HESI MED SURG EXIT EXAM V1 2026 | 150 NGN Questions | Real
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SECTION 1: STANDARD FORMAT ITEMS (Questions 1-105)
Question 1: Cardiovascular – Complex Heart Failure with Cardiogenic Shock
A 78-year-old client with a history of chronic heart failure (EF 25%) is admitted with
acute decompensated heart failure. Initial vital signs: BP 88/52 mmHg, HR 118 bpm
(irregularly irregular), RR 28/min, SpO2 89% on 2L NC. The client is cool, clammy, and
confused. Pulmonary artery catheter (PAC) shows: PAWP 28 mmHg, CI 1.8 L/min/m²,
SVR 1,400 dynes/sec/cm⁻⁵. The provider orders dobutamine 5 mcg/kg/min IV and
furosemide 80 mg IV. Thirty minutes later, the client's BP drops to 72/48 mmHg, HR
increases to 132 bpm, and the client becomes unresponsive to verbal stimuli.
What is the priority nursing action at this time?
A. Increase the dobutamine infusion rate to 10 mcg/kg/min to improve cardiac output
B. Administer the scheduled furosemide to reduce preload and improve cardiac function
C. Prepare for immediate insertion of an intra-aortic balloon pump (IABP) and notify the
provider of worsening cardiogenic shock [CORRECT]
D. Position the client in high Fowler's position and increase oxygen to 6L NC
Correct Answer: C
Rationale:
,Option A: Incorrect. Increasing dobutamine in the presence of worsening hypotension
(72/48 mmHg) and unresponsiveness is contraindicated. Dobutamine is a positive
inotrope that also causes vasodilation, which can further reduce blood pressure in
hypotensive clients. The client's hemodynamic profile (low CI, high PAWP, high SVR)
indicates cardiogenic shock with inadequate tissue perfusion. Increasing dobutamine
without addressing the profound hypotension could precipitate cardiovascular collapse.
The appropriate intervention would be to add a vasopressor (norepinephrine) or
mechanical circulatory support, not increase the inotrope alone.
Option B: Incorrect. Administering furosemide in this scenario is dangerous. While the
client has elevated PAWP (28 mmHg) indicating pulmonary congestion, the profound
hypotension (72/48 mmHg) and unresponsiveness indicate inadequate perfusion.
Diuretics further reduce preload and can worsen hypotension and organ perfusion. In
cardiogenic shock with hypotension, diuresis is contraindicated until hemodynamic
stability is achieved, often requiring mechanical support or vasopressors.
Option C: Correct. The client has developed refractory cardiogenic shock evidenced by:
worsening hypotension despite inotropic support, altered mental status
(unresponsiveness), tachycardia, and low cardiac index (1.8 L/min/m²). The
hemodynamic profile (high PAWP, low CI, high SVR) indicates left ventricular failure with
inadequate systemic perfusion. Intra-aortic balloon pump (IABP) or other mechanical
circulatory support (Impella, ECMO) is indicated for cardiogenic shock refractory to
medical therapy. The nurse must immediately notify the provider and prepare for
mechanical support while continuing to monitor hemodynamics. This represents the
highest priority using the ABC framework and the NCSBN Clinical Judgment
Measurement Model—recognizing life-threatening deterioration and taking immediate
collaborative action.
,Option D: Incorrect. While positioning and oxygen are supportive measures, they are
insufficient for this life-threatening situation. High Fowler's position may further reduce
venous return and worsen hypotension in shock states. The client requires definitive
intervention for refractory shock, not supportive measures alone. This option represents
a delay in critical care that could result in death.
Question 2 (SATA – 4 correct): Respiratory – ARDS with Ventilator Management
A 45-year-old client with ARDS secondary to sepsis is intubated and on mechanical
ventilation. Current settings: Volume Control SIMV, TV 400 mL (6 mL/kg IBW), RR 16,
FiO2 0.80, PEEP 12 cm H₂O. Arterial blood gas: pH 7.32, PaCO2 48 mmHg, PaO2 58
mmHg, HCO3 24 mEq/L, SaO2 88%. The nurse is implementing lung-protective
ventilation strategies.
Which interventions are appropriate for this client? Select all that apply.
