HESI Med Surg Final Exam Review Questions
And Well Graded Solutions With Rationales
Updated 2026 2027
Ace your Evolve Elsevier HESI Medical-Surgical Final Exam with this premium study
guide! Features 220 high-yield Select-All-That-Apply (SATA) questions with detailed,
italicized rationales tracking actual exam concepts. Covers core systems: Cardiovascular,
Respiratory, Endocrine, Renal, Neuro, and Shock prioritization. Built to maximize your
HESI exit score and build clinical judgment. Perfect for Chamberlain, GCU, and top
nursing programs. Download now to study smart and pass on your first try!
Question 1: Cardiac (Heart Failure)
A nurse is assessing a client admitted with acute decompensated heart failure.
Which clinical manifestations should the nurse expect to find? Select all that apply.
A) Jugular venous distention
B) Dependent bilateral pitting edema
C) Dyspnea and audible crackles in the lung bases
D) Flat neck veins when lying supine
E) Bradycardia and bounding peripheral pulses
F) Weight gain of 3 pounds in 24 hours
Rationale: Acute decompensated heart failure involves both right-sided and left-
sided fluid overload. Right-sided failure leads to systemic venous congestion,
causing jugular venous distention, dependent edema, and rapid weight gain from
fluid retention. Left-sided failure causes pulmonary congestion, leading to dyspnea
and crackles. Flat neck veins and bradycardia are not expected findings in fluid
overload.
Question 2: Endocrine (Diabetic Ketoacidosis)
A client with Type 1 Diabetes Mellitus is admitted to the emergency department with
Diabetic Ketoacidosis (DKA). Which laboratory and clinical findings should the nurse
anticipate? Select all that apply.
1|Page
,A) Arterial blood pH of 7.45
B) Blood glucose level of 450 mg/dL
C) Deep, rapid respirations (Kussmaul breathing)
D) Serum bicarbonate level of 12 mEq/L
E) Negative serum ketones
F) Polyuria and profound dehydration
Rationale: DKA is characterized by severe hyperglycemia (typically >250 mg/dL),
metabolic acidosis (pH < 7.35, bicarbonate < 18 mEq/L), and ketosis. Kussmaul
respirations are the body's compensatory mechanism to blow off excess carbon
dioxide. Osmotic diuresis from high glucose levels results in polyuria and severe
volume depletion.
Question 3: Respiratory (Mechanical Ventilation)
A nurse is caring for a mechanically ventilated client on positive pressure ventilation.
Which interventions should the nurse implement to prevent Ventilator-Associated
Pneumonia (VAP)? Select all that apply.
A) Maintain the head of the bed elevated at 30 to 45 degrees
B) Instill sterile normal saline into the endotracheal tube before suctioning
C) Perform oral care with chlorhexidine solution every 12 hours
D) Conduct a daily "sedation vacation" and assess readiness to wean
E) Change the ventilator circuit tubing every 24 hours
F) Administer prescribed peptic ulcer disease prophylaxis
Rationale: Evidence-based VAP prevention bundles include keeping the head of the
bed elevated, performing regular chlorhexidine oral care, implementing daily
sedation interruptions to assess for extubation, and providing stress ulcer
prophylaxis. Routine saline instillation and daily ventilator circuit changes are
outdated practices that actually increase infection risk.
Question 4: Renal (Acute Kidney Injury)
A client with acute kidney injury (AKI) is in the oliguric phase. Which clinical and
laboratory assessments require immediate notification to the healthcare provider?
Select all that apply.
A) Serum potassium level of 6.2 mEq/L
B) New onset of peaked T waves on the ECG
C) Serum creatinine increase from 1.2 mg/dL to 2.0 mg/dL
D) Crackles in the lungs and a respiratory rate of 28 breaths/minute
E) Urine output of 350 mL over the last 24 hours
F) Mild fatigue and generalized pruritus
Rationale: Hyperkalemia (>5.0 mEq/L) is a life-threatening complication of the
oliguric phase of AKI that can cause lethal cardiac dysrhythmias, indicated by
peaked T waves. Fluid volume overload leading to pulmonary congestion (crackles,
tachypnea) is another emergency. While elevated creatinine and oliguria are
expected in AKI, they do not represent the immediate life-threatening emergencies
that hyperkalemia and respiratory distress do.
Question 5: Perioperative (Malignant Hyperthermia)
2|Page
,A client undergoing general anesthesia during an emergency laparotomy develops
malignant hyperthermia. Which clinical signs should the nurse recognize as early or
progressive indicators of this crisis? Select all that apply.
