HESI CRITICAL CARE EX AM W ITH NGN
QUESTIONS
2026 Edition | NCLEX-NGN Aligned | Nursing Exam Questions
Critical Care Registered Nurse & CCRN Preparation
Student Name: ________________________ Date: _______________ Score: _______ / 100
This HESI Critical Care Exam provides 100 multiple-choice questions covering hemodynamic monitoring, all shock
states, ARDS and mechanical ventilation, AKI and CRRT, ACLS 2025-2026 guidelines, acute coronary syndromes,
pulmonary embolism, neurological emergencies, endocrine and electrolyte crises, poisoning and overdose, critical
care pharmacology, nutrition support, IABP, acid-base interpretation, coagulopathy, targeted temperature
management, ethical and end-of-life care, ICU safety, and NGN-style clinical judgment with CJMM integration.
Hem odyn am ic Mon itor in g
1. The nurse is preparing to zero an arterial line transducer. At which anatomical landmark should the
transducer be leveled?
Answer: B. Phlebostatic axis at the fourth intercostal space, mid-axillary line
Rationale: The transducer must be leveled at the phlebostatic axis (fourth intercostal space, mid-axillary line) to
reference pressure measurements to the right atrium. Leveling at any other site introduces hydrostatic error and
produces inaccurate pressure readings.
A) Mid-sternal line at the fourth intercostal space
B) Phlebostatic axis at the fourth intercostal space, mid-axillary line
C) Level of the radial artery insertion site
D) Fifth intercostal space at the left mid-clavicular line
2. A patient has an arterial line in place. The nurse performs a fast-flush (square wave) test and observes
a rapid upstroke, one oscillation above the baseline, a sharp return to baseline, and one oscillation
below. The nurse documents this result as:
Answer: B. Optimally damped waveform with appropriate dynamic response
Rationale: An optimally damped square wave test shows one to two oscillations above and below the baseline
before returning. This indicates the monitoring system has an appropriate frequency response and will accurately
reproduce the arterial pressure waveform.
A) Overdamped waveform indicating air in the tubing
B) Optimally damped waveform with appropriate dynamic response
C) Underdamped waveform suggesting catheter whip artifact
D) Critically damped waveform requiring transducer replacement
3. The nurse notes the arterial waveform on a patient's monitor has a slurred upstroke, loss of the
dicrotic notch, and a systolic pressure that reads 88 mmHg while the non-invasive BP cuff reads 128/74
mmHg. Which action should the nurse take first?
Answer: B. Check for air bubbles, clots, or kinks in the tubing and aspirate/flush the line
,Rationale: These findings indicate overdamping, which most commonly results from air bubbles, partial catheter
occlusion by thrombus, or tubing kinks. The first action is to troubleshoot the system by aspirating and flushing the
catheter and inspecting the tubing. falsely lowers systolic and elevates diastolic readings.
A) Withdraw the arterial catheter by 1–2 cm
B) Check for air bubbles, clots, or kinks in the tubing and aspirate/flush the line
C) Replace the transducer with a new disposable set
D) Reposition the patient's arm to the level of the heart
4. A patient's central venous pressure (CVP) reading is 12 mmHg. The nurse assesses jugular venous
distention, bilateral crackles, and an S3 gallop. Which hemodynamic interpretation is most consistent
with these findings?
Answer: B. Fluid overload with increased right ventricular preload
Rationale: Normal CVP is 2–8 mmHg. A CVP of 12 mmHg with JVD, crackles, and S3 gallop indicates volume
overload and elevated right atrial pressure (increased preload). While other conditions can elevate CVP, the
combination of crackles and S3 suggests biventricular failure from fluid overload.
A) Hypovolemia with decreased preload
B) Fluid overload with increased right ventricular preload
C) Cardiac tamponade with equalized diastolic pressures
D) Cor pulmonale with isolated right-sided failure
5. While inserting a central venous catheter into the right internal jugular vein, the patient suddenly
complains of sharp chest pain and dyspnea. Breath sounds are absent on the right side. The nurse should
immediately prepare for which intervention?
Answer: C. Chest tube insertion at the fifth intercostal space, mid-axillary line
Rationale: Absent breath sounds on the right after central line insertion indicate a pneumothorax, the most common
mechanical complication of central venous catheter placement. A chest tube at the fifth intercostal space, mid-
axillary line (triangle of safety) is the definitive treatment for a significant pneumothorax.
