HESI Med-Surg RN Custom Exam Med-Surg
II Advanced Medical-Surgical Nursing Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: COMPLEX CARDIOVASCULAR & HEMATOLOGIC DISORDERS Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 68-year-old male with a history of nonischemic dilated cardiomyopathy and an ejection
fraction of 20% is admitted with acute decompensated heart failure. His vital signs are BP
88/52 mmHg, HR 118 bpm, RR 28/min, SpO2 89% on 2 L NC. He has cool, clammy extremities
and a urine output of 15 mL/hr for the past 4 hours. The provider orders dobutamine infusion
and furosemide 80 mg IV push. Which nursing action is the priority before initiating the
ordered therapies?
A. Insert a Foley catheter to monitor hourly urine output
B. Obtain a 12-lead ECG and establish continuous telemetry monitoring
C. Administer a 500 mL bolus of normal saline to improve preload
D. Draw peak and trough levels before starting dobutamine
Correct Answer: B
Rationale: In acute decompensated heart failure with hypotension and tachycardia,
continuous telemetry monitoring is essential before initiating inotropic therapy because
dobutamine can precipitate ventricular arrhythmias, and the patient is already
hemodynamically unstable with a low EF. Although hourly urine output monitoring is
important, it does not take precedence over cardiac monitoring when an arrhythmogenic
agent is ordered. HESI often tests whether you prioritize cardiac monitoring over other
interventions when inotropes are involved in a patient with severe cardiomyopathy.
Question 2 of 50
A 54-year-old female with a known thoracic aortic aneurysm (5.8 cm) presents to the
emergency department with sudden, tearing chest pain radiating to her interscapular area. Her
BP is 186/112 mmHg in the right arm and 94/58 mmHg in the left arm. She is diaphoretic and
,anxious. After establishing IV access and placing the patient on a monitor, which intervention
should the nurse anticipate as the immediate priority?
A. Prepare the patient for emergent endovascular aortic repair
B. Initiate a nicardipine infusion to reduce systolic BP to 100–120 mmHg
C. Administer morphine sulfate 4 mg IV for pain control
D. Insert a large-bore peripheral IV and begin a normal saline bolus
Correct Answer: B
Rationale: In suspected acute aortic dissection, immediate blood pressure control with a
beta-blocker or vasodilator such as nicardipine is the priority to reduce shear stress on the
aortic wall and prevent rupture, targeting systolic BP of 100–120 mmHg. While pain control is
important, uncontrolled hypertension poses a more immediate threat of aortic rupture and
hemodynamic collapse. HESI advanced questions frequently require you to address the
life-threatening hemodynamic issue before symptom management.
Question 3 of 50
A 42-year-old female with a history of systemic lupus erythematosus is admitted with
petechiae, oozing from IV sites, and hematuria. Her labs reveal platelets 22,000/mm³,
fibrinogen 85 mg/dL, D-dimer >80,000 ng/mL, PT 28 seconds, and aPTT 76 seconds. The
provider suspects disseminated intravascular coagulation (DIC) secondary to sepsis. Which
intervention should the nurse prepare to administer first?
A. Transfuse 6 units of fresh frozen plasma
B. Administer heparin 5 units/kg/hr continuous infusion
C. Give a platelet transfusion of 10 units
D. Infuse cryoprecipitate to replace fibrinogen
Correct Answer: A
Rationale: In DIC with active bleeding and prolonged PT/PTT, fresh frozen plasma is the
priority to replace consumed clotting factors and control hemorrhage, as the patient has
oozing and hematuria indicating active bleeding. Although cryoprecipitate raises fibrinogen,
FFP addresses multiple factor deficiencies simultaneously and is indicated first when
bleeding is present. HESI tests your ability to distinguish between bleeding-predominant DIC,
where clotting factor replacement is critical, and thrombotic-predominant DIC, where
low-dose heparin may be considered.
Question 4 of 50
A 29-year-old male with sickle cell disease presents with severe vaso-occlusive crisis
involving his chest, back, and extremities. His vital signs are T 38.9°C, HR 132 bpm, RR
26/min, BP 94/60 mmHg. Labs show Hgb 5.2 g/dL, WBC 18,500/mm³, and reticulocyte count
, 12%. He reports 10/10 pain and is becoming increasingly confused. Which nursing
intervention is the priority at this time?
