HESI MED SURG III FINAL EXAM 2026/2027 | Verified Edition
Questions and Answers | Advanced Medical-Surgical
Nursing | Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1-35)
Q1: A 68-year-old patient with end-stage heart failure (NYHA Class IV) is being evaluated for
LVAD placement. Which finding would MOST strongly contraindicate placement of a
continuous-flow LVAD?
A. Left ventricular ejection fraction of 12%
B. Right atrial pressure of 18 mmHg with a cardiac index of 1.6 L/min/m²
C. Presence of moderate aortic insufficiency
D. Serum creatinine of 1.8 mg/dL with BUN of 32 mg/dL
Correct Answer: B
Rationale: Elevated right atrial pressure (>15 mmHg) combined with low cardiac index (<2.0
L/min/m²) indicates right ventricular failure, which is the strongest contraindication for isolated
LVAD placement because the RV cannot tolerate the increased venous return. Option A is
actually an indication for LVAD. Option C (moderate AI) may require concurrent aortic valve
repair but is not an absolute contraindication. Option D represents mild renal dysfunction
common in HF and may improve with LVAD support. HESI pearl: Always assess RV function
before LVAD—the RV is the Achilles' heel of mechanical circulatory support. (AHA/ACC 2026
Mechanical Circulatory Support Guidelines)
Q2: A patient 3 weeks post-orthotopic heart transplant presents with fever, fatigue, and
biopsy-confirmed Grade 2R acute cellular rejection. Which medication regimen should the nurse
anticipate will be initiated FIRST?
A. High-dose methylprednisolone IV pulse therapy
B. Antithymocyte globulin (ATG) infusion
C. Increase in current tacrolimus trough goal to 12-15 ng/mL
D. Methotrexate 15 mg/m² IV weekly
Correct Answer: A
Rationale: Grade 2R (moderate) acute cellular rejection is first-line treated with IV
methylprednisolone pulse therapy (typically 1000 mg/day for 3 days) to rapidly suppress T-cell
,mediated inflammation. Option B (ATG) is reserved for hemodynamically compromising
rejection or steroid-resistant rejection. Option C is inappropriate because simply increasing
tacrolimus takes days to reach steady state and risks toxicity. Option D (methotrexate) is used
for rejection prophylaxis in certain protocols, not acute treatment. HESI pearl: Steroid pulse is
the universal first response for moderate rejection; save the heavy biologics for hemodynamic
compromise. (ISHLT 2026 Guidelines)
Q3: A 72-year-old with an LVAD at home reports the pump alarm is sounding and the pump flow
reading has dropped from 5.2 to 2.8 L/min. The patient is diaphoretic with BP 78/50 mmHg.
What is the FIRST action the nurse should instruct the patient to take?
A. Check the driveline for kinks or disconnection
B. Lie flat with legs elevated and call 911
C. Connect the backup controller and verify power source
D. Administer a 500 mL normal saline bolus at home
Correct Answer: C
Rationale: The priority is ensuring the pump has adequate power and control. Connecting the
backup controller and verifying the power source addresses the most common cause of low flow
alarms (power failure, controller malfunction, or battery depletion). Option A (driveline check) is
important but is a secondary assessment after ensuring the system has power. Option B delays
critical intervention; positioning does not fix a mechanical issue. Option D is unsafe—giving
fluids to a patient with potential pump thrombosis or suction event can worsen the situation.
HESI pearl: Power → Controller → Driveline → Patient—always troubleshoot the LVAD system
before manipulating the patient. (Intermacs 2026 User Manual)
Q4: A patient with advanced heart failure on sacubitril/valsartan, carvedilol, spironolactone, and
furosemide has a potassium level of 5.8 mEq/L with peaked T waves on ECG. Which
medication should the nurse hold FIRST?
A. Sacubitril/valsartan
B. Carvedilol
C. Spironolactone
D. Furosemide
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic that directly contributes to
hyperkalemia and must be held immediately with a potassium of 5.8 mEq/L and ECG changes.
Option A (sacubitril/valsartan) also carries hyperkalemia risk but the ARNI is the foundational HF
,therapy and spironolactone is easier to hold and restart. Option B (carvedilol) does not cause
hyperkalemia. Option D (furosemide) is a potassium-wasting loop diuretic that would actually
help lower potassium and should NOT be held. HESI pearl: When hyperkalemia hits with ECG
changes, the MRA (spironolactone/eplerenone) is the first to hold—it's the most direct
potassium offender and the most expendable of the quadruple therapy. (AHA/ACC 2026 HF
Guidelines)
Q5: A 58-year-old with a HeartMate 3 LVAD presents to the ED with elevated LDH (890 IU/L),
plasma-free hemoglobin of 45 mg/dL, and pump power readings that have increased by 4 watts
over the past week. What is the MOST likely diagnosis?