A) Generalized muscle rigidity or jaw clenching
B) Rapid rise in end-tidal carbon dioxide (ETCO2)
C) Sudden drop in core body temperature
D) Unexplained sinus tachycardia
E) Profound bradycardia and hypotension
F) Hyperkalemia and mottled skin
Rationale: Malignant hyperthermia is a hypermetabolic crisis triggered by volatile
anesthetic gases or succinylcholine. The earliest signs are an unexplained rise in
end-tidal CO2 and sinus tachycardia, closely followed by severe muscle or jaw
rigidity. High fever is actually a late sign. Cellular breakdown causes hyperkalemia
and skin mottling.
Question 6: Cardiovascular (Infective Endocarditis)
A nurse evaluates a client diagnosed with acute infective endocarditis. Which
assessment findings should the nurse document as specific clinical manifestations of
this disease process? Select all that apply.
A) Splinter hemorrhages under the fingernails
B) Painful, tender nodules on the pads of the fingers (Osler's nodes)
C) Painless, erythematous macules on the palms and soles (Janeway lesions)
D) Bilateral malar rash across the bridge of the nose
E) Absence of any audible cardiac murmurs
F) New onset or worsening of a cardiac murmur
Rationale: Classic signs of infective endocarditis result from microemboli and
immunological responses, including splinter hemorrhages, Osler's nodes, and
Janeway lesions. Due to structural valve damage from bacterial vegetations, a new
or changing cardiac murmur is a definitive feature. A malar rash indicates systemic
lupus erythematosus.
Question 7: Gastrointestinal (Hepatic Encephalopathy)
The nurse is planning care for a client with cirrhosis who has developed stage 2
hepatic encephalopathy. Which nursing interventions should be included in the care
plan? Select all that apply.
A) Administer lactulose as prescribed to achieve 2 to 3 soft stools daily
B) Encourage a high-protein diet to rebuild lean muscle mass
C) Monitor serum ammonia levels regularly
D) Assess for the presence of asterixis (flapping tremors of the hands)
E) Administer prescribed sedatives to manage restlessness
F) Implement strict fall precautions and monitor cognitive status
Rationale: Hepatic encephalopathy is caused by toxic accumulation of ammonia.
Lactulose reduces ammonia levels by expelling it through the GI tract; the goal is 2
to 3 soft stools daily. Monitoring ammonia, assessing for asterixis, and utilizing fall
safety are essential due to cognitive decline. High protein intake can worsen
ammonia production, and sedatives mask neurological changes.
3|Page
, Question 8: Hematology (Sickle Cell Crisis)
A client with sickle cell anemia is admitted to the medical-surgical unit in an acute
vaso-occlusive crisis. Which nursing actions are essential components of this client's
care? Select all that apply.
A) Administer continuous intravenous fluids as prescribed
B) Apply cold compresses or ice packs directly to painful joints
C) Administer scheduled opioid analgesics around-the-clock
D) Provide supplemental oxygen if oxygen saturation drops below 92%
E) Restrict total daily fluid intake to prevent fluid volume overload
F) Encourage bed rest and avoid strenuous physical exertion
Rationale: Vaso-occlusive crisis management targets severe pain and ischemia.
High-volume hydration is vital to reduce blood viscosity and stop sickling. Scheduled
opioid analgesics address severe bone and joint pain. Oxygen supports tissue
oxygenation to prevent further sickling. Cold compresses trigger vasoconstriction
and must be avoided; warmth is preferred.
Question 9: Neurological (Increased Intracranial Pressure)
The nurse is monitoring a client who sustained a severe traumatic brain injury. Which
clinical assessments are components of Cushing's triad, indicating dangerously high
intracranial pressure? Select all that apply.
A) Tachycardia
B) Bradycardia
C) Systolic hypertension with a widening pulse pressure
D) Hypotension with a narrowing pulse pressure
E) Irregular, altered respiratory patterns (e.g., Cheyne-Stokes)
F) Persistent tachypnea with a normal rhythm
Rationale: Cushing's triad is a late sign of increased intracranial pressure (ICP)
indicating brainstem herniation. It consists of three specific components:
bradycardia, systolic hypertension causing a widened pulse pressure, and irregular,
altered respirations. Tachycardia and hypotension are associated with shock, not
increased ICP.
Question 10: Immunological (Anaphylaxis)
An adult client on the medical-surgical floor experiences sudden laryngeal edema,
diffuse wheezing, and hypotension immediately after beginning an IV antibiotic
infusion. Which actions should the nurse perform immediately? Select all that apply.