A. Initiate a simple transfusion of 2 units packed red blood cells
B. Begin aggressive isotonic IV fluid resuscitation and oxygen therapy
C. Administer morphine sulfate 2–4 mg IV every 2 hours PRN
D. Apply warm compresses to affected joints and encourage ambulation
Correct Answer: B
Rationale: In acute chest syndrome or severe vaso-occlusive crisis with hypoxia,
hypotension, and altered mental status, aggressive IV hydration and supplemental oxygen are
the priority to reduce sickling, improve perfusion, and prevent further organ damage. While
pain management is essential, the patient is showing signs of hypovolemia and possible
acute chest syndrome, which can rapidly progress to respiratory failure. HESI emphasizes
that in sickle cell crisis, oxygenation and perfusion take precedence over analgesia when
hemodynamic instability or respiratory compromise is present.
Question 5 of 50
A 76-year-old male with atrial fibrillation on warfarin (INR 2.5) presents with acute onset
left-sided weakness and aphasia. CT scan reveals a large right middle cerebral artery
ischemic stroke. His vital signs are stable, but the neurosurgeon is concerned about
hemorrhagic conversion. The provider orders alteplase (tPA) 0.9 mg/kg IV. Which nursing
assessment is most critical before initiating the infusion?
A. Confirm the exact time of symptom onset and verify no recent surgery
B. Check the INR and ensure it is below 1.5 before starting tPA
C. Assess for signs of pulmonary embolism as a contraindication
D. Verify that the patient has received aspirin 325 mg within 24 hours
Correct Answer: B
Rationale: For ischemic stroke thrombolysis, an INR above 1.5 is a contraindication to tPA
due to the high risk of intracranial hemorrhage, and this patient on warfarin with an INR of 2.5
would be ineligible unless the INR can be corrected. Although confirming time of onset is
standard, the presence of therapeutic anticoagulation with an elevated INR makes tPA
administration dangerous and must be addressed first. HESI advanced questions often test
absolute contraindications to thrombolytic therapy, and therapeutic warfarin anticoagulation
is a classic trap.
Question 6 of 50
A 61-year-old female is post-op day 2 after coronary artery bypass grafting (CABG) x4. She
develops sudden dyspnea, tachycardia, and a drop in SpO2 from 96% to 84% on 2 L NC. Her
II Advanced Medical-Surgical Nursing Official
Practice Exam Actual Exam 2026/2027 with
Detailed Rationales | Complete Exam-Style
Questions | Pass Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: COMPLEX CARDIOVASCULAR & HEMATOLOGIC DISORDERS Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 68-year-old male with a history of nonischemic dilated cardiomyopathy and an ejection
fraction of 20% is admitted with acute decompensated heart failure. His vital signs are BP
88/52 mmHg, HR 118 bpm, RR 28/min, SpO2 89% on 2 L NC. He has cool, clammy extremities
and a urine output of 15 mL/hr for the past 4 hours. The provider orders dobutamine infusion
and furosemide 80 mg IV push. Which nursing action is the priority before initiating the
ordered therapies?
A. Insert a Foley catheter to monitor hourly urine output
B. Obtain a 12-lead ECG and establish continuous telemetry monitoring
C. Administer a 500 mL bolus of normal saline to improve preload
D. Draw peak and trough levels before starting dobutamine
Correct Answer: B
Rationale: In acute decompensated heart failure with hypotension and tachycardia,
continuous telemetry monitoring is essential before initiating inotropic therapy because
dobutamine can precipitate ventricular arrhythmias, and the patient is already
hemodynamically unstable with a low EF. Although hourly urine output monitoring is
important, it does not take precedence over cardiac monitoring when an arrhythmogenic
agent is ordered. HESI often tests whether you prioritize cardiac monitoring over other
interventions when inotropes are involved in a patient with severe cardiomyopathy.
Question 2 of 50
A 54-year-old female with a known thoracic aortic aneurysm (5.8 cm) presents to the
emergency department with sudden, tearing chest pain radiating to her interscapular area. Her
BP is 186/112 mmHg in the right arm and 94/58 mmHg in the left arm. She is diaphoretic and
,anxious. After establishing IV access and placing the patient on a monitor, which intervention
should the nurse anticipate as the immediate priority?