A. Pump thrombosis
B. Device infection
C. Hemolysis from high shear stress
D. Aortic insufficiency progression
Correct Answer: A
Rationale: The triad of elevated LDH, elevated plasma-free hemoglobin, and rising pump power
is the classic presentation of LVAD pump thrombosis. The increasing power reflects the pump
working harder against a clot. Option B (infection) would present with fever, elevated WBC, and
inflammatory markers, not this laboratory pattern. Option C is a distractor—hemolysis is a
consequence of pump thrombosis, not the primary diagnosis. Option D would show decreasing
pump flow and echocardiographic findings but not the LDH/pHgb pattern. HESI pearl: LDH +
plasma-free hemoglobin + power spikes = pump thrombosis triad. This is a
surgical/anticoagulation emergency. (Intermacs 2026 Data)
Q6: A patient is being considered for heart transplant and undergoes right heart catheterization.
Results: PAP 58/28 mmHg (mean 42), PCWP 22 mmHg, cardiac output 3.8 L/min, PVR 5.3
Wood units. Which intervention is MOST appropriate before listing?
A. Nitroprusside infusion to reduce PVR
B. Milrinone infusion with repeat catheterization
C. Immediate listing with high urgency status
D. Dobutamine stress echocardiography
Correct Answer: B
Rationale: A PVR >5 Wood units is a relative contraindication to heart transplant due to risk of
acute right ventricular failure post-transplant. Milrinone (a PDE-3 inhibitor) reduces PVR through
vasodilation and improves cardiac output through inotropy; repeat cath after milrinone assesses
, PVR reversibility. Option A (nitroprusside) is less ideal because it can cause coronary steal and
requires arterial line monitoring. Option C is incorrect because listing with fixed PVR >5 carries
prohibitive mortality. Option D assesses ischemia, not PVR reversibility. HESI pearl: Transplant
candidacy requires PVR <5 Wood units or demonstrable reversibility—milrinone is the test of
choice. (ISHLT 2026 Listing Criteria)
Q7: [RHYTHM STRIP DESCRIPTION 1] A 62-year-old post-MI patient has a rhythm strip
showing irregular R-R intervals, absence of distinct P waves, undulating fibrillatory baseline
between QRS complexes, and ventricular rate of 142 bpm. Blood pressure is 82/50 mmHg, and
the patient reports severe palpitations and dyspnea. What is the IMMEDIATE priority
intervention?
A. Administer IV diltiazem 0.25 mg/kg over 2 minutes
B. Perform synchronized cardioversion at 120 joules
C. Administer IV amiodarone 150 mg over 10 minutes
D. Apply transcutaneous pacing and initiate at 80 ppm
Correct Answer: B
Rationale: The rhythm is atrial fibrillation with rapid ventricular response (RVR) complicated by
hypotension (82/50 mmHg), which is an unstable rhythm requiring immediate synchronized
cardioversion. Option A (diltiazem) is contraindicated in hypotension—it would further depress
BP. Option C (amiodarone) is appropriate for stable AFib with RVR but too slow for this unstable
presentation. Option D (pacing) is for bradycardia/heart block, not tachyarrhythmias. HESI pearl:
Unstable tachycardia + hypotension = synchronized cardioversion. Always verify the "sync"
button is on to avoid shocking on the T wave. (AHA ACLS 2026)
Q8: [RHYTHM STRIP DESCRIPTION 2] A telemetry nurse observes a rhythm strip showing
regular R-R intervals, rate 38 bpm, narrow QRS complexes, each preceded by a P wave that is
not associated with the QRS (PR interval varies), and more P waves than QRS complexes. The
patient is lightheaded with BP 88/54 mmHg. What is the correct interpretation and action?
A. Second-degree AV Block Type I; administer atropine 0.5 mg IV
B. Second-degree AV Block Type II; prepare for transvenous pacing
C. Third-degree heart block; apply transcutaneous pacing immediately
D. First-degree AV block with sinus bradycardia; observe and monitor
Correct Answer: C
Rationale: The description of complete AV dissociation with more P waves than QRS complexes
and no consistent PR relationship is third-degree (complete) heart block. With hypotension and
symptoms, this is a perfusion emergency requiring immediate transcutaneous pacing. Option A
Questions and Answers | Advanced Medical-Surgical
Nursing | Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1-35)
Q1: A 68-year-old patient with end-stage heart failure (NYHA Class IV) is being evaluated for
LVAD placement. Which finding would MOST strongly contraindicate placement of a
continuous-flow LVAD?
