HESI MED SURG III FINAL EXAM Actual
Questions and Verified Answers
(2026/2027) Advanced Medical-Surgical
Nursing
Domain 1: Complex Cardiovascular Disorders
Q1: A patient with acute decompensated heart failure (ADHF) has the following
hemodynamic parameters: pulmonary artery pressure (PAP) 48/22 mm Hg, pulmonary
artery wedge pressure (PAWP) 28 mm Hg, cardiac index (CI) 1.9 L/min/m², and
systemic vascular resistance (SVR) 1650 dynes/sec/cm⁻⁵. The patient is receiving
dobutamine at 5 mcg/kg/min. Which adjustment should the nurse anticipate?
A. Increase dobutamine to improve contractility [CORRECT]
B. Add norepinephrine to increase SVR
C. Decrease dobutamine due to risk of arrhythmia
D. Administer a fluid bolus to increase preload
Correct Answer: A
Rationale: The patient presents with low cardiac index (<2.2 L/min/m² indicates low
output) and elevated PAWP (>18 mm Hg indicates volume overload/poor left ventricular
function) consistent with cardiogenic shock secondary to heart failure. Dobutamine is a
positive inotrope that increases contractility and reduces afterload. The current dose is
inadequate to achieve therapeutic CI (>2.2), so increasing the dose is indicated.
Norepinephrine (B) would further increase afterload (SVR is already elevated at 1650,
normal 800-1200), worsening cardiac workload. Fluid bolus (D) is contraindicated with
PAWP 28 mm Hg as it would worsen pulmonary edema.
,Q2: A patient is 4 hours post-cardiac catheterization with stent placement via right
femoral access. The nurse observes an 8 cm hard hematoma at the puncture site with
expanding ecchymosis. The patient complains of severe groin pain and
lightheadedness. Vital signs: BP 88/52 mm Hg, HR 128 bpm, RR 24. Which intervention
is the priority?
A. Apply firm manual pressure 2-3 cm above the puncture site and activate rapid
response [CORRECT]
B. Document the findings and notify the physician within 30 minutes
C. Remove the femoral sheath to release the accumulated blood
D. Apply a sandbag and elevate the head of the bed to 45 degrees
Correct Answer: A
Rationale: Expanding hematoma with hemodynamic instability (hypotension,
tachycardia) indicates active arterial hemorrhage requiring immediate manual pressure
to achieve hemostasis, activation of rapid response team, and preparation for possible
vascular surgery intervention. Femoral artery pseudoaneurysm or retroperitoneal bleed
must be ruled out. Removing the sheath (C) without visualization and surgical backup is
contraindicated and may worsen bleeding. A sandbag (D) provides insufficient pressure
for active hemorrhage.
Q3: A patient with a history of hypertension presents with "tearing" chest pain radiating
to the back. Blood pressure is 198/112 mm Hg in the right arm and 164/98 mm Hg in
the left arm. CT angiography reveals a Stanford Type A aortic dissection. Which
medication should the nurse prepare to administer first?
A. IV nitroglycerin infusion
B. IV esmolol or labetalol to reduce heart rate and blood pressure [CORRECT]
C. IV heparin bolus and infusion
D. Oral aspirin 325 mg
Correct Answer: B
Rationale: The immediate goal in aortic dissection is to reduce shear stress on the
aortic wall by lowering heart rate (<60 bpm) and blood pressure (systolic <120 mm Hg)
using beta-blockade (esmolol, labetalol, or metoprolol) before vasodilators.
Beta-blockers reduce dp/dt (change in pressure over time), preventing propagation of
,the dissection. Nitroglycerin (A) causes reflex tachycardia, increasing shear stress.
Anticoagulation (C) and antiplatelet agents (D) are contraindicated in acute dissection
due to risk of bleeding into the false lumen or pericardium.
Q4: A patient with infective endocarditis (IE) develops acute left-sided weakness and
aphasia. Transesophageal echocardiogram reveals a 12 mm vegetation on the mitral
valve. Which complication has most likely occurred?
A. Valvular rupture with acute regurgitation
B. Septic embolization causing stroke [CORRECT]
C. Myocardial abscess formation
D. Pericardial tamponade
Correct Answer: B
Rationale: Large vegetations (>10 mm) on the mitral valve are high-risk for embolization,
particularly to the cerebral circulation (middle cerebral artery territory causing
contralateral weakness and aphasia). Embolic events occur in 20-50% of IE cases and
are more common with left-sided lesions and larger vegetations. Anticoagulation is
generally avoided in native valve IE due to increased hemorrhagic transformation risk of
septic emboli. Urgent valve surgery may be indicated for large vegetations with
recurrent emboli.