A) Air embolism protocol — place patient in left lateral decubitus with head down
B) Needle thoracostomy at the second intercostal space, mid-clavicular line
C) Chest tube insertion at the fifth intercostal space, mid-axillary line
D) Administration of 100% oxygen via non-rebreather mask only
6. The nurse is analyzing a CVP waveform and identifies a large positive deflection that occurs just before
the 'c' wave, coinciding with the P wave on the ECG. This wave is most prominent in which condition?
Answer: C. Right atrial hypertrophy
Rationale: The 'a' wave represents atrial contraction and occurs just after the P wave. Large 'a' waves (cannon a
waves) can occur in atrial hypertrophy or AV dissociation, but a consistently prominent a wave with each P wave is
characteristic of right atrial hypertrophy or decreased right ventricular compliance. Cannon a waves occurring
irregularly suggest AV dissociation.
A) Tricuspid regurgitation
B) Atrial fibrillation
C) Right atrial hypertrophy
, D) Complete heart block
7. A pulmonary artery catheter (Swan-Ganz) is floated and the bedside monitor shows the following
progression: RA waveform → RV waveform → PA waveform → PAWP waveform obtained when the
balloon is inflated. The PAWP reading is 28 mmHg. Which condition does this value most strongly
suggest?
Answer: B. Left ventricular failure with pulmonary congestion
Rationale: Normal PAWP (also called PCWP) is 6–12 mmHg and reflects left ventricular preload. A PAWP of 28
mmHg is markedly elevated and indicates increased left atrial and left ventricular end-diastolic pressure, consistent
with left ventricular failure and pulmonary congestion. In ARDS, PAWP is typically normal (<18 mmHg).
A) Acute respiratory distress syndrome (ARDS)
B) Left ventricular failure with pulmonary congestion
C) Hypovolemic shock
D) Pulmonary embolism
8. The nurse is calculating systemic vascular resistance (SVR) for a patient. The hemodynamic parameters
are: MAP 70 mmHg, CVP 8 mmHg, cardiac output (CO) 4.5 L/min. Which SVR value is correct? (Formula:
SVR = [MAP − CVP] / CO × 80)
Answer: B. 1,104 dynes·sec/cm⁵
Rationale: SVR = [(70 − 8) / 4.5] × 80 = (.5) × 80 = 13.78 × 80 = 1,102 dynes·sec/cm⁵. The closest value is 1,104.
Normal SVR is 800–1,200 dynes·sec/cm⁵, so this value falls within the normal range, suggesting appropriate
afterload.
A) 704 dynes·sec/cm⁵
B) 1,104 dynes·sec/cm⁵
C) 1,244 dynes·sec/cm⁵
D) 1,377 dynes·sec/cm⁵
9. A patient with a pulmonary artery catheter has a cardiac output of 3.2 L/min, a heart rate of 108 bpm,
and a body surface area of 1.9 m². What is the patient's cardiac index, and what does it indicate?
Answer: A. 1.68 L/min/m² — indicating low output and potential cardiogenic shock
Rationale: Cardiac index (CI) = CO / BSA = 3..9 = 1.68 L/min/m². Normal CI is 2.5–4.0 L/min/m². A CI below 2.2
L/min/m² indicates decreased cardiac output. A CI below 2.0 L/min/m² is consistent with cardiogenic shock and
warrants immediate intervention.
A) 1.68 L/min/m² — indicating low output and potential cardiogenic shock
B) 2.96 L/min/m² — within normal limits
C) 1.68 L/min/m² — within normal limits for a critically ill patient
D) 3.82 L/min/m² — indicating hyperdynamic circulatory state
10. A patient is being monitored with non-invasive cardiac output monitoring (NICOM) via bioreactance.
The nurse understands that which statement about NICOM is correct?
Answer: B. NICOM measures changes in thoracic bioimpedance to calculate stroke volume
continuously
, Rationale: NICOM uses bioreactance technology to analyze changes in thoracic bioimpedance (frequency shifts of an
applied alternating current across the chest) to continuously calculate stroke volume and cardiac output. It is non-
invasive, does not require catheter calibration, and provides beat-to-beat trending, though it may be less accurate
than thermodilution in certain conditions.
A) NICOM requires placement of a pulmonary artery catheter for calibration
B) NICOM measures changes in thoracic bioimpedance to calculate stroke volume continuously
C) NICOM is more accurate than thermodilution for cardiac output measurement in patients with
severe aortic regurgitation
D) NICOM directly measures left atrial pressure through transthoracic electrical signals
Sh ock States — H ypovolem ic & Car diogen ic
11. A patient arrives to the ED after a motor vehicle crash with estimated blood loss of 1,500 mL. Blood
pressure is 108/78 mmHg (baseline 130/82), heart rate is 112 bpm, respiratory rate is 24, and skin is cool
and pale. Urine output is 30 mL/hr. The nurse identifies that this patient is in which stage of hypovolemic
shock?