A) Stop the antibiotic infusion immediately
B) Place the client in a high-Fowler's position with legs dependent
C) Administer intramuscular epinephrine (1:1000) as prescribed
D) Maintain a patent airway and prepare to deliver supplemental oxygen
E) Administer an oral dose of diphenhydramine right away
F) Establish or preserve IV access with 0.9% normal saline infusion
Rationale: Anaphylactic shock requires immediate intervention to maintain airway
and perfusion. The nurse must stop the offending allergen, administer IM
epinephrine (the first-line drug), protect the airway with oxygen, and maintain IV
4|Page
And Well Graded Solutions With Rationales
Updated 2026 2027
Ace your Evolve Elsevier HESI Medical-Surgical Final Exam with this premium study
guide! Features 220 high-yield Select-All-That-Apply (SATA) questions with detailed,
italicized rationales tracking actual exam concepts. Covers core systems: Cardiovascular,
Respiratory, Endocrine, Renal, Neuro, and Shock prioritization. Built to maximize your
HESI exit score and build clinical judgment. Perfect for Chamberlain, GCU, and top
nursing programs. Download now to study smart and pass on your first try!
Question 1: Cardiac (Heart Failure)
A nurse is assessing a client admitted with acute decompensated heart failure.
Which clinical manifestations should the nurse expect to find? Select all that apply.
A) Jugular venous distention
B) Dependent bilateral pitting edema
C) Dyspnea and audible crackles in the lung bases
D) Flat neck veins when lying supine
E) Bradycardia and bounding peripheral pulses
F) Weight gain of 3 pounds in 24 hours
Rationale: Acute decompensated heart failure involves both right-sided and left-
sided fluid overload. Right-sided failure leads to systemic venous congestion,
causing jugular venous distention, dependent edema, and rapid weight gain from
fluid retention. Left-sided failure causes pulmonary congestion, leading to dyspnea
and crackles. Flat neck veins and bradycardia are not expected findings in fluid
overload.
Question 2: Endocrine (Diabetic Ketoacidosis)
A client with Type 1 Diabetes Mellitus is admitted to the emergency department with
Diabetic Ketoacidosis (DKA). Which laboratory and clinical findings should the nurse
anticipate? Select all that apply.
1|Page
,A) Arterial blood pH of 7.45
B) Blood glucose level of 450 mg/dL
C) Deep, rapid respirations (Kussmaul breathing)
D) Serum bicarbonate level of 12 mEq/L
E) Negative serum ketones
F) Polyuria and profound dehydration
Rationale: DKA is characterized by severe hyperglycemia (typically >250 mg/dL),
metabolic acidosis (pH < 7.35, bicarbonate < 18 mEq/L), and ketosis. Kussmaul
respirations are the body's compensatory mechanism to blow off excess carbon
dioxide. Osmotic diuresis from high glucose levels results in polyuria and severe
volume depletion.
Question 3: Respiratory (Mechanical Ventilation)
A nurse is caring for a mechanically ventilated client on positive pressure ventilation.
Which interventions should the nurse implement to prevent Ventilator-Associated
Pneumonia (VAP)? Select all that apply.
A) Maintain the head of the bed elevated at 30 to 45 degrees
B) Instill sterile normal saline into the endotracheal tube before suctioning
C) Perform oral care with chlorhexidine solution every 12 hours
D) Conduct a daily "sedation vacation" and assess readiness to wean
E) Change the ventilator circuit tubing every 24 hours
F) Administer prescribed peptic ulcer disease prophylaxis
Rationale: Evidence-based VAP prevention bundles include keeping the head of the
bed elevated, performing regular chlorhexidine oral care, implementing daily
sedation interruptions to assess for extubation, and providing stress ulcer
prophylaxis. Routine saline instillation and daily ventilator circuit changes are
outdated practices that actually increase infection risk.
Question 4: Renal (Acute Kidney Injury)
A client with acute kidney injury (AKI) is in the oliguric phase. Which clinical and
laboratory assessments require immediate notification to the healthcare provider?
Select all that apply.
A) Serum potassium level of 6.2 mEq/L
B) New onset of peaked T waves on the ECG
C) Serum creatinine increase from 1.2 mg/dL to 2.0 mg/dL
D) Crackles in the lungs and a respiratory rate of 28 breaths/minute
E) Urine output of 350 mL over the last 24 hours
F) Mild fatigue and generalized pruritus
Rationale: Hyperkalemia (>5.0 mEq/L) is a life-threatening complication of the
oliguric phase of AKI that can cause lethal cardiac dysrhythmias, indicated by
peaked T waves. Fluid volume overload leading to pulmonary congestion (crackles,
tachypnea) is another emergency. While elevated creatinine and oliguria are
expected in AKI, they do not represent the immediate life-threatening emergencies
that hyperkalemia and respiratory distress do.
Question 5: Perioperative (Malignant Hyperthermia)
2|Page
,A client undergoing general anesthesia during an emergency laparotomy develops
malignant hyperthermia. Which clinical signs should the nurse recognize as early or
progressive indicators of this crisis? Select all that apply.