A. Left ventricular ejection fraction of 12%
B. Right atrial pressure of 18 mmHg with a cardiac index of 1.6 L/min/m²
C. Presence of moderate aortic insufficiency
D. Serum creatinine of 1.8 mg/dL with BUN of 32 mg/dL
Correct Answer: B
Rationale: Elevated right atrial pressure (>15 mmHg) combined with low cardiac index (<2.0
L/min/m²) indicates right ventricular failure, which is the strongest contraindication for isolated
LVAD placement because the RV cannot tolerate the increased venous return. Option A is
actually an indication for LVAD. Option C (moderate AI) may require concurrent aortic valve
repair but is not an absolute contraindication. Option D represents mild renal dysfunction
common in HF and may improve with LVAD support. HESI pearl: Always assess RV function
before LVAD—the RV is the Achilles' heel of mechanical circulatory support. (AHA/ACC 2026
Mechanical Circulatory Support Guidelines)
Q2: A patient 3 weeks post-orthotopic heart transplant presents with fever, fatigue, and
biopsy-confirmed Grade 2R acute cellular rejection. Which medication regimen should the nurse
anticipate will be initiated FIRST?
A. High-dose methylprednisolone IV pulse therapy
B. Antithymocyte globulin (ATG) infusion
C. Increase in current tacrolimus trough goal to 12-15 ng/mL
D. Methotrexate 15 mg/m² IV weekly
Correct Answer: A
Rationale: Grade 2R (moderate) acute cellular rejection is first-line treated with IV
methylprednisolone pulse therapy (typically 1000 mg/day for 3 days) to rapidly suppress T-cell
,mediated inflammation. Option B (ATG) is reserved for hemodynamically compromising
rejection or steroid-resistant rejection. Option C is inappropriate because simply increasing
tacrolimus takes days to reach steady state and risks toxicity. Option D (methotrexate) is used
for rejection prophylaxis in certain protocols, not acute treatment. HESI pearl: Steroid pulse is
the universal first response for moderate rejection; save the heavy biologics for hemodynamic
compromise. (ISHLT 2026 Guidelines)
Q3: A 72-year-old with an LVAD at home reports the pump alarm is sounding and the pump flow
reading has dropped from 5.2 to 2.8 L/min. The patient is diaphoretic with BP 78/50 mmHg.
What is the FIRST action the nurse should instruct the patient to take?
A. Check the driveline for kinks or disconnection
B. Lie flat with legs elevated and call 911
C. Connect the backup controller and verify power source
D. Administer a 500 mL normal saline bolus at home
Correct Answer: C
Rationale: The priority is ensuring the pump has adequate power and control. Connecting the
backup controller and verifying the power source addresses the most common cause of low flow
alarms (power failure, controller malfunction, or battery depletion). Option A (driveline check) is
important but is a secondary assessment after ensuring the system has power. Option B delays
critical intervention; positioning does not fix a mechanical issue. Option D is unsafe—giving
fluids to a patient with potential pump thrombosis or suction event can worsen the situation.
HESI pearl: Power → Controller → Driveline → Patient—always troubleshoot the LVAD system
before manipulating the patient. (Intermacs 2026 User Manual)
Q4: A patient with advanced heart failure on sacubitril/valsartan, carvedilol, spironolactone, and
furosemide has a potassium level of 5.8 mEq/L with peaked T waves on ECG. Which
medication should the nurse hold FIRST?
A. Sacubitril/valsartan
B. Carvedilol
C. Spironolactone
D. Furosemide
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic that directly contributes to
hyperkalemia and must be held immediately with a potassium of 5.8 mEq/L and ECG changes.
Option A (sacubitril/valsartan) also carries hyperkalemia risk but the ARNI is the foundational HF
,therapy and spironolactone is easier to hold and restart. Option B (carvedilol) does not cause
hyperkalemia. Option D (furosemide) is a potassium-wasting loop diuretic that would actually
help lower potassium and should NOT be held. HESI pearl: When hyperkalemia hits with ECG
changes, the MRA (spironolactone/eplerenone) is the first to hold—it's the most direct
potassium offender and the most expendable of the quadruple therapy. (AHA/ACC 2026 HF
Guidelines)
Q5: A 58-year-old with a HeartMate 3 LVAD presents to the ED with elevated LDH (890 IU/L),
plasma-free hemoglobin of 45 mg/dL, and pump power readings that have increased by 4 watts
over the past week. What is the MOST likely diagnosis?