Answer: B. Class II — mild, 15–30% blood volume loss (750–1,500 mL)
Rationale: With 1,500 mL blood loss (approximately 30% of blood volume in a 70 kg adult), tachycardia, narrowed
pulse pressure (30 mmHg), and cool/pale skin, this patient is in Class II hypovolemic shock. BP is maintained through
compensatory vasoconstriction and tachycardia. Class III would show a more significant drop in BP and decreased
urine output below 20 mL/hr.
A) Class I — compensated, <15% blood volume loss
B) Class II — mild, 15–30% blood volume loss (750–1,500 mL)
C) Class III — moderate, 30–40% blood volume loss (1,500–2,000 mL)
D) Class IV — severe, >40% blood volume loss (>2,000 mL)
12. A patient in hypovolemic shock has a blood pressure of 78/50 mmHg, heart rate of 136 bpm, capillary
refill of 5 seconds, and urine output of 10 mL over the past hour. The nurse anticipates which priority
intervention?
Answer: C. Rapid infusion of 1–2 L lactated Ringer's over 15–20 minutes via large-bore IV
Rationale: This patient is in Class III/IV hypovolemic shock with signs of inadequate perfusion. The priority
intervention is aggressive volume resuscitation with isotonic crystalloids (lactated Ringer's or 0.9% normal saline)
administered rapidly through two large-bore IVs (16-gauge or larger). Vasopressors are not first-line without
adequate volume resuscitation.
A) Administration of albumin 25% for oncotic pressure support
B) Initiation of a norepinephrine infusion at 0.05 mcg/kg/min
C) Rapid infusion of 1–2 L lactated Ringer's over 15–20 minutes via large-bore IV
D) Placement of a pulmonary artery catheter for hemodynamic optimization
13. After a patient with hemorrhagic shock receives 3 L of lactated Ringer's, the blood pressure remains
82/54 mmHg and the hematocrit drops to 18%. Which blood product should the nurse prepare to
administer next?
Answer: A. Packed red blood cells (pRBCs)
QUESTIONS
2026 Edition | NCLEX-NGN Aligned | Nursing Exam Questions
Critical Care Registered Nurse & CCRN Preparation
Student Name: ________________________ Date: _______________ Score: _______ / 100
This HESI Critical Care Exam provides 100 multiple-choice questions covering hemodynamic monitoring, all shock
states, ARDS and mechanical ventilation, AKI and CRRT, ACLS 2025-2026 guidelines, acute coronary syndromes,
pulmonary embolism, neurological emergencies, endocrine and electrolyte crises, poisoning and overdose, critical
care pharmacology, nutrition support, IABP, acid-base interpretation, coagulopathy, targeted temperature
management, ethical and end-of-life care, ICU safety, and NGN-style clinical judgment with CJMM integration.
Hem odyn am ic Mon itor in g
1. The nurse is preparing to zero an arterial line transducer. At which anatomical landmark should the
transducer be leveled?
Answer: B. Phlebostatic axis at the fourth intercostal space, mid-axillary line
Rationale: The transducer must be leveled at the phlebostatic axis (fourth intercostal space, mid-axillary line) to
reference pressure measurements to the right atrium. Leveling at any other site introduces hydrostatic error and
produces inaccurate pressure readings.
A) Mid-sternal line at the fourth intercostal space
B) Phlebostatic axis at the fourth intercostal space, mid-axillary line
C) Level of the radial artery insertion site
D) Fifth intercostal space at the left mid-clavicular line
2. A patient has an arterial line in place. The nurse performs a fast-flush (square wave) test and observes
a rapid upstroke, one oscillation above the baseline, a sharp return to baseline, and one oscillation
below. The nurse documents this result as:
Answer: B. Optimally damped waveform with appropriate dynamic response
Rationale: An optimally damped square wave test shows one to two oscillations above and below the baseline
before returning. This indicates the monitoring system has an appropriate frequency response and will accurately
reproduce the arterial pressure waveform.
A) Overdamped waveform indicating air in the tubing
B) Optimally damped waveform with appropriate dynamic response
C) Underdamped waveform suggesting catheter whip artifact
D) Critically damped waveform requiring transducer replacement
3. The nurse notes the arterial waveform on a patient's monitor has a slurred upstroke, loss of the
dicrotic notch, and a systolic pressure that reads 88 mmHg while the non-invasive BP cuff reads 128/74
mmHg. Which action should the nurse take first?