A) Generalized muscle rigidity or jaw clenching
B) Rapid rise in end-tidal carbon dioxide (ETCO2)
C) Sudden drop in core body temperature
D) Unexplained sinus tachycardia
E) Profound bradycardia and hypotension
F) Hyperkalemia and mottled skin
Rationale: Malignant hyperthermia is a hypermetabolic crisis triggered by volatile
anesthetic gases or succinylcholine. The earliest signs are an unexplained rise in
end-tidal CO2 and sinus tachycardia, closely followed by severe muscle or jaw
rigidity. High fever is actually a late sign. Cellular breakdown causes hyperkalemia
and skin mottling.
Question 6: Cardiovascular (Infective Endocarditis)
A nurse evaluates a client diagnosed with acute infective endocarditis. Which
assessment findings should the nurse document as specific clinical manifestations of
this disease process? Select all that apply.
A) Splinter hemorrhages under the fingernails
B) Painful, tender nodules on the pads of the fingers (Osler's nodes)
C) Painless, erythematous macules on the palms and soles (Janeway lesions)
D) Bilateral malar rash across the bridge of the nose
E) Absence of any audible cardiac murmurs
F) New onset or worsening of a cardiac murmur
Rationale: Classic signs of infective endocarditis result from microemboli and
immunological responses, including splinter hemorrhages, Osler's nodes, and
Janeway lesions. Due to structural valve damage from bacterial vegetations, a new
or changing cardiac murmur is a definitive feature. A malar rash indicates systemic
lupus erythematosus.
Question 7: Gastrointestinal (Hepatic Encephalopathy)
The nurse is planning care for a client with cirrhosis who has developed stage 2
hepatic encephalopathy. Which nursing interventions should be included in the care
plan? Select all that apply.
A) Administer lactulose as prescribed to achieve 2 to 3 soft stools daily
B) Encourage a high-protein diet to rebuild lean muscle mass
C) Monitor serum ammonia levels regularly
D) Assess for the presence of asterixis (flapping tremors of the hands)
E) Administer prescribed sedatives to manage restlessness
F) Implement strict fall precautions and monitor cognitive status
Rationale: Hepatic encephalopathy is caused by toxic accumulation of ammonia.
Lactulose reduces ammonia levels by expelling it through the GI tract; the goal is 2
to 3 soft stools daily. Monitoring ammonia, assessing for asterixis, and utilizing fall
safety are essential due to cognitive decline. High protein intake can worsen
ammonia production, and sedatives mask neurological changes.
3|Page
, Question 8: Hematology (Sickle Cell Crisis)
A client with sickle cell anemia is admitted to the medical-surgical unit in an acute
vaso-occlusive crisis. Which nursing actions are essential components of this client's
care? Select all that apply.
A) Administer continuous intravenous fluids as prescribed
B) Apply cold compresses or ice packs directly to painful joints
C) Administer scheduled opioid analgesics around-the-clock
D) Provide supplemental oxygen if oxygen saturation drops below 92%
E) Restrict total daily fluid intake to prevent fluid volume overload
F) Encourage bed rest and avoid strenuous physical exertion
Rationale: Vaso-occlusive crisis management targets severe pain and ischemia.
High-volume hydration is vital to reduce blood viscosity and stop sickling. Scheduled
opioid analgesics address severe bone and joint pain. Oxygen supports tissue
oxygenation to prevent further sickling. Cold compresses trigger vasoconstriction
and must be avoided; warmth is preferred.
Question 9: Neurological (Increased Intracranial Pressure)
The nurse is monitoring a client who sustained a severe traumatic brain injury. Which
clinical assessments are components of Cushing's triad, indicating dangerously high
intracranial pressure? Select all that apply.
A) Tachycardia
B) Bradycardia
C) Systolic hypertension with a widening pulse pressure
D) Hypotension with a narrowing pulse pressure
E) Irregular, altered respiratory patterns (e.g., Cheyne-Stokes)
F) Persistent tachypnea with a normal rhythm
Rationale: Cushing's triad is a late sign of increased intracranial pressure (ICP)
indicating brainstem herniation. It consists of three specific components:
bradycardia, systolic hypertension causing a widened pulse pressure, and irregular,
altered respirations. Tachycardia and hypotension are associated with shock, not
increased ICP.
Question 10: Immunological (Anaphylaxis)
An adult client on the medical-surgical floor experiences sudden laryngeal edema,
diffuse wheezing, and hypotension immediately after beginning an IV antibiotic
infusion. Which actions should the nurse perform immediately? Select all that apply.
A) Stop the antibiotic infusion immediately
B) Place the client in a high-Fowler's position with legs dependent
C) Administer intramuscular epinephrine (1:1000) as prescribed
D) Maintain a patent airway and prepare to deliver supplemental oxygen
E) Administer an oral dose of diphenhydramine right away
F) Establish or preserve IV access with 0.9% normal saline infusion
Rationale: Anaphylactic shock requires immediate intervention to maintain airway
and perfusion. The nurse must stop the offending allergen, administer IM
epinephrine (the first-line drug), protect the airway with oxygen, and maintain IV
4|Page