A. Pump thrombosis
B. Device infection
C. Hemolysis from high shear stress
D. Aortic insufficiency progression
Correct Answer: A
Rationale: The triad of elevated LDH, elevated plasma-free hemoglobin, and rising pump power
is the classic presentation of LVAD pump thrombosis. The increasing power reflects the pump
working harder against a clot. Option B (infection) would present with fever, elevated WBC, and
inflammatory markers, not this laboratory pattern. Option C is a distractor—hemolysis is a
consequence of pump thrombosis, not the primary diagnosis. Option D would show decreasing
pump flow and echocardiographic findings but not the LDH/pHgb pattern. HESI pearl: LDH +
plasma-free hemoglobin + power spikes = pump thrombosis triad. This is a
surgical/anticoagulation emergency. (Intermacs 2026 Data)
Q6: A patient is being considered for heart transplant and undergoes right heart catheterization.
Results: PAP 58/28 mmHg (mean 42), PCWP 22 mmHg, cardiac output 3.8 L/min, PVR 5.3
Wood units. Which intervention is MOST appropriate before listing?
A. Nitroprusside infusion to reduce PVR
B. Milrinone infusion with repeat catheterization
C. Immediate listing with high urgency status
D. Dobutamine stress echocardiography
Correct Answer: B
Rationale: A PVR >5 Wood units is a relative contraindication to heart transplant due to risk of
acute right ventricular failure post-transplant. Milrinone (a PDE-3 inhibitor) reduces PVR through
vasodilation and improves cardiac output through inotropy; repeat cath after milrinone assesses
, PVR reversibility. Option A (nitroprusside) is less ideal because it can cause coronary steal and
requires arterial line monitoring. Option C is incorrect because listing with fixed PVR >5 carries
prohibitive mortality. Option D assesses ischemia, not PVR reversibility. HESI pearl: Transplant
candidacy requires PVR <5 Wood units or demonstrable reversibility—milrinone is the test of
choice. (ISHLT 2026 Listing Criteria)
Q7: [RHYTHM STRIP DESCRIPTION 1] A 62-year-old post-MI patient has a rhythm strip
showing irregular R-R intervals, absence of distinct P waves, undulating fibrillatory baseline
between QRS complexes, and ventricular rate of 142 bpm. Blood pressure is 82/50 mmHg, and
the patient reports severe palpitations and dyspnea. What is the IMMEDIATE priority
intervention?
A. Administer IV diltiazem 0.25 mg/kg over 2 minutes
B. Perform synchronized cardioversion at 120 joules
C. Administer IV amiodarone 150 mg over 10 minutes
D. Apply transcutaneous pacing and initiate at 80 ppm
Correct Answer: B
Rationale: The rhythm is atrial fibrillation with rapid ventricular response (RVR) complicated by
hypotension (82/50 mmHg), which is an unstable rhythm requiring immediate synchronized
cardioversion. Option A (diltiazem) is contraindicated in hypotension—it would further depress
BP. Option C (amiodarone) is appropriate for stable AFib with RVR but too slow for this unstable
presentation. Option D (pacing) is for bradycardia/heart block, not tachyarrhythmias. HESI pearl:
Unstable tachycardia + hypotension = synchronized cardioversion. Always verify the "sync"
button is on to avoid shocking on the T wave. (AHA ACLS 2026)
Q8: [RHYTHM STRIP DESCRIPTION 2] A telemetry nurse observes a rhythm strip showing
regular R-R intervals, rate 38 bpm, narrow QRS complexes, each preceded by a P wave that is
not associated with the QRS (PR interval varies), and more P waves than QRS complexes. The
patient is lightheaded with BP 88/54 mmHg. What is the correct interpretation and action?
A. Second-degree AV Block Type I; administer atropine 0.5 mg IV
B. Second-degree AV Block Type II; prepare for transvenous pacing
C. Third-degree heart block; apply transcutaneous pacing immediately
D. First-degree AV block with sinus bradycardia; observe and monitor
Correct Answer: C
Rationale: The description of complete AV dissociation with more P waves than QRS complexes
and no consistent PR relationship is third-degree (complete) heart block. With hypotension and
symptoms, this is a perfusion emergency requiring immediate transcutaneous pacing. Option A
