2025/2026 HESI Critical Care Exams
(Versions 1, 2 & 3) | NGN-Style Case
Scenarios | Verified Answers with Rationales
Question 1: A patient in septic shock has a pulmonary artery catheter. Which
finding indicates adequate tissue perfusion?
A) CVP 12 mmHg
B) ScvO2 >70%, lactate <2 mmol/L
C) PAOP 20 mmHg
D) SVR 600 dynes
*Rationale:-- ScvO2 ≥70% reflects balance between oxygen delivery and
consumption. Lactate normalization indicates resolution of anaerobic metabolism.
2025 SCCM guidelines target ScvO2 ≥70% in early goal-directed therapy.*
Question 2: In cardiogenic shock, what does a high PAOP with low CI indicate?
A) Hypovolemia
B) Left ventricular failure
C) Vasodilation
D) Tamponade
*Rationale:-- PAOP >18 mmHg with CI <2.2 L/min/m² is classic for left
ventricular pump failure. Management includes inotropes (dobutamine) or
mechanical circulatory support (Impella, IABP).*
Question 3: What is the priority action when an arterial line waveform shows
overdamping?
A) Increase flush pressure
B) Remove air bubbles, check tubing connections
C) Zero the system
D) Change transducer
,Rationale:-- Overdamping (slow upstroke, loss of dicrotic notch) is often due to air
bubbles, loose connections, or kinked tubing. Fast-flush test confirms. Correcting
these restores waveform fidelity.
Question 4: A patient on intra-aortic balloon pump (IABP) has 1:1 augmentation.
What indicates optimal timing?
A) Diastolic dip
B) Inflation at dicrotic notch, deflation before systole
C) High afterload
D) Early inflation
*Rationale:-- Optimal IABP timing: inflation at the dicrotic notch (aortic valve
closure) to augment diastolic pressure; deflation just before systole to reduce
afterload. 2025 guidelines use auto-timing with R-wave trigger.*
Question 5: What does a square wave on fast-flush testing of an arterial line
indicate?
A) Underdamping
B) Optimal damping coefficient (0.6–0.9)
C) Overdamping
D) Air in line
*Rationale:-- A square wave followed by 1–2 oscillations indicates optimal
dynamic response. Underdamping shows multiple oscillations; overdamping shows
a slurred return. Fast-flush should be performed every shift.*
Question 6: In ARDS, which PiCCO parameter guides fluid management?
A) GEDV >1200 mL/m²
B) EVLWI <7 mL/kg, GEDVI 680–800 mL/m²
C) CI >5
D) SVV >15%
*Rationale:-- Extra-vascular lung water index (EVLWI) <7 mL/kg suggests
minimal pulmonary edema. Global end-diastolic volume index (GEDVI) 680–800
mL/m² indicates adequate preload. Conservative fluid strategy is recommended in
ARDS.*
,Question 7: What is the target MAP in vasopressor-dependent shock?
A) >55 mmHg
B) ≥65 mmHg (≥70–75 if chronic hypertension)
C) >80 mmHg
D) <60 mmHg
Rationale:-- Surviving Sepsis Campaign (2025) recommends initial MAP target
≥65 mmHg. Higher targets (70–75) may be considered for patients with chronic
hypertension to maintain organ perfusion.
Question 8: A patient with systemic vascular resistance (SVR) of 400 dynes has
warm extremities. What is the shock type?
A) Cardiogenic
B) Distributive (vasodilatory)
C) Hypovolemic
D) Obstructive
*Rationale:-- Low SVR (<800 dynes) with warm, vasodilated extremities
indicates distributive shock (septic, anaphylactic, neurogenic). First-line
vasopressor is norepinephrine.*
Question 9: What indicates successful fluid resuscitation in hypovolemic shock?
A) SVV >13%
B) SVV <10%, lactate clearance >10%/hr
C) PAOP >18 mmHg
D) CI <2.2
Rationale:-- Stroke volume variation (SVV) <10% suggests fluid responsiveness
has been achieved. Lactate clearance >10% per hour indicates improved tissue
perfusion. Passive leg raise can also assess fluid responsiveness.
Question 10: In cardiac tamponade, what pressures equalize on pulmonary artery
catheter?
A) PAOP and RAP
, B) RAP = PAOP = PAD (diastolic equalization)
C) CI high
D) SVR low
*Rationale:-- Diastolic equalization (RAP, PA diastolic, PAOP all within 5
mmHg) is a classic finding in tamponade. Pericardiocentesis is the priority
intervention. 2025 guidelines recommend echo-guided drainage.*
Question 11: What is the cardiac output (CO) formula using thermodilution?
A) HR × SV
B) (Tb – Ti) × constant / area under curve
C) MAP – CVP / SVR
D) VO2 / (CaO2 – CvO2)
Rationale:-- Thermodilution CO = (injectate temperature change) integrated over
time. The Stewart-Hamilton equation uses the area under the thermodilution curve.
Three injections are averaged for accuracy.
Question 12: A patient on norepinephrine 0.5 mcg/kg/min has urine output 15
mL/hr. What is the next action?
A) Increase norepinephrine dose
B) Add vasopressin 0.03 units/min, assess lactate
C) Stop infusion
D) Give fluid bolus
*Rationale:-- Persistent oliguria despite norepinephrine suggests vasopressin
deficiency or refractory shock. Adding low-dose vasopressin (0.03 U/min) is
catecholamine-sparing. 2025 ANDROMEDA-SHOCK trial supports this
approach.*
Question 13: What does a narrow pulse pressure with high CVP indicate?