A. Increase PEEP to 15 cm H₂O to improve oxygenation [CORRECT]
B. Assess for permissive hypercapnia and ensure pH remains ≥ 7.25 [CORRECT]
C. Prepare for prone positioning if PaO2/FiO2 ratio remains < 150 [CORRECT]
D. Increase tidal volume to 550 mL to improve ventilation
E. Administer neuromuscular blocking agents (NMBAs) to prevent ventilator
dyssynchrony [CORRECT]
F. Decrease FiO2 to 0.60 to reduce oxygen toxicity risk
Correct Answer: A, B, C, E
Rationale:
, Option A: Correct. Increasing PEEP is appropriate in ARDS to recruit alveoli, improve
oxygenation, and reduce intrapulmonary shunting. The current PaO2 of 58 mmHg on
80% FiO2 indicates severe hypoxemia (PaO2/FiO2 ratio = 72.5). PEEP titration up to 15
cm H₂O is within lung-protective strategy guidelines (ARDSNet protocol) to achieve
adequate oxygenation while limiting FiO2. The nurse should monitor for hemodynamic
compromise with PEEP increases.
Option B: Correct. Permissive hypercapnia is a standard lung-protective strategy in
ARDS. The current pH of 7.32 with PaCO2 48 is acceptable if hemodynamically
tolerated. The ARDSNet protocol allows pH as low as 7.25-7.30 to minimize
ventilator-induced lung injury from high tidal volumes. The nurse must monitor for
complications (cerebral vasodilation, arrhythmias) but should not increase ventilation to
normalize PaCO2 at the expense of lung protection.
Option C: Correct. Prone positioning is indicated for moderate-to-severe ARDS
(PaO2/FiO2 < 150) to improve V/Q matching, reduce lung compression, and enhance
secretion drainage. The client's ratio of 72.5 meets criteria for proning. The nurse
should prepare for this intervention, ensuring hemodynamic stability and proper
positioning to prevent complications.
Option D: Incorrect. Increasing tidal volume to 550 mL (approximately 8.25 mL/kg for
average adult) violates lung-protective ventilation principles. ARDSNet guidelines
specify 6 mL/kg ideal body weight to prevent volutrauma and barotrauma. Higher tidal
volumes increase mortality in ARDS. The current 400 mL is appropriate; if ventilation is
inadequate, other strategies (increase RR, adjust I:E ratio, prone positioning) should be
used.
Option E: Correct. Neuromuscular blocking agents (cisatracurium, vecuronium) are
indicated in severe ARDS (PaO2/FiO2 < 150) to prevent patient-ventilator dyssynchrony,
reduce oxygen consumption, and facilitate lung-protective ventilation. The nurse must
Q&A with Verified Answers | Complete Exam Simulation | Pass
Guaranteed - A+ Graded
SECTION 1: STANDARD FORMAT ITEMS (Questions 1-105)
Question 1: Cardiovascular – Complex Heart Failure with Cardiogenic Shock
A 78-year-old client with a history of chronic heart failure (EF 25%) is admitted with
acute decompensated heart failure. Initial vital signs: BP 88/52 mmHg, HR 118 bpm
(irregularly irregular), RR 28/min, SpO2 89% on 2L NC. The client is cool, clammy, and
confused. Pulmonary artery catheter (PAC) shows: PAWP 28 mmHg, CI 1.8 L/min/m²,
SVR 1,400 dynes/sec/cm⁻⁵. The provider orders dobutamine 5 mcg/kg/min IV and
furosemide 80 mg IV. Thirty minutes later, the client's BP drops to 72/48 mmHg, HR
increases to 132 bpm, and the client becomes unresponsive to verbal stimuli.
What is the priority nursing action at this time?
A. Increase the dobutamine infusion rate to 10 mcg/kg/min to improve cardiac output
B. Administer the scheduled furosemide to reduce preload and improve cardiac function
C. Prepare for immediate insertion of an intra-aortic balloon pump (IABP) and notify the
provider of worsening cardiogenic shock [CORRECT]
D. Position the client in high Fowler's position and increase oxygen to 6L NC
Correct Answer: C
Rationale:
,Option A: Incorrect. Increasing dobutamine in the presence of worsening hypotension
(72/48 mmHg) and unresponsiveness is contraindicated. Dobutamine is a positive
inotrope that also causes vasodilation, which can further reduce blood pressure in
hypotensive clients. The client's hemodynamic profile (low CI, high PAWP, high SVR)
indicates cardiogenic shock with inadequate tissue perfusion. Increasing dobutamine
without addressing the profound hypotension could precipitate cardiovascular collapse.
The appropriate intervention would be to add a vasopressor (norepinephrine) or
mechanical circulatory support, not increase the inotrope alone.
Option B: Incorrect. Administering furosemide in this scenario is dangerous. While the
client has elevated PAWP (28 mmHg) indicating pulmonary congestion, the profound
hypotension (72/48 mmHg) and unresponsiveness indicate inadequate perfusion.
