HESI Med-Surg II Exam (2025/2026) — 130 Advanced
Medical-Surgical Nursing Questions with Correct
Answers & Detailed Rationales
1. A 67-year-old male returns from CABG surgery 4 hours ago. His mediastinal
chest tube output was 75 mL/hr for the first 3 hours but suddenly drops to 5 mL/hr.
His BP falls to 88/50 mm Hg and HR rises to 120 beats/min. Which complication
should the nurse suspect first?
A. Reversal of narcotic sedation
B. Acute cardiac tamponade
C. Hypovolemia from diuresis
D. Dislodgement of the chest tube
Correct Answer: B
Rationale: An abrupt decrease in chest-tube drainage coupled with hemodynamic
collapse strongly suggests clot obstruction of the tube, leading to pericardial
accumulation and tamponade. Falling output despite hemodynamic instability is a classic
red-flag that requires immediate notification of the surgical team and preparation for
emergency mediastinal exploration. Hypovolemia would usually show continued or
increased drainage, while tube dislodgement would be accompanied by subcutaneous
emphysema or visible displacement. Reversal of sedation does not cause shock.
2. The ICU nurse is caring for a mechanically ventilated client with ARDS. PEEP is
14 cm H₂O and FiO₂ is 0.80. Recent ABG: pH 7.28, PaCO₂ 52 mm Hg, PaO₂ 58
mm Hg, HCO₃ 24 mEq/L. Which ventilator adjustment should the nurse
anticipate?
A. Increase PEEP to 18 cm H₂O
B. Increase FiO₂ to 1.0
C. Implement prone positioning
D. Increase tidal volume to 12 mL/kg
,Correct Answer: C
Rationale: Severe ARDS (P/F < 100) with refractory hypoxemia despite high PEEP/FiO₂
warrants prone positioning to recruit dorsal lung units and improve V/Q matching per
ARDSNet protocols. Further increases in PEEP/FiO₂ risk barotrauma and oxygen
toxicity. High tidal volumes are contraindicated (goal 6 mL/kg) to prevent
ventilator-induced lung injury.
3. A client with DKA has received 4 L of isotonic fluid and an insulin infusion.
Current labs: glucose 250 mg/dL, K⁺ 3.2 mEq/L, pH 7.25, HCO₃ 15 mEq/L. Which
order should the nurse implement first?
A. Add dextrose to the IV and continue insulin
B. Switch to ½ NS at 150 mL/hr
C. Administer 40 mEq KCl IV over 4 h
D. Give sodium bicarbonate 1 amp IV
Correct Answer: C
Rationale: Insulin drives potassium intracellularly; hypokalemia (K⁺ < 3.3) predisposes to
ventricular dysrhythmias and must be corrected before insulin continues. Once K⁺ is ≥
3.3, dextrose can be added to prevent hypoglycemia while insulin finishes closing the
anion gap. Bicarbonate is reserved for pH < 6.9 with hemodynamic instability.
4. A 58-year-old female in thyroid storm has a temperature of 40.2 °C and HR 160
beats/min. Which intervention is most important during the first hour of care?
A. Give propylthiouracil 600 mg per NG tube
B. Infuse propranolol 1 mg IV q5 min
C. Apply ice packs and cooled IV fluids
D. Administer hydrocortisone 300 mg IV
Correct Answer: C
Rationale: Rapid cooling reduces metabolic demand and prevents protein denaturation; it
is the only intervention that directly lowers core temperature and should begin within
,minutes. Antithyroid drugs and beta-blockers slow hormone synthesis and adrenergic
response but do not correct hyperthermia. Steroids treat possible adrenal insufficiency but
are lower priority than temperature control.
5. A client with a T5 complete spinal cord injury develops severe hypertension (BP
210/110 mm Hg) and a pounding headache 30 min after a large bladder spasm. HR
is 46 beats/min. Which condition is occurring?
A. Autonomic dysreflexia
B. Paroxysmal hypertension
C. Neurogenic shock
D. Malignant hypertension
Correct Answer: A
Rationale: Autonomic dysreflexia is a life-threatening reflex sympathetic discharge
triggered by noxious stimuli below the level of injury (commonly bladder or bowel
distension). It presents with severe hypertension, bradycardia, and headache. Immediate
stimulus removal (catheterization) and rapid-acting antihypertensives are required.
Neurogenic shock presents with hypotension and bradycardia.