Answer: B. Check for air bubbles, clots, or kinks in the tubing and aspirate/flush the line
,Rationale: These findings indicate overdamping, which most commonly results from air bubbles, partial catheter
occlusion by thrombus, or tubing kinks. The first action is to troubleshoot the system by aspirating and flushing the
catheter and inspecting the tubing. falsely lowers systolic and elevates diastolic readings.
A) Withdraw the arterial catheter by 1–2 cm
B) Check for air bubbles, clots, or kinks in the tubing and aspirate/flush the line
C) Replace the transducer with a new disposable set
D) Reposition the patient's arm to the level of the heart
4. A patient's central venous pressure (CVP) reading is 12 mmHg. The nurse assesses jugular venous
distention, bilateral crackles, and an S3 gallop. Which hemodynamic interpretation is most consistent
with these findings?
Answer: B. Fluid overload with increased right ventricular preload
Rationale: Normal CVP is 2–8 mmHg. A CVP of 12 mmHg with JVD, crackles, and S3 gallop indicates volume
overload and elevated right atrial pressure (increased preload). While other conditions can elevate CVP, the
combination of crackles and S3 suggests biventricular failure from fluid overload.
A) Hypovolemia with decreased preload
B) Fluid overload with increased right ventricular preload
C) Cardiac tamponade with equalized diastolic pressures
D) Cor pulmonale with isolated right-sided failure
5. While inserting a central venous catheter into the right internal jugular vein, the patient suddenly
complains of sharp chest pain and dyspnea. Breath sounds are absent on the right side. The nurse should
immediately prepare for which intervention?
Answer: C. Chest tube insertion at the fifth intercostal space, mid-axillary line
Rationale: Absent breath sounds on the right after central line insertion indicate a pneumothorax, the most common
mechanical complication of central venous catheter placement. A chest tube at the fifth intercostal space, mid-
axillary line (triangle of safety) is the definitive treatment for a significant pneumothorax.
A) Air embolism protocol — place patient in left lateral decubitus with head down
B) Needle thoracostomy at the second intercostal space, mid-clavicular line
C) Chest tube insertion at the fifth intercostal space, mid-axillary line
D) Administration of 100% oxygen via non-rebreather mask only
6. The nurse is analyzing a CVP waveform and identifies a large positive deflection that occurs just before
the 'c' wave, coinciding with the P wave on the ECG. This wave is most prominent in which condition?
Answer: C. Right atrial hypertrophy
Rationale: The 'a' wave represents atrial contraction and occurs just after the P wave. Large 'a' waves (cannon a
waves) can occur in atrial hypertrophy or AV dissociation, but a consistently prominent a wave with each P wave is
characteristic of right atrial hypertrophy or decreased right ventricular compliance. Cannon a waves occurring
irregularly suggest AV dissociation.
A) Tricuspid regurgitation
B) Atrial fibrillation
C) Right atrial hypertrophy
, D) Complete heart block
7. A pulmonary artery catheter (Swan-Ganz) is floated and the bedside monitor shows the following
progression: RA waveform → RV waveform → PA waveform → PAWP waveform obtained when the
balloon is inflated. The PAWP reading is 28 mmHg. Which condition does this value most strongly
suggest?
Answer: B. Left ventricular failure with pulmonary congestion
Rationale: Normal PAWP (also called PCWP) is 6–12 mmHg and reflects left ventricular preload. A PAWP of 28
mmHg is markedly elevated and indicates increased left atrial and left ventricular end-diastolic pressure, consistent
with left ventricular failure and pulmonary congestion. In ARDS, PAWP is typically normal (<18 mmHg).
A) Acute respiratory distress syndrome (ARDS)
B) Left ventricular failure with pulmonary congestion
C) Hypovolemic shock
D) Pulmonary embolism
8. The nurse is calculating systemic vascular resistance (SVR) for a patient. The hemodynamic parameters
are: MAP 70 mmHg, CVP 8 mmHg, cardiac output (CO) 4.5 L/min. Which SVR value is correct? (Formula:
SVR = [MAP − CVP] / CO × 80)
Answer: B. 1,104 dynes·sec/cm⁵
Rationale: SVR = [(70 − 8) / 4.5] × 80 = (.5) × 80 = 13.78 × 80 = 1,102 dynes·sec/cm⁵. The closest value is 1,104.