Q5: A patient with an implantable cardioverter-defibrillator (ICD) receives a shock while
ambulating in the hallway. The patient states, "I feel fine now." Which assessment is the
priority?
A. Check the device pocket for signs of infection
B. Obtain a 12-lead ECG and interrogate the device [CORRECT]
C. Apply a magnet over the generator to disable therapy
D. Prepare for immediate external cardioversion
Correct Answer: B
Rationale: Any ICD shock delivery requires immediate evaluation including 12-lead ECG
to assess rhythm, electrolytes, and device interrogation to determine if the shock was
appropriate (ventricular tachycardia/fibrillation) or inappropriate (supraventricular
tachycardia, lead fracture, noise). The patient feeling fine suggests successful
, termination of arrhythmia, but underlying cause (electrolyte imbalance, ischemia, drug
effect) must be identified. Magnet application (C) is reserved for incessant shocks or
during procedures; applying it now would prevent life-saving therapy if needed.
Q6: A patient post-transcatheter aortic valve replacement (TAVR) develops a new-onset
left bundle branch block and intermittent third-degree heart block. Which intervention
should the nurse anticipate?
A. Emergent surgical valve replacement
B. Temporary transvenous pacing and possible permanent pacemaker placement
[CORRECT]
C. Administration of atropine 1 mg IV every 3 minutes
D. Initiation of transcutaneous pacing only
Correct Answer: B
Rationale: Conduction abnormalities occur in 10-30% of TAVR patients due to
mechanical compression of the conduction system by the prosthetic valve.
Third-degree heart block requires temporary transvenous pacing (via femoral or jugular
access) with preparation for permanent pacemaker implantation if block persists
>24-48 hours. Atropine (C) is ineffective for infranodal blocks. Transcutaneous pacing
(D) is temporizing only; transvenous pacing provides more reliable capture for sustained
support.
Q7: A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving
epoprostenol (Flolan) via continuous IV infusion. The nurse notes the medication bag is
empty and the patient reports increased dyspnea and fatigue. Which action is the
priority?
A. Obtain a STAT chest X-ray
B. Prepare a new infusion bag immediately using the same tubing [CORRECT]
C. Administer supplemental oxygen at 10 L/min via non-rebreather
D. Draw blood for BNP and arterial blood gas analysis
Correct Answer: B
Rationale: Epoprostenol has a half-life of 3-5 minutes; interruption of infusion causes
rapid rebound pulmonary hypertension potentially leading to death. The priority is
Questions and Verified Answers
(2026/2027) Advanced Medical-Surgical
Nursing
Domain 1: Complex Cardiovascular Disorders
Q1: A patient with acute decompensated heart failure (ADHF) has the following
hemodynamic parameters: pulmonary artery pressure (PAP) 48/22 mm Hg, pulmonary
artery wedge pressure (PAWP) 28 mm Hg, cardiac index (CI) 1.9 L/min/m², and
systemic vascular resistance (SVR) 1650 dynes/sec/cm⁻⁵. The patient is receiving
dobutamine at 5 mcg/kg/min. Which adjustment should the nurse anticipate?
A. Increase dobutamine to improve contractility [CORRECT]
B. Add norepinephrine to increase SVR
C. Decrease dobutamine due to risk of arrhythmia
D. Administer a fluid bolus to increase preload
Correct Answer: A
Rationale: The patient presents with low cardiac index (<2.2 L/min/m² indicates low
output) and elevated PAWP (>18 mm Hg indicates volume overload/poor left ventricular
function) consistent with cardiogenic shock secondary to heart failure. Dobutamine is a
positive inotrope that increases contractility and reduces afterload. The current dose is
inadequate to achieve therapeutic CI (>2.2), so increasing the dose is indicated.
Norepinephrine (B) would further increase afterload (SVR is already elevated at 1650,
normal 800-1200), worsening cardiac workload. Fluid bolus (D) is contraindicated with
PAWP 28 mm Hg as it would worsen pulmonary edema.
,Q2: A patient is 4 hours post-cardiac catheterization with stent placement via right
femoral access. The nurse observes an 8 cm hard hematoma at the puncture site with
expanding ecchymosis. The patient complains of severe groin pain and
lightheadedness. Vital signs: BP 88/52 mm Hg, HR 128 bpm, RR 24. Which intervention
is the priority?
A. Apply firm manual pressure 2-3 cm above the puncture site and activate rapid
response [CORRECT]
B. Document the findings and notify the physician within 30 minutes
C. Remove the femoral sheath to release the accumulated blood
D. Apply a sandbag and elevate the head of the bed to 45 degrees
Correct Answer: A
Rationale: Expanding hematoma with hemodynamic instability (hypotension,
tachycardia) indicates active arterial hemorrhage requiring immediate manual pressure
to achieve hemostasis, activation of rapid response team, and preparation for possible
vascular surgery intervention. Femoral artery pseudoaneurysm or retroperitoneal bleed
must be ruled out. Removing the sheath (C) without visualization and surgical backup is
contraindicated and may worsen bleeding. A sandbag (D) provides insufficient pressure
for active hemorrhage.