6. A client with severe sepsis has received 30 mL/kg crystalloid but remains
hypotensive (MAP 55 mm Hg). A central line is placed and a vasopressor is
prescribed. Which inotropic agent is recommended first-line per Surviving Sepsis
guidelines?
A. Dopamine 10 μg/kg/min
B. Norepinephrine 0.1 μg/kg/min
C. Epinephrine 0.05 μg/kg/min
D. Phenylephrine 0.5 μg/kg/min
Correct Answer: B
Rationale: Norepinephrine is the preferred first-line vasopressor for septic shock due to
potent alpha-1 activity and reliable blood pressure elevation with fewer arrhythmias than
, dopamine. Epinephrine is added as second-line, and phenylephrine is used when
tachyarrhythmias limit norepinephrine.
7. A client with acute liver failure develops increasing agitation and asterixis. Serum
ammonia is 180 μg/dL. Which dietary modification should the nurse anticipate?
A. High-protein supplements to promote regeneration
B. Limit protein to 0.6–0.8 g/kg/day temporarily
C. Provide branched-chain amino acids only
D. Initiate total parenteral nutrition with 1.5 g/kg protein
Correct Answer: B
Rationale: Reducing protein intake lowers ammonia production and aids in controlling
hepatic encephalopathy while still supplying minimal substrate for healing. Once
lactulose/rifaximin take effect, protein can be liberalized. BCAAs are expensive and
reserved for refractory cases.
8. A postoperative craniotomy client’s urine output averages 400 mL/hr for 3
consecutive hours. Serum Na⁺ is 158 mEq/L and urine specific gravity 1.002.
Which complication is likely?
A. Syndrome of inappropriate ADH
B. Diabetes insipidus
C. Acute tubular necrosis
D. Cerebral salt wasting
Correct Answer: B
Rationale: Hypotonic polyuria with rising serum sodium and low USG after pituitary or
hypothalamic surgery is pathognomonic for central diabetes insipidus. Treatment includes
volume replacement and desmopressin. SIADH presents with hyponatremia and
concentrated urine; CSW causes hyponatremia and volume depletion.
9. A client with acute pancreatitis becomes febrile, hypotensive, and tachypneic 48
hours after admission. WBC is 22,000/mm³ and lactate 4 mmol/L. Which
Medical-Surgical Nursing Questions with Correct
Answers & Detailed Rationales
1. A 67-year-old male returns from CABG surgery 4 hours ago. His mediastinal
chest tube output was 75 mL/hr for the first 3 hours but suddenly drops to 5 mL/hr.
His BP falls to 88/50 mm Hg and HR rises to 120 beats/min. Which complication
should the nurse suspect first?
A. Reversal of narcotic sedation
B. Acute cardiac tamponade
C. Hypovolemia from diuresis
D. Dislodgement of the chest tube
Correct Answer: B
Rationale: An abrupt decrease in chest-tube drainage coupled with hemodynamic
collapse strongly suggests clot obstruction of the tube, leading to pericardial
accumulation and tamponade. Falling output despite hemodynamic instability is a classic
red-flag that requires immediate notification of the surgical team and preparation for
emergency mediastinal exploration. Hypovolemia would usually show continued or
increased drainage, while tube dislodgement would be accompanied by subcutaneous
emphysema or visible displacement. Reversal of sedation does not cause shock.
2. The ICU nurse is caring for a mechanically ventilated client with ARDS. PEEP is
14 cm H₂O and FiO₂ is 0.80. Recent ABG: pH 7.28, PaCO₂ 52 mm Hg, PaO₂ 58
mm Hg, HCO₃ 24 mEq/L. Which ventilator adjustment should the nurse
anticipate?
A. Increase PEEP to 18 cm H₂O
B. Increase FiO₂ to 1.0
C. Implement prone positioning
D. Increase tidal volume to 12 mL/kg
,Correct Answer: C
Rationale: Severe ARDS (P/F < 100) with refractory hypoxemia despite high PEEP/FiO₂
warrants prone positioning to recruit dorsal lung units and improve V/Q matching per
ARDSNet protocols. Further increases in PEEP/FiO₂ risk barotrauma and oxygen
toxicity. High tidal volumes are contraindicated (goal 6 mL/kg) to prevent
ventilator-induced lung injury.
3. A client with DKA has received 4 L of isotonic fluid and an insulin infusion.
Current labs: glucose 250 mg/dL, K⁺ 3.2 mEq/L, pH 7.25, HCO₃ 15 mEq/L. Which
order should the nurse implement first?
