NIGHTINGALE COLLEGE BSN
HESI 266 Medical-Surgical Nursing
Comprehensive Study Guide
2026/2027 Edition | 300 Verified Questions | 100% Correct Solutions
Aligned with NGN Standards, NCSBN CJMM, and HESI Exit Exam Format
Bachelor of Science in Nursing Program
,Cardiovascular Nursing
Questions 1–20 (20 items)
1. A 62-year-old man returns from the PACU following a three-vessel coronary artery bypass graft
(CABG). The nurse notes 200 mL of serosanguineous drainage in the chest tube collection
chamber during the first hour. Which finding requires immediate notification of the surgeon?
A. 200 mL of serosanguineous drainage in the first hour
B. 150 mL of bloody drainage per hour for two consecutive hours
C. Intermittent bubbling in the water seal chamber with coughing
D. Fluctuation of the fluid level in the water seal with respiration
✓ Correct: B. 150 mL of bloody drainage per hour for two consecutive hours
Rationale: Chest tube drainage exceeding 150 mL/hr for two or more consecutive hours is considered
excessive and may indicate active postoperative hemorrhage, requiring immediate surgical evaluation.
Expected drainage after CABG is typically less than 100 mL/hr in the first several hours and should
progressively decrease. Serosanguineous drainage of 200 mL in the first hour (A) is within acceptable
limits initially. Intermittent bubbling with coughing (C) is normal and represents air expulsion from the
pleural space. Tidaling or fluctuation (D) indicates the system is patent and communicating with the
pleural space. The nurse should also assess for signs of hypovolemia such as tachycardia, hypotension, and
decreased urine output. (Ignatavicius & Workman, Ch. 35; HESI RN Review Module, Cardiovascular
System)
2. A 58-year-old woman with chronic heart failure reports increasing dyspnea on exertion and a 5-
pound weight gain over the past week. The nurse assesses bilateral crackles in the lung bases,
jugular venous distension at 6 cm above the sternal angle, and 2+ pitting edema in both lower
extremities. Which pathophysiologic mechanism best explains these findings?
A. Decreased preload causing reduced renal perfusion and oliguria
B. Activation of the renin-angiotensin-aldosterone system (RAAS) causing sodium and water retention
C. Increased cardiac output leading to volume depletion and thirst
D. Excessive diuretic therapy causing prerenal azotemia and dehydration
✓ Correct: B. Activation of the renin-angiotensin-aldosterone system (RAAS) causing sodium
and water retention
Rationale: Heart failure triggers RAAS activation due to decreased renal perfusion from reduced cardiac
output. Angiotensin II promotes sodium and water retention, aldosterone increases sodium reabsorption,
and antidiuretic hormone release exacerbates fluid retention. This results in hypervolemia, manifesting as
JVD, pulmonary crackles from fluid transudation into alveoli, and peripheral edema. Weight gain reflects
total body fluid excess. Decreased preload (A) would cause decreased venous return, not fluid overload.
Increased cardiac output (C) is the opposite of heart failure pathophysiology. Diuretic excess (D) would
cause dehydration with weight loss, not weight gain and edema. Monitoring daily weights is the most
reliable indicator of fluid balance. (Lewis et al., Ch. 30; HESI RN Review Module, Cardiovascular System)
3. A 70-year-old man arrives in the emergency department with substernal chest pressure that
began 2 hours ago, radiating to the left arm and jaw. He is diaphoretic with nausea. The 12-lead
ECG shows ST-segment elevation in leads II, III, and aVF. Initial troponin I is 0.4 ng/mL
(reference < 0.04). What is the nurse's priority action?