Normal SVR is 800–1,200 dynes·sec/cm⁵, so this value falls within the normal range, suggesting appropriate
afterload.
A) 704 dynes·sec/cm⁵
B) 1,104 dynes·sec/cm⁵
C) 1,244 dynes·sec/cm⁵
D) 1,377 dynes·sec/cm⁵
9. A patient with a pulmonary artery catheter has a cardiac output of 3.2 L/min, a heart rate of 108 bpm,
and a body surface area of 1.9 m². What is the patient's cardiac index, and what does it indicate?
Answer: A. 1.68 L/min/m² — indicating low output and potential cardiogenic shock
Rationale: Cardiac index (CI) = CO / BSA = 3..9 = 1.68 L/min/m². Normal CI is 2.5–4.0 L/min/m². A CI below 2.2
L/min/m² indicates decreased cardiac output. A CI below 2.0 L/min/m² is consistent with cardiogenic shock and
warrants immediate intervention.
A) 1.68 L/min/m² — indicating low output and potential cardiogenic shock
B) 2.96 L/min/m² — within normal limits
C) 1.68 L/min/m² — within normal limits for a critically ill patient
D) 3.82 L/min/m² — indicating hyperdynamic circulatory state
10. A patient is being monitored with non-invasive cardiac output monitoring (NICOM) via bioreactance.
The nurse understands that which statement about NICOM is correct?
Answer: B. NICOM measures changes in thoracic bioimpedance to calculate stroke volume
continuously
, Rationale: NICOM uses bioreactance technology to analyze changes in thoracic bioimpedance (frequency shifts of an
applied alternating current across the chest) to continuously calculate stroke volume and cardiac output. It is non-
invasive, does not require catheter calibration, and provides beat-to-beat trending, though it may be less accurate
than thermodilution in certain conditions.
A) NICOM requires placement of a pulmonary artery catheter for calibration
B) NICOM measures changes in thoracic bioimpedance to calculate stroke volume continuously
C) NICOM is more accurate than thermodilution for cardiac output measurement in patients with
severe aortic regurgitation
D) NICOM directly measures left atrial pressure through transthoracic electrical signals
Sh ock States — H ypovolem ic & Car diogen ic
11. A patient arrives to the ED after a motor vehicle crash with estimated blood loss of 1,500 mL. Blood
pressure is 108/78 mmHg (baseline 130/82), heart rate is 112 bpm, respiratory rate is 24, and skin is cool
and pale. Urine output is 30 mL/hr. The nurse identifies that this patient is in which stage of hypovolemic
shock?
Answer: B. Class II — mild, 15–30% blood volume loss (750–1,500 mL)
Rationale: With 1,500 mL blood loss (approximately 30% of blood volume in a 70 kg adult), tachycardia, narrowed
pulse pressure (30 mmHg), and cool/pale skin, this patient is in Class II hypovolemic shock. BP is maintained through
compensatory vasoconstriction and tachycardia. Class III would show a more significant drop in BP and decreased
urine output below 20 mL/hr.
A) Class I — compensated, <15% blood volume loss
B) Class II — mild, 15–30% blood volume loss (750–1,500 mL)
C) Class III — moderate, 30–40% blood volume loss (1,500–2,000 mL)
D) Class IV — severe, >40% blood volume loss (>2,000 mL)
12. A patient in hypovolemic shock has a blood pressure of 78/50 mmHg, heart rate of 136 bpm, capillary
refill of 5 seconds, and urine output of 10 mL over the past hour. The nurse anticipates which priority
intervention?
Answer: C. Rapid infusion of 1–2 L lactated Ringer's over 15–20 minutes via large-bore IV
Rationale: This patient is in Class III/IV hypovolemic shock with signs of inadequate perfusion. The priority
intervention is aggressive volume resuscitation with isotonic crystalloids (lactated Ringer's or 0.9% normal saline)
administered rapidly through two large-bore IVs (16-gauge or larger). Vasopressors are not first-line without
adequate volume resuscitation.
A) Administration of albumin 25% for oncotic pressure support
B) Initiation of a norepinephrine infusion at 0.05 mcg/kg/min
C) Rapid infusion of 1–2 L lactated Ringer's over 15–20 minutes via large-bore IV
D) Placement of a pulmonary artery catheter for hemodynamic optimization
13. After a patient with hemorrhagic shock receives 3 L of lactated Ringer's, the blood pressure remains
82/54 mmHg and the hematocrit drops to 18%. Which blood product should the nurse prepare to
administer next?
Answer: A. Packed red blood cells (pRBCs)