A. Add dextrose to the IV and continue insulin
B. Switch to ½ NS at 150 mL/hr
C. Administer 40 mEq KCl IV over 4 h
D. Give sodium bicarbonate 1 amp IV
Correct Answer: C
Rationale: Insulin drives potassium intracellularly; hypokalemia (K⁺ < 3.3) predisposes to
ventricular dysrhythmias and must be corrected before insulin continues. Once K⁺ is ≥
3.3, dextrose can be added to prevent hypoglycemia while insulin finishes closing the
anion gap. Bicarbonate is reserved for pH < 6.9 with hemodynamic instability.
4. A 58-year-old female in thyroid storm has a temperature of 40.2 °C and HR 160
beats/min. Which intervention is most important during the first hour of care?
A. Give propylthiouracil 600 mg per NG tube
B. Infuse propranolol 1 mg IV q5 min
C. Apply ice packs and cooled IV fluids
D. Administer hydrocortisone 300 mg IV
Correct Answer: C
Rationale: Rapid cooling reduces metabolic demand and prevents protein denaturation; it
is the only intervention that directly lowers core temperature and should begin within
,minutes. Antithyroid drugs and beta-blockers slow hormone synthesis and adrenergic
response but do not correct hyperthermia. Steroids treat possible adrenal insufficiency but
are lower priority than temperature control.
5. A client with a T5 complete spinal cord injury develops severe hypertension (BP
210/110 mm Hg) and a pounding headache 30 min after a large bladder spasm. HR
is 46 beats/min. Which condition is occurring?
A. Autonomic dysreflexia
B. Paroxysmal hypertension
C. Neurogenic shock
D. Malignant hypertension
Correct Answer: A
Rationale: Autonomic dysreflexia is a life-threatening reflex sympathetic discharge
triggered by noxious stimuli below the level of injury (commonly bladder or bowel
distension). It presents with severe hypertension, bradycardia, and headache. Immediate
stimulus removal (catheterization) and rapid-acting antihypertensives are required.
Neurogenic shock presents with hypotension and bradycardia.
6. A client with severe sepsis has received 30 mL/kg crystalloid but remains
hypotensive (MAP 55 mm Hg). A central line is placed and a vasopressor is
prescribed. Which inotropic agent is recommended first-line per Surviving Sepsis
guidelines?
A. Dopamine 10 μg/kg/min
B. Norepinephrine 0.1 μg/kg/min
C. Epinephrine 0.05 μg/kg/min
D. Phenylephrine 0.5 μg/kg/min
Correct Answer: B
Rationale: Norepinephrine is the preferred first-line vasopressor for septic shock due to
potent alpha-1 activity and reliable blood pressure elevation with fewer arrhythmias than
, dopamine. Epinephrine is added as second-line, and phenylephrine is used when
tachyarrhythmias limit norepinephrine.
7. A client with acute liver failure develops increasing agitation and asterixis. Serum
ammonia is 180 μg/dL. Which dietary modification should the nurse anticipate?
A. High-protein supplements to promote regeneration
B. Limit protein to 0.6–0.8 g/kg/day temporarily
C. Provide branched-chain amino acids only
D. Initiate total parenteral nutrition with 1.5 g/kg protein
Correct Answer: B
Rationale: Reducing protein intake lowers ammonia production and aids in controlling
hepatic encephalopathy while still supplying minimal substrate for healing. Once
lactulose/rifaximin take effect, protein can be liberalized. BCAAs are expensive and
reserved for refractory cases.
8. A postoperative craniotomy client’s urine output averages 400 mL/hr for 3
consecutive hours. Serum Na⁺ is 158 mEq/L and urine specific gravity 1.002.
Which complication is likely?
A. Syndrome of inappropriate ADH
B. Diabetes insipidus
C. Acute tubular necrosis
D. Cerebral salt wasting
Correct Answer: B
Rationale: Hypotonic polyuria with rising serum sodium and low USG after pituitary or
hypothalamic surgery is pathognomonic for central diabetes insipidus. Treatment includes
volume replacement and desmopressin. SIADH presents with hyponatremia and
concentrated urine; CSW causes hyponatremia and volume depletion.
9. A client with acute pancreatitis becomes febrile, hypotensive, and tachypneic 48
hours after admission. WBC is 22,000/mm³ and lactate 4 mmol/L. Which