A. Administer prescribed aspirin 325 mg chewed and obtain IV access
B. Wait for a second troponin level in 6 hours before initiating treatment
C. Encourage the patient to walk to the bathroom to obtain a urine specimen
D. Apply warm compresses to the chest to relieve muscle discomfort
✓ Correct: A. Administer prescribed aspirin 325 mg chewed and obtain IV access
2
, Rationale: This patient is presenting with an acute ST-elevation myocardial infarction (STEMI) of the
inferior wall. Troponin I is a highly specific cardiac biomarker that rises within 2-4 hours of myocardial
injury; a level of 0.4 ng/mL confirms myocardial cell damage. The priority nursing action is to administer
aspirin (antiplatelet effect inhibits thromboxane A2) and establish IV access for medication administration,
per the MONA (morphine, oxygen, nitroglycerin, aspirin) protocol and current ACLS guidelines. Waiting
for a second troponin (B) delays reperfusion therapy, which is time-critical. Having the patient walk (C)
increases myocardial oxygen demand and risks cardiac arrest. Warm compresses (D) are inappropriate
for ischemic chest pain. Reperfusion therapy (PCI or fibrinolytics) should be initiated within door-to-
balloon time of 90 minutes. (Ignatavicius & Workman, Ch. 34; HESI RN Review Module, Cardiovascular
System)
4. A 66-year-old woman newly diagnosed with atrial fibrillation is prescribed warfarin
(Coumadin). The nurse provides discharge teaching about anticoagulation therapy. Which
statement by the patient indicates a need for further education?
A. "I should have my blood drawn regularly to check my INR level."
B. "I will use a soft-bristled toothbrush and an electric razor."
C. "I can take aspirin or ibuprofen whenever I have a headache."
D. "I should eat consistent amounts of foods containing vitamin K."
✓ Correct: C. "I can take aspirin or ibuprofen whenever I have a headache."
Rationale: Warfarin is a vitamin K antagonist that impairs synthesis of clotting factors II, VII, IX, and X.
Taking NSAIDs such as aspirin or ibuprofen concurrently increases bleeding risk through additive
antiplatelet effects and gastric mucosal irritation. Patients on warfarin should avoid NSAIDs and use
acetaminophen for mild pain instead. Regular INR monitoring (A) is essential; the therapeutic range for
atrial fibrillation is typically 2.0-3.0. Using a soft toothbrush and electric razor (B) reduces bleeding risk.
Consistent vitamin K intake (D) prevents fluctuations in warfarin efficacy, as vitamin K-rich foods (dark
leafy greens, broccoli) can counteract warfarin's effect. The patient should also be taught to report signs of
bleeding such as bruising, melena, hematuria, and prolonged bleeding from minor cuts. (Lewis et al., Ch.
31; HESI RN Review Module, Cardiovascular System)
5. A 55-year-old man suddenly collapses in the cardiac telemetry unit. The monitor shows a
chaotic, irregular waveform with no discernible P waves, QRS complexes, or T waves. The patient
is unresponsive, and no pulses are palpable. What is the nurse's immediate intervention?
A. Begin CPR and administer epinephrine 1 mg IV every 3-5 minutes
B. Defibrillate immediately with 200 joules biphasic and resume CPR
C. Administer amiodarone 300 mg IV bolus and prepare for cardioversion
D. Perform carotid sinus massage to attempt to restore normal rhythm
✓ Correct: B. Defibrillate immediately with 200 joules biphasic and resume CPR
Rationale: The described rhythm is ventricular fibrillation (VF), a lethal dysrhythmia causing ineffective
quivering of the ventricles with no cardiac output. VF is a shockable rhythm per ACLS guidelines. The
immediate intervention is defibrillation to depolarize the entire myocardium simultaneously, allowing the
natural pacemaker to resume an organized rhythm. Defibrillation should be delivered as soon as possible,
with CPR resumed immediately after the shock. Epinephrine (A) is given after the first defibrillation
attempt if VF persists, not as the initial action. Amiodarone (C) is a second-line antiarrhythmic for
refractory VF/pulseless VT after epinephrine. Carotid sinus massage (D) is used for supraventricular
tachycardia, not VF, and is contraindicated in pulseless patients. Time to defibrillation is the most critical
determinant of survival; each minute delay decreases survival by 7-10%. (Ignatavicius & Workman, Ch.
34; AHA ACLS Guidelines; HESI RN Review Module, Cardiovascular System)
6. A 72-year-old woman is admitted for total knee arthroplasty. The surgeon orders sequential
compression devices (SCDs) as DVT prophylaxis. Which nursing action is most appropriate
regarding SCD application?
