs then intubate
Answer: C
Rationale: High risk for CO₂ narcosis; hypoxic drive is blunted—reduce O₂,
monitor for respiratory acidosis.
4. Post thyroidectomy, the client develops stridor 30 min after extubation.
What should the nurse grab first?
A. Tracheostomy set
B. IV calcium gluconate
C. Oral airway
D. 100% O₂ mask
Answer: A
Rationale: Stridor = airway obstruction from edema or hematoma; keep
tracheostomy tray at bedside per policy.
5. Which urine output for a 70 kg adult should trigger acute kidney injury
“alert” criteria?
A. 35 mL/hr
B. 25 mL/hr
C. 15 mL/hr
D. 50 mL/hr
Answer: C
Rationale: <0.5 mL/kg/hr for 6 h = oliguria; 15 mL/hr = ~0.2 mL/kg/hr → AKI
stage 1.
, 3
6. A client with DKA receives an insulin drip. Which value best indicates the
insulin is effective?
A. K+ drops from 4.0 to 3.2 mEq/L
B. Glucose falls from 450 to 250 mg/dL
C. HCO₃ rises from 14 to 18 mEq/L
D. pH increases from 7.20 to 7.32
Answer: D
Rationale: Rising pH shows reversal of ketoacidosis, the primary goal; glucose
falls first but acidosis correction is key.
7. The nurse notes these VS for a client 4 h post-open AAA repair: BP 86/50,
HR 120, urine 20 mL/hr, abdomen firm. What should the nurse suspect?
A. Acute urinary retention
B. Hemorrhagic shock
C. Paralytic ileus
D. Cardiogenic shock
Answer: B
Rationale: Hypotension + tachycardia + oliguria + firm abdomen = possible graft
leak/retroperitoneal bleed—emergency.
8. A client with cirrhosis has a large-volume paracentesis (6 L removed). For
which complication should the nurse monitor?
A. Hypernatremia
B. Hypoglycemia
C. Paracentesis-induced circulatory dysfunction (PICD)
D. Hyperkalemia
Answer: C
Rationale: Rapid fluid shift → decreased effective circulating volume → PICD,
azotemia, hypotension.
, 4
9. Which assessment finding supports acute rejection of a renal transplant
(happened 10 days ago)?
A. 2-lb weight loss
B. Decreased serum creatinine
C. Pain at incision site
D. Temperature 38.2 °C, graft tenderness, Cr ↑25%
Answer: D
Rationale: Classic acute rejection: fever, graft pain/swelling, rising creatinine,
decreased urine.
10.A client with MS receives oxybutynin 5 mg PO BID. Which side effect
should the nurse teach the client to expect?
A. Urinary frequency
B. Dry mouth
C. Diarrhea
D. Sedation
Answer: B
Rationale: Anticholinergic → dry mouth, constipation, blurred vision.
11.A client with MG is in crisis and receives pyridostigmine 60 mg PO. One
hour later the client complains of increased weakness. What should the nurse
suspect?
A. Under-medication
B. Cholinergic crisis
C. Myasthenic crisis
D. Steroid-induced myopathy
Answer: B
Rationale: Overdose of anticholinesterase → cholinergic crisis (muscle
fasciculations then weakness); hold drug, prepare edrophonium test.