A) Hypovolemia
B) Tamponade or RV failure
C) Vasodilation
D) Hypervolemia
(Versions 1, 2 & 3) | NGN-Style Case
Scenarios | Verified Answers with Rationales
Question 1: A patient in septic shock has a pulmonary artery catheter. Which
finding indicates adequate tissue perfusion?
A) CVP 12 mmHg
B) ScvO2 >70%, lactate <2 mmol/L
C) PAOP 20 mmHg
D) SVR 600 dynes
*Rationale:-- ScvO2 ≥70% reflects balance between oxygen delivery and
consumption. Lactate normalization indicates resolution of anaerobic metabolism.
2025 SCCM guidelines target ScvO2 ≥70% in early goal-directed therapy.*
Question 2: In cardiogenic shock, what does a high PAOP with low CI indicate?
A) Hypovolemia
B) Left ventricular failure
C) Vasodilation
D) Tamponade
*Rationale:-- PAOP >18 mmHg with CI <2.2 L/min/m² is classic for left
ventricular pump failure. Management includes inotropes (dobutamine) or
mechanical circulatory support (Impella, IABP).*
Question 3: What is the priority action when an arterial line waveform shows
overdamping?
A) Increase flush pressure
B) Remove air bubbles, check tubing connections
C) Zero the system
D) Change transducer
,Rationale:-- Overdamping (slow upstroke, loss of dicrotic notch) is often due to air
bubbles, loose connections, or kinked tubing. Fast-flush test confirms. Correcting
these restores waveform fidelity.
Question 4: A patient on intra-aortic balloon pump (IABP) has 1:1 augmentation.
What indicates optimal timing?
A) Diastolic dip
B) Inflation at dicrotic notch, deflation before systole
C) High afterload
D) Early inflation
*Rationale:-- Optimal IABP timing: inflation at the dicrotic notch (aortic valve
closure) to augment diastolic pressure; deflation just before systole to reduce
afterload. 2025 guidelines use auto-timing with R-wave trigger.*
Question 5: What does a square wave on fast-flush testing of an arterial line
indicate?
A) Underdamping
B) Optimal damping coefficient (0.6–0.9)
C) Overdamping
D) Air in line
*Rationale:-- A square wave followed by 1–2 oscillations indicates optimal
dynamic response. Underdamping shows multiple oscillations; overdamping shows
a slurred return. Fast-flush should be performed every shift.*
Question 6: In ARDS, which PiCCO parameter guides fluid management?
A) GEDV >1200 mL/m²
B) EVLWI <7 mL/kg, GEDVI 680–800 mL/m²
C) CI >5
D) SVV >15%
*Rationale:-- Extra-vascular lung water index (EVLWI) <7 mL/kg suggests
minimal pulmonary edema. Global end-diastolic volume index (GEDVI) 680–800
mL/m² indicates adequate preload. Conservative fluid strategy is recommended in
ARDS.*
,Question 7: What is the target MAP in vasopressor-dependent shock?
A) >55 mmHg
B) ≥65 mmHg (≥70–75 if chronic hypertension)
C) >80 mmHg
D) <60 mmHg
Rationale:-- Surviving Sepsis Campaign (2025) recommends initial MAP target
≥65 mmHg. Higher targets (70–75) may be considered for patients with chronic
hypertension to maintain organ perfusion.
Question 8: A patient with systemic vascular resistance (SVR) of 400 dynes has
warm extremities. What is the shock type?
A) Cardiogenic
B) Distributive (vasodilatory)
C) Hypovolemic
D) Obstructive
*Rationale:-- Low SVR (<800 dynes) with warm, vasodilated extremities
indicates distributive shock (septic, anaphylactic, neurogenic). First-line
vasopressor is norepinephrine.*
Question 9: What indicates successful fluid resuscitation in hypovolemic shock?
A) SVV >13%
B) SVV <10%, lactate clearance >10%/hr
C) PAOP >18 mmHg
D) CI <2.2
Rationale:-- Stroke volume variation (SVV) <10% suggests fluid responsiveness
has been achieved. Lactate clearance >10% per hour indicates improved tissue
perfusion. Passive leg raise can also assess fluid responsiveness.
Question 10: In cardiac tamponade, what pressures equalize on pulmonary artery
catheter?
A) PAOP and RAP
, B) RAP = PAOP = PAD (diastolic equalization)
C) CI high
D) SVR low
*Rationale:-- Diastolic equalization (RAP, PA diastolic, PAOP all within 5
mmHg) is a classic finding in tamponade. Pericardiocentesis is the priority
intervention. 2025 guidelines recommend echo-guided drainage.*
Question 11: What is the cardiac output (CO) formula using thermodilution?
A) HR × SV
B) (Tb – Ti) × constant / area under curve
C) MAP – CVP / SVR
D) VO2 / (CaO2 – CvO2)
Rationale:-- Thermodilution CO = (injectate temperature change) integrated over
time. The Stewart-Hamilton equation uses the area under the thermodilution curve.
Three injections are averaged for accuracy.
Question 12: A patient on norepinephrine 0.5 mcg/kg/min has urine output 15
mL/hr. What is the next action?
A) Increase norepinephrine dose
B) Add vasopressin 0.03 units/min, assess lactate
C) Stop infusion
D) Give fluid bolus
*Rationale:-- Persistent oliguria despite norepinephrine suggests vasopressin
deficiency or refractory shock. Adding low-dose vasopressin (0.03 U/min) is
catecholamine-sparing. 2025 ANDROMEDA-SHOCK trial supports this
approach.*
Question 13: What does a narrow pulse pressure with high CVP indicate?
A) Hypovolemia
B) Tamponade or RV failure
C) Vasodilation
D) Hypervolemia