3
, A. Remove the SCDs during sleep to promote patient comfort and rest
B. Apply the SCDs over the patient's clothing for easier removal during ambulation
C. Ensure proper fit with the device snug on the lower leg from ankle to below the knee
D. Place the SCDs on the unaffected leg only to protect the surgical site
✓ Correct: C. Ensure proper fit with the device snug on the lower leg from ankle to below the
knee
Rationale: SCDs should be applied snugly on the lower extremity from the ankle to below the knee to
promote venous return through intermittent pneumatic compression, reducing stasis and DVT risk. A
proper fit ensures effective graduated compression. Removing SCDs during sleep (A) is incorrect; they
should remain on continuously except during ambulation or bathing. Applying over clothing (B) reduces
compression effectiveness and is improper technique. Applying to only the unaffected leg (D) provides
incomplete prophylaxis, as the surgical leg is at highest risk for DVT due to immobility, vessel injury, and
hypercoagulability (Virchow triad). The nurse should assess skin integrity, neurovascular status, and
device function hourly. Additional DVT prophylaxis may include subcutaneous enoxaparin (Lovenox) and
early ambulation. (Lewis et al., Ch. 32; HESI RN Review Module, Cardiovascular System)
7. A 45-year-old woman who is 5 days postpartum suddenly develops severe dyspnea, sharp
pleuritic chest pain, and tachycardia. Oxygen saturation is 88% on room air. She appears anxious
and diaphoretic. Which condition should the nurse suspect, and what is the likely underlying
cause?
A. Myocardial infarction secondary to coronary artery spasm
B. Pulmonary embolism from deep vein thrombosis in the lower extremity
C. Pneumothorax from ruptured blebs in the lung parenchyma
D. Aspiration pneumonia from gastroesophageal reflux during labor
✓ Correct: B. Pulmonary embolism from deep vein thrombosis in the lower extremity
Rationale: This patient's presentation is classic for pulmonary embolism (PE), with the triad of dyspnea,
pleuritic chest pain, and tachycardia. Postpartum women are at high risk for DVT and PE due to venous
stasis, pelvic vessel compression during pregnancy, hypercoagulable state (increased fibrinogen and
clotting factors), and decreased mobility. The pleuritic chest pain (worsens with inspiration) results from
pulmonary infarction and inflammation of the pleura. MI (A) is less likely in a young postpartum woman
without cardiac risk factors and would typically present with substernal pressure. Spontaneous
pneumothorax (C) causes sudden dyspnea and pleuritic pain but is not associated with the postpartum
period. Aspiration pneumonia (D) typically presents with fever and productive cough over hours to days,
not sudden onset. The nurse should immediately initiate oxygen, elevate the head of bed, and prepare for
CT pulmonary angiography and anticoagulation. (Ignatavicius & Workman, Ch. 34; HESI RN Review
Module, Cardiovascular System)
8. A 52-year-old man with a history of hypertension presents to the emergency department with a
blood pressure of 210/130 mmHg, severe occipital headache, blurred vision, and confusion. He
reports epistaxis earlier in the day. Which assessment finding would best indicate end-organ
damage requiring immediate intervention?
A. Heart rate of 98 beats/minute with regular rhythm
B. Complaint of mild bilateral ankle edema at the end of the day
C. New-onset slurred speech and right-sided facial droop
D. Blood glucose level of 142 mg/dL on random sampling
✓ Correct: C. New-onset slurred speech and right-sided facial droop
Rationale: This patient is in hypertensive crisis with BP 210/130 mmHg. The presence of neurological
changes (confusion) with severe headache and visual disturbances suggests hypertensive emergency with
end-organ damage. New-onset slurred speech and facial droop (C) indicate acute neurological injury,
likely a hypertensive hemorrhagic stroke or encephalopathy, requiring immediate BP reduction in a
4
HESI 266 Medical-Surgical Nursing
Comprehensive Study Guide
2026/2027 Edition | 300 Verified Questions | 100% Correct Solutions
Aligned with NGN Standards, NCSBN CJMM, and HESI Exit Exam Format
Bachelor of Science in Nursing Program
,Cardiovascular Nursing
Questions 1–20 (20 items)
1. A 62-year-old man returns from the PACU following a three-vessel coronary artery bypass graft
(CABG). The nurse notes 200 mL of serosanguineous drainage in the chest tube collection
chamber during the first hour. Which finding requires immediate notification of the surgeon?