Q3: A patient with a history of hypertension presents with "tearing" chest pain radiating
to the back. Blood pressure is 198/112 mm Hg in the right arm and 164/98 mm Hg in
the left arm. CT angiography reveals a Stanford Type A aortic dissection. Which
medication should the nurse prepare to administer first?
A. IV nitroglycerin infusion
B. IV esmolol or labetalol to reduce heart rate and blood pressure [CORRECT]
C. IV heparin bolus and infusion
D. Oral aspirin 325 mg
Correct Answer: B
Rationale: The immediate goal in aortic dissection is to reduce shear stress on the
aortic wall by lowering heart rate (<60 bpm) and blood pressure (systolic <120 mm Hg)
using beta-blockade (esmolol, labetalol, or metoprolol) before vasodilators.
Beta-blockers reduce dp/dt (change in pressure over time), preventing propagation of
,the dissection. Nitroglycerin (A) causes reflex tachycardia, increasing shear stress.
Anticoagulation (C) and antiplatelet agents (D) are contraindicated in acute dissection
due to risk of bleeding into the false lumen or pericardium.
Q4: A patient with infective endocarditis (IE) develops acute left-sided weakness and
aphasia. Transesophageal echocardiogram reveals a 12 mm vegetation on the mitral
valve. Which complication has most likely occurred?
A. Valvular rupture with acute regurgitation
B. Septic embolization causing stroke [CORRECT]
C. Myocardial abscess formation
D. Pericardial tamponade
Correct Answer: B
Rationale: Large vegetations (>10 mm) on the mitral valve are high-risk for embolization,
particularly to the cerebral circulation (middle cerebral artery territory causing
contralateral weakness and aphasia). Embolic events occur in 20-50% of IE cases and
are more common with left-sided lesions and larger vegetations. Anticoagulation is
generally avoided in native valve IE due to increased hemorrhagic transformation risk of
septic emboli. Urgent valve surgery may be indicated for large vegetations with
recurrent emboli.
Q5: A patient with an implantable cardioverter-defibrillator (ICD) receives a shock while
ambulating in the hallway. The patient states, "I feel fine now." Which assessment is the
priority?
A. Check the device pocket for signs of infection
B. Obtain a 12-lead ECG and interrogate the device [CORRECT]
C. Apply a magnet over the generator to disable therapy
D. Prepare for immediate external cardioversion
Correct Answer: B
Rationale: Any ICD shock delivery requires immediate evaluation including 12-lead ECG
to assess rhythm, electrolytes, and device interrogation to determine if the shock was
appropriate (ventricular tachycardia/fibrillation) or inappropriate (supraventricular
tachycardia, lead fracture, noise). The patient feeling fine suggests successful
, termination of arrhythmia, but underlying cause (electrolyte imbalance, ischemia, drug
effect) must be identified. Magnet application (C) is reserved for incessant shocks or
during procedures; applying it now would prevent life-saving therapy if needed.
Q6: A patient post-transcatheter aortic valve replacement (TAVR) develops a new-onset
left bundle branch block and intermittent third-degree heart block. Which intervention
should the nurse anticipate?
A. Emergent surgical valve replacement
B. Temporary transvenous pacing and possible permanent pacemaker placement
[CORRECT]
C. Administration of atropine 1 mg IV every 3 minutes
D. Initiation of transcutaneous pacing only
Correct Answer: B
Rationale: Conduction abnormalities occur in 10-30% of TAVR patients due to
mechanical compression of the conduction system by the prosthetic valve.
Third-degree heart block requires temporary transvenous pacing (via femoral or jugular
access) with preparation for permanent pacemaker implantation if block persists
>24-48 hours. Atropine (C) is ineffective for infranodal blocks. Transcutaneous pacing
(D) is temporizing only; transvenous pacing provides more reliable capture for sustained
support.
Q7: A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving
epoprostenol (Flolan) via continuous IV infusion. The nurse notes the medication bag is
empty and the patient reports increased dyspnea and fatigue. Which action is the
priority?
A. Obtain a STAT chest X-ray
B. Prepare a new infusion bag immediately using the same tubing [CORRECT]
C. Administer supplemental oxygen at 10 L/min via non-rebreather
D. Draw blood for BNP and arterial blood gas analysis
Correct Answer: B
Rationale: Epoprostenol has a half-life of 3-5 minutes; interruption of infusion causes
rapid rebound pulmonary hypertension potentially leading to death. The priority is
