HESI Med-Surg II Practice Exam (2025/2026) —
130 Advanced Medical-Surgical Nursing Questions
with Correct Answers & Detailed Rationales
1. A patient is admitted with acute anterior ST-elevation myocardial infarction (STEMI).
The nurse notes new onset of a loud holosystolic murmur at the apex with radiation to the
axilla. The patient becomes acutely dyspneic and hypotensive. Which complication
should the nurse suspect?
A. Ventricular septal defect (VSD)
B. Papillary muscle rupture
C. Dressler syndrome
D. Right ventricular infarction
Correct Answer: B
Rationale: Papillary muscle rupture is a life-threatening mechanical complication of acute
MI that typically occurs 2-7 days post-infarction, most commonly with inferior MIs
affecting the posteromedial papillary muscle. The acute onset of a loud holosystolic
murmur at the apex with radiation to the axilla, combined with acute pulmonary edema
and hypotension, is pathognomonic for papillary muscle rupture causing acute mitral
regurgitation. Ventricular septal defect would produce a harsh holosystolic murmur at the
left sternal border, Dressler syndrome presents days to weeks later with pericarditis and
,fever, and right ventricular infarction would show JVD, clear lungs, and hypotension
without a new murmur.
2. A patient with ARDS is receiving mechanical ventilation with PEEP 15 cm H2O and
FiO2 80%. ABG results show pH 7.28, PaCO2 52 mmHg, PaO2 68 mmHg, HCO3 24
mEq/L. The nurse should anticipate which intervention?
A. Increase PEEP to 20 cm H2O
B. Initiate prone positioning
C. Decrease FiO2 to 60%
D. Administer sodium bicarbonate
Correct Answer: B
Rationale: This patient has severe ARDS based on the Berlin criteria (PaO2/FiO2 ratio
<100 mmHg) with acute respiratory acidosis indicating ventilator-induced lung injury
risk. Prone positioning is a evidence-based intervention for severe ARDS that improves
oxygenation by recruiting dependent lung regions and reducing ventilator-induced lung
injury. Increasing PEEP further could cause barotrauma, decreasing FiO2 would worsen
hypoxemia, and bicarbonate administration is contraindicated in acute respiratory
acidosis. The ARDSnet prone positioning protocol should be initiated within 36 hours of
ARDS onset for patients with PaO2/FiO2 <150 mmHg.
3. A patient with DKA receives an insulin infusion at 8 units/hour. After 4 hours, the
blood glucose decreases from 580 mg/dL to 320 mg/dL. The nurse notes K+ 3.2 mEq/L
and the patient reports muscle weakness. Which action is priority?
A. Decrease insulin infusion rate
,B. Administer IV potassium supplementation
C. Switch to D5W with insulin
D. Obtain 12-lead ECG
Correct Answer: B
Rationale: Hypokalemia (K+ 3.2 mEq/L) with muscle weakness during DKA treatment is
a medical emergency requiring immediate potassium replacement. Insulin drives
potassium intracellularly, and rapid correction of acidosis further lowers serum
potassium. Muscle weakness can progress to life-threatening arrhythmias. The insulin
infusion should continue at the current rate while potassium is aggressively replaced, as
stopping insulin would worsen DKA. D5W is appropriate when glucose reaches 250-300
mg/dL but doesn't address the hypokalemia. An ECG is important but shouldn't delay
potassium replacement in symptomatic hypokalemia.
4. A patient with increased intracranial pressure (ICP) receives mannitol 1 g/kg IV.
Which assessment finding indicates the medication is effective?
A. Decreased blood pressure
B. Increased urine output
C. Decreased level of consciousness
D. Increased heart rate
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces ICP by creating an osmotic
gradient, drawing fluid from brain tissue into the intravascular space, which is then
, excreted renally. Increased urine output (osmotic diuresis) indicates the medication is
working to reduce cerebral edema. The goal is to see improved neurological status (not
decreased LOC), and vital sign changes are not primary indicators of mannitol
effectiveness. Mannitol should increase serum osmolality by 10-20 mOsm/kg and
produce a brisk diuresis within 15-30 minutes of administration.
5. A patient with acute pancreatitis reports severe abdominal pain radiating to the back
and vomiting. Which nursing intervention is priority?
A. Administer morphine 4 mg IV
B. Insert nasogastric tube
C. Maintain NPO status and initiate fluid resuscitation
D. Prepare for emergency surgery
Correct Answer: C
Rationale: The priority for acute pancreatitis is aggressive fluid resuscitation (typically
250-500 mL/hour of isotonic crystalloid) to prevent pancreatic necrosis and maintain
perfusion, combined with NPO status to rest the pancreas. Pain management is important
but secondary to volume resuscitation. Nasogastric tube insertion is only indicated for
severe ileus or intractable vomiting. Emergency surgery is rarely indicated in acute
pancreatitis unless complications like infected necrosis develop. The patient's
hemodynamic status, urine output, and laboratory trends guide fluid resuscitation goals.
6. A patient in septic shock has received 3 liters of crystalloid but remains hypotensive
(MAP 55 mmHg) with altered mental status. Central venous pressure is 12 mmHg.
Which vasopressor should the nurse prepare?