A. 200 mL of serosanguineous drainage in the first hour
B. 150 mL of bloody drainage per hour for two consecutive hours
C. Intermittent bubbling in the water seal chamber with coughing
D. Fluctuation of the fluid level in the water seal with respiration
✓ Correct: B. 150 mL of bloody drainage per hour for two consecutive hours
Rationale: Chest tube drainage exceeding 150 mL/hr for two or more consecutive hours is considered
excessive and may indicate active postoperative hemorrhage, requiring immediate surgical evaluation.
Expected drainage after CABG is typically less than 100 mL/hr in the first several hours and should
progressively decrease. Serosanguineous drainage of 200 mL in the first hour (A) is within acceptable
limits initially. Intermittent bubbling with coughing (C) is normal and represents air expulsion from the
pleural space. Tidaling or fluctuation (D) indicates the system is patent and communicating with the
pleural space. The nurse should also assess for signs of hypovolemia such as tachycardia, hypotension, and
decreased urine output. (Ignatavicius & Workman, Ch. 35; HESI RN Review Module, Cardiovascular
System)
2. A 58-year-old woman with chronic heart failure reports increasing dyspnea on exertion and a 5-
pound weight gain over the past week. The nurse assesses bilateral crackles in the lung bases,
jugular venous distension at 6 cm above the sternal angle, and 2+ pitting edema in both lower
extremities. Which pathophysiologic mechanism best explains these findings?
A. Decreased preload causing reduced renal perfusion and oliguria
B. Activation of the renin-angiotensin-aldosterone system (RAAS) causing sodium and water retention
C. Increased cardiac output leading to volume depletion and thirst
D. Excessive diuretic therapy causing prerenal azotemia and dehydration
✓ Correct: B. Activation of the renin-angiotensin-aldosterone system (RAAS) causing sodium
and water retention
Rationale: Heart failure triggers RAAS activation due to decreased renal perfusion from reduced cardiac
output. Angiotensin II promotes sodium and water retention, aldosterone increases sodium reabsorption,
and antidiuretic hormone release exacerbates fluid retention. This results in hypervolemia, manifesting as
JVD, pulmonary crackles from fluid transudation into alveoli, and peripheral edema. Weight gain reflects
total body fluid excess. Decreased preload (A) would cause decreased venous return, not fluid overload.
Increased cardiac output (C) is the opposite of heart failure pathophysiology. Diuretic excess (D) would
cause dehydration with weight loss, not weight gain and edema. Monitoring daily weights is the most
reliable indicator of fluid balance. (Lewis et al., Ch. 30; HESI RN Review Module, Cardiovascular System)
3. A 70-year-old man arrives in the emergency department with substernal chest pressure that
began 2 hours ago, radiating to the left arm and jaw. He is diaphoretic with nausea. The 12-lead
ECG shows ST-segment elevation in leads II, III, and aVF. Initial troponin I is 0.4 ng/mL
(reference < 0.04). What is the nurse's priority action?
A. Administer prescribed aspirin 325 mg chewed and obtain IV access
B. Wait for a second troponin level in 6 hours before initiating treatment
C. Encourage the patient to walk to the bathroom to obtain a urine specimen
D. Apply warm compresses to the chest to relieve muscle discomfort
✓ Correct: A. Administer prescribed aspirin 325 mg chewed and obtain IV access
2
, Rationale: This patient is presenting with an acute ST-elevation myocardial infarction (STEMI) of the
inferior wall. Troponin I is a highly specific cardiac biomarker that rises within 2-4 hours of myocardial
injury; a level of 0.4 ng/mL confirms myocardial cell damage. The priority nursing action is to administer
aspirin (antiplatelet effect inhibits thromboxane A2) and establish IV access for medication administration,
per the MONA (morphine, oxygen, nitroglycerin, aspirin) protocol and current ACLS guidelines. Waiting
for a second troponin (B) delays reperfusion therapy, which is time-critical. Having the patient walk (C)
increases myocardial oxygen demand and risks cardiac arrest. Warm compresses (D) are inappropriate
for ischemic chest pain. Reperfusion therapy (PCI or fibrinolytics) should be initiated within door-to-
balloon time of 90 minutes. (Ignatavicius & Workman, Ch. 34; HESI RN Review Module, Cardiovascular
System)
4. A 66-year-old woman newly diagnosed with atrial fibrillation is prescribed warfarin
(Coumadin). The nurse provides discharge teaching about anticoagulation therapy. Which
statement by the patient indicates a need for further education?