A. Prepare the patient for emergent endovascular aortic repair
B. Initiate a nicardipine infusion to reduce systolic BP to 100–120 mmHg
C. Administer morphine sulfate 4 mg IV for pain control
D. Insert a large-bore peripheral IV and begin a normal saline bolus
Correct Answer: B
Rationale: In suspected acute aortic dissection, immediate blood pressure control with a
beta-blocker or vasodilator such as nicardipine is the priority to reduce shear stress on the
aortic wall and prevent rupture, targeting systolic BP of 100–120 mmHg. While pain control is
important, uncontrolled hypertension poses a more immediate threat of aortic rupture and
hemodynamic collapse. HESI advanced questions frequently require you to address the
life-threatening hemodynamic issue before symptom management.
Question 3 of 50
A 42-year-old female with a history of systemic lupus erythematosus is admitted with
petechiae, oozing from IV sites, and hematuria. Her labs reveal platelets 22,000/mm³,
fibrinogen 85 mg/dL, D-dimer >80,000 ng/mL, PT 28 seconds, and aPTT 76 seconds. The
provider suspects disseminated intravascular coagulation (DIC) secondary to sepsis. Which
intervention should the nurse prepare to administer first?
A. Transfuse 6 units of fresh frozen plasma
B. Administer heparin 5 units/kg/hr continuous infusion
C. Give a platelet transfusion of 10 units
D. Infuse cryoprecipitate to replace fibrinogen
Correct Answer: A
Rationale: In DIC with active bleeding and prolonged PT/PTT, fresh frozen plasma is the
priority to replace consumed clotting factors and control hemorrhage, as the patient has
oozing and hematuria indicating active bleeding. Although cryoprecipitate raises fibrinogen,
FFP addresses multiple factor deficiencies simultaneously and is indicated first when
bleeding is present. HESI tests your ability to distinguish between bleeding-predominant DIC,
where clotting factor replacement is critical, and thrombotic-predominant DIC, where
low-dose heparin may be considered.
Question 4 of 50
A 29-year-old male with sickle cell disease presents with severe vaso-occlusive crisis
involving his chest, back, and extremities. His vital signs are T 38.9°C, HR 132 bpm, RR
26/min, BP 94/60 mmHg. Labs show Hgb 5.2 g/dL, WBC 18,500/mm³, and reticulocyte count
, 12%. He reports 10/10 pain and is becoming increasingly confused. Which nursing
intervention is the priority at this time?
A. Initiate a simple transfusion of 2 units packed red blood cells
B. Begin aggressive isotonic IV fluid resuscitation and oxygen therapy
C. Administer morphine sulfate 2–4 mg IV every 2 hours PRN
D. Apply warm compresses to affected joints and encourage ambulation
Correct Answer: B
Rationale: In acute chest syndrome or severe vaso-occlusive crisis with hypoxia,
hypotension, and altered mental status, aggressive IV hydration and supplemental oxygen are
the priority to reduce sickling, improve perfusion, and prevent further organ damage. While
pain management is essential, the patient is showing signs of hypovolemia and possible
acute chest syndrome, which can rapidly progress to respiratory failure. HESI emphasizes
that in sickle cell crisis, oxygenation and perfusion take precedence over analgesia when
hemodynamic instability or respiratory compromise is present.
Question 5 of 50
A 76-year-old male with atrial fibrillation on warfarin (INR 2.5) presents with acute onset
left-sided weakness and aphasia. CT scan reveals a large right middle cerebral artery
ischemic stroke. His vital signs are stable, but the neurosurgeon is concerned about
hemorrhagic conversion. The provider orders alteplase (tPA) 0.9 mg/kg IV. Which nursing
assessment is most critical before initiating the infusion?
A. Confirm the exact time of symptom onset and verify no recent surgery
B. Check the INR and ensure it is below 1.5 before starting tPA
C. Assess for signs of pulmonary embolism as a contraindication
D. Verify that the patient has received aspirin 325 mg within 24 hours
Correct Answer: B
Rationale: For ischemic stroke thrombolysis, an INR above 1.5 is a contraindication to tPA
due to the high risk of intracranial hemorrhage, and this patient on warfarin with an INR of 2.5
would be ineligible unless the INR can be corrected. Although confirming time of onset is
standard, the presence of therapeutic anticoagulation with an elevated INR makes tPA
administration dangerous and must be addressed first. HESI advanced questions often test
absolute contraindications to thrombolytic therapy, and therapeutic warfarin anticoagulation
is a classic trap.
Question 6 of 50
A 61-year-old female is post-op day 2 after coronary artery bypass grafting (CABG) x4. She
develops sudden dyspnea, tachycardia, and a drop in SpO2 from 96% to 84% on 2 L NC. Her
