, 2026 MED SURG HESI EXAM V1 – NGN STYLE
CASE SCENARIO 1 (Questions 1–8)
Heart Failure Exacerbation – NGN Unfolding
Patient Presentation:
Mrs. E.G., 72 years old, admitted with worsening shortness of breath,
orthopnea, and 3+ pitting edema to the knees. PMH: hypertension,
HFrEF (EF 35%), CKD stage 3. Vital signs: HR 118 (irregular), BP
98/60, RR 28, SpO2 89% on 2L NC. Lungs: crackles bilateral bases.
ECG: atrial fibrillation. BNP 2100 pg/mL.
1. Which assessment finding is the earliest indicator of worsening
heart failure?
• A) Jugular vein distention
• B) Weight gain of 2 kg in 3 days
• C) Peripheral edema
• D) Crackles
Rationale: Daily weight is the most sensitive indicator of fluid
retention. Weight gain precedes visible edema or crackles.
2. Drag and drop (Cloze): The nurse should first
administer oxygenoxygen to maintain SpO2 >90%,
then furosemideIVfurosemideIV for diuresis, and prepare
, for continuousECGmonitoringcontinuousECGmonitoring due to
irregular rhythm.
3. Bowtie Question (NGN):
Place the 1 most likely condition in the center, 2 priority
interventions on the left, and 2 complications on the right.
Interventions Complications
Condition (Center)
(Left) (Right)
Acute decompensated heart failure Acute respirator
IV furosemide
(ADHF) failure
Oxygen therapy Cardiogenic shoc
Rationale: ADHF requires rapid diuresis and oxygenation.
Complications include respiratory failure and worsening low output.
4. The patient’s potassium level is 3.2 mEq/L after two doses of
furosemide. Which action is most appropriate?
• A) Give third dose of furosemide
• B) Hold next furosemide and notify provider for potassium
replacement
• C) Administer digoxin immediately
, • D) Give normal saline bolus
Rationale: Severe hypokalemia (3.2) increases risk of digoxin toxicity
and arrhythmias. Replace potassium before further diuresis.
5. Matrix Question: Indicate whether each finding is consistent
with left-sided HF or right-sided HF.
Finding Left-sided HF Right-sided HF
Crackles Yes No
Jugular vein distention No Yes
Orthopnea Yes No
Peripheral edema No Yes
Hepatomegaly No Yes
6. The patient is started on carvedilol. Which finding would
require holding the medication?
• A) HR 68 bpm
• B) Systolic BP 84 mmHg
• C) RR 20
CASE SCENARIO 1 (Questions 1–8)
Heart Failure Exacerbation – NGN Unfolding
Patient Presentation:
Mrs. E.G., 72 years old, admitted with worsening shortness of breath,
orthopnea, and 3+ pitting edema to the knees. PMH: hypertension,
HFrEF (EF 35%), CKD stage 3. Vital signs: HR 118 (irregular), BP
98/60, RR 28, SpO2 89% on 2L NC. Lungs: crackles bilateral bases.
ECG: atrial fibrillation. BNP 2100 pg/mL.
1. Which assessment finding is the earliest indicator of worsening
heart failure?
• A) Jugular vein distention
• B) Weight gain of 2 kg in 3 days
• C) Peripheral edema
• D) Crackles
Rationale: Daily weight is the most sensitive indicator of fluid
retention. Weight gain precedes visible edema or crackles.
2. Drag and drop (Cloze): The nurse should first
administer oxygenoxygen to maintain SpO2 >90%,
then furosemideIVfurosemideIV for diuresis, and prepare
, for continuousECGmonitoringcontinuousECGmonitoring due to
irregular rhythm.
3. Bowtie Question (NGN):
Place the 1 most likely condition in the center, 2 priority
interventions on the left, and 2 complications on the right.
Interventions Complications
Condition (Center)
(Left) (Right)
Acute decompensated heart failure Acute respirator
IV furosemide
(ADHF) failure
Oxygen therapy Cardiogenic shoc
Rationale: ADHF requires rapid diuresis and oxygenation.
Complications include respiratory failure and worsening low output.
4. The patient’s potassium level is 3.2 mEq/L after two doses of
furosemide. Which action is most appropriate?
• A) Give third dose of furosemide
• B) Hold next furosemide and notify provider for potassium
replacement
• C) Administer digoxin immediately
, • D) Give normal saline bolus
Rationale: Severe hypokalemia (3.2) increases risk of digoxin toxicity
and arrhythmias. Replace potassium before further diuresis.
5. Matrix Question: Indicate whether each finding is consistent
with left-sided HF or right-sided HF.
Finding Left-sided HF Right-sided HF
Crackles Yes No
Jugular vein distention No Yes
Orthopnea Yes No
Peripheral edema No Yes
Hepatomegaly No Yes
6. The patient is started on carvedilol. Which finding would
require holding the medication?
• A) HR 68 bpm
• B) Systolic BP 84 mmHg
• C) RR 20