130 Advanced Medical-Surgical Nursing Questions
with Correct Answers & Detailed Rationales
1. A patient is admitted with acute anterior ST-elevation myocardial infarction (STEMI).
The nurse notes new onset of a loud holosystolic murmur at the apex with radiation to the
axilla. The patient becomes acutely dyspneic and hypotensive. Which complication
should the nurse suspect?
A. Ventricular septal defect (VSD)
B. Papillary muscle rupture
C. Dressler syndrome
D. Right ventricular infarction
Correct Answer: B
Rationale: Papillary muscle rupture is a life-threatening mechanical complication of acute
MI that typically occurs 2-7 days post-infarction, most commonly with inferior MIs
affecting the posteromedial papillary muscle. The acute onset of a loud holosystolic
murmur at the apex with radiation to the axilla, combined with acute pulmonary edema
and hypotension, is pathognomonic for papillary muscle rupture causing acute mitral
regurgitation. Ventricular septal defect would produce a harsh holosystolic murmur at the
left sternal border, Dressler syndrome presents days to weeks later with pericarditis and
,fever, and right ventricular infarction would show JVD, clear lungs, and hypotension
without a new murmur.
2. A patient with ARDS is receiving mechanical ventilation with PEEP 15 cm H2O and
FiO2 80%. ABG results show pH 7.28, PaCO2 52 mmHg, PaO2 68 mmHg, HCO3 24
mEq/L. The nurse should anticipate which intervention?
A. Increase PEEP to 20 cm H2O
B. Initiate prone positioning
C. Decrease FiO2 to 60%
D. Administer sodium bicarbonate
Correct Answer: B
Rationale: This patient has severe ARDS based on the Berlin criteria (PaO2/FiO2 ratio
<100 mmHg) with acute respiratory acidosis indicating ventilator-induced lung injury
risk. Prone positioning is a evidence-based intervention for severe ARDS that improves
oxygenation by recruiting dependent lung regions and reducing ventilator-induced lung
injury. Increasing PEEP further could cause barotrauma, decreasing FiO2 would worsen
hypoxemia, and bicarbonate administration is contraindicated in acute respiratory
acidosis. The ARDSnet prone positioning protocol should be initiated within 36 hours of
ARDS onset for patients with PaO2/FiO2 <150 mmHg.
3. A patient with DKA receives an insulin infusion at 8 units/hour. After 4 hours, the
blood glucose decreases from 580 mg/dL to 320 mg/dL. The nurse notes K+ 3.2 mEq/L
and the patient reports muscle weakness. Which action is priority?
A. Decrease insulin infusion rate
,B. Administer IV potassium supplementation
C. Switch to D5W with insulin
D. Obtain 12-lead ECG
Correct Answer: B
Rationale: Hypokalemia (K+ 3.2 mEq/L) with muscle weakness during DKA treatment is
a medical emergency requiring immediate potassium replacement. Insulin drives
potassium intracellularly, and rapid correction of acidosis further lowers serum
potassium. Muscle weakness can progress to life-threatening arrhythmias. The insulin
infusion should continue at the current rate while potassium is aggressively replaced, as
stopping insulin would worsen DKA. D5W is appropriate when glucose reaches 250-300
mg/dL but doesn't address the hypokalemia. An ECG is important but shouldn't delay
potassium replacement in symptomatic hypokalemia.
4. A patient with increased intracranial pressure (ICP) receives mannitol 1 g/kg IV.
Which assessment finding indicates the medication is effective?
A. Decreased blood pressure
B. Increased urine output
C. Decreased level of consciousness
D. Increased heart rate
Correct Answer: B
Rationale: Mannitol is an osmotic diuretic that reduces ICP by creating an osmotic
gradient, drawing fluid from brain tissue into the intravascular space, which is then
, excreted renally. Increased urine output (osmotic diuresis) indicates the medication is
working to reduce cerebral edema. The goal is to see improved neurological status (not
decreased LOC), and vital sign changes are not primary indicators of mannitol
effectiveness. Mannitol should increase serum osmolality by 10-20 mOsm/kg and
produce a brisk diuresis within 15-30 minutes of administration.
5. A patient with acute pancreatitis reports severe abdominal pain radiating to the back
and vomiting. Which nursing intervention is priority?
A. Administer morphine 4 mg IV
B. Insert nasogastric tube
C. Maintain NPO status and initiate fluid resuscitation
D. Prepare for emergency surgery
Correct Answer: C
Rationale: The priority for acute pancreatitis is aggressive fluid resuscitation (typically
250-500 mL/hour of isotonic crystalloid) to prevent pancreatic necrosis and maintain
perfusion, combined with NPO status to rest the pancreas. Pain management is important
but secondary to volume resuscitation. Nasogastric tube insertion is only indicated for
severe ileus or intractable vomiting. Emergency surgery is rarely indicated in acute
pancreatitis unless complications like infected necrosis develop. The patient's
hemodynamic status, urine output, and laboratory trends guide fluid resuscitation goals.
6. A patient in septic shock has received 3 liters of crystalloid but remains hypotensive
(MAP 55 mmHg) with altered mental status. Central venous pressure is 12 mmHg.
Which vasopressor should the nurse prepare?