Diuretics further reduce preload and can worsen hypotension and organ perfusion. In
cardiogenic shock with hypotension, diuresis is contraindicated until hemodynamic
stability is achieved, often requiring mechanical support or vasopressors.
Option C: Correct. The client has developed refractory cardiogenic shock evidenced by:
worsening hypotension despite inotropic support, altered mental status
(unresponsiveness), tachycardia, and low cardiac index (1.8 L/min/m²). The
hemodynamic profile (high PAWP, low CI, high SVR) indicates left ventricular failure with
inadequate systemic perfusion. Intra-aortic balloon pump (IABP) or other mechanical
circulatory support (Impella, ECMO) is indicated for cardiogenic shock refractory to
medical therapy. The nurse must immediately notify the provider and prepare for
mechanical support while continuing to monitor hemodynamics. This represents the
highest priority using the ABC framework and the NCSBN Clinical Judgment
Measurement Model—recognizing life-threatening deterioration and taking immediate
collaborative action.
,Option D: Incorrect. While positioning and oxygen are supportive measures, they are
insufficient for this life-threatening situation. High Fowler's position may further reduce
venous return and worsen hypotension in shock states. The client requires definitive
intervention for refractory shock, not supportive measures alone. This option represents
a delay in critical care that could result in death.
Question 2 (SATA – 4 correct): Respiratory – ARDS with Ventilator Management
A 45-year-old client with ARDS secondary to sepsis is intubated and on mechanical
ventilation. Current settings: Volume Control SIMV, TV 400 mL (6 mL/kg IBW), RR 16,
FiO2 0.80, PEEP 12 cm H₂O. Arterial blood gas: pH 7.32, PaCO2 48 mmHg, PaO2 58
mmHg, HCO3 24 mEq/L, SaO2 88%. The nurse is implementing lung-protective
ventilation strategies.
Which interventions are appropriate for this client? Select all that apply.
A. Increase PEEP to 15 cm H₂O to improve oxygenation [CORRECT]
B. Assess for permissive hypercapnia and ensure pH remains ≥ 7.25 [CORRECT]
C. Prepare for prone positioning if PaO2/FiO2 ratio remains < 150 [CORRECT]
D. Increase tidal volume to 550 mL to improve ventilation
E. Administer neuromuscular blocking agents (NMBAs) to prevent ventilator
dyssynchrony [CORRECT]
F. Decrease FiO2 to 0.60 to reduce oxygen toxicity risk
Correct Answer: A, B, C, E
Rationale:
, Option A: Correct. Increasing PEEP is appropriate in ARDS to recruit alveoli, improve
oxygenation, and reduce intrapulmonary shunting. The current PaO2 of 58 mmHg on
80% FiO2 indicates severe hypoxemia (PaO2/FiO2 ratio = 72.5). PEEP titration up to 15
cm H₂O is within lung-protective strategy guidelines (ARDSNet protocol) to achieve
adequate oxygenation while limiting FiO2. The nurse should monitor for hemodynamic
compromise with PEEP increases.
Option B: Correct. Permissive hypercapnia is a standard lung-protective strategy in
ARDS. The current pH of 7.32 with PaCO2 48 is acceptable if hemodynamically
tolerated. The ARDSNet protocol allows pH as low as 7.25-7.30 to minimize
ventilator-induced lung injury from high tidal volumes. The nurse must monitor for
complications (cerebral vasodilation, arrhythmias) but should not increase ventilation to
normalize PaCO2 at the expense of lung protection.
Option C: Correct. Prone positioning is indicated for moderate-to-severe ARDS
(PaO2/FiO2 < 150) to improve V/Q matching, reduce lung compression, and enhance
secretion drainage. The client's ratio of 72.5 meets criteria for proning. The nurse
should prepare for this intervention, ensuring hemodynamic stability and proper
positioning to prevent complications.
Option D: Incorrect. Increasing tidal volume to 550 mL (approximately 8.25 mL/kg for
average adult) violates lung-protective ventilation principles. ARDSNet guidelines
specify 6 mL/kg ideal body weight to prevent volutrauma and barotrauma. Higher tidal
volumes increase mortality in ARDS. The current 400 mL is appropriate; if ventilation is
inadequate, other strategies (increase RR, adjust I:E ratio, prone positioning) should be
used.
Option E: Correct. Neuromuscular blocking agents (cisatracurium, vecuronium) are
indicated in severe ARDS (PaO2/FiO2 < 150) to prevent patient-ventilator dyssynchrony,
reduce oxygen consumption, and facilitate lung-protective ventilation. The nurse must