A. "I should have my blood drawn regularly to check my INR level."
B. "I will use a soft-bristled toothbrush and an electric razor."
C. "I can take aspirin or ibuprofen whenever I have a headache."
D. "I should eat consistent amounts of foods containing vitamin K."
✓ Correct: C. "I can take aspirin or ibuprofen whenever I have a headache."
Rationale: Warfarin is a vitamin K antagonist that impairs synthesis of clotting factors II, VII, IX, and X.
Taking NSAIDs such as aspirin or ibuprofen concurrently increases bleeding risk through additive
antiplatelet effects and gastric mucosal irritation. Patients on warfarin should avoid NSAIDs and use
acetaminophen for mild pain instead. Regular INR monitoring (A) is essential; the therapeutic range for
atrial fibrillation is typically 2.0-3.0. Using a soft toothbrush and electric razor (B) reduces bleeding risk.
Consistent vitamin K intake (D) prevents fluctuations in warfarin efficacy, as vitamin K-rich foods (dark
leafy greens, broccoli) can counteract warfarin's effect. The patient should also be taught to report signs of
bleeding such as bruising, melena, hematuria, and prolonged bleeding from minor cuts. (Lewis et al., Ch.
31; HESI RN Review Module, Cardiovascular System)
5. A 55-year-old man suddenly collapses in the cardiac telemetry unit. The monitor shows a
chaotic, irregular waveform with no discernible P waves, QRS complexes, or T waves. The patient
is unresponsive, and no pulses are palpable. What is the nurse's immediate intervention?
A. Begin CPR and administer epinephrine 1 mg IV every 3-5 minutes
B. Defibrillate immediately with 200 joules biphasic and resume CPR
C. Administer amiodarone 300 mg IV bolus and prepare for cardioversion
D. Perform carotid sinus massage to attempt to restore normal rhythm
✓ Correct: B. Defibrillate immediately with 200 joules biphasic and resume CPR
Rationale: The described rhythm is ventricular fibrillation (VF), a lethal dysrhythmia causing ineffective
quivering of the ventricles with no cardiac output. VF is a shockable rhythm per ACLS guidelines. The
immediate intervention is defibrillation to depolarize the entire myocardium simultaneously, allowing the
natural pacemaker to resume an organized rhythm. Defibrillation should be delivered as soon as possible,
with CPR resumed immediately after the shock. Epinephrine (A) is given after the first defibrillation
attempt if VF persists, not as the initial action. Amiodarone (C) is a second-line antiarrhythmic for
refractory VF/pulseless VT after epinephrine. Carotid sinus massage (D) is used for supraventricular
tachycardia, not VF, and is contraindicated in pulseless patients. Time to defibrillation is the most critical
determinant of survival; each minute delay decreases survival by 7-10%. (Ignatavicius & Workman, Ch.
34; AHA ACLS Guidelines; HESI RN Review Module, Cardiovascular System)
6. A 72-year-old woman is admitted for total knee arthroplasty. The surgeon orders sequential
compression devices (SCDs) as DVT prophylaxis. Which nursing action is most appropriate
regarding SCD application?
3
, A. Remove the SCDs during sleep to promote patient comfort and rest
B. Apply the SCDs over the patient's clothing for easier removal during ambulation
C. Ensure proper fit with the device snug on the lower leg from ankle to below the knee
D. Place the SCDs on the unaffected leg only to protect the surgical site
✓ Correct: C. Ensure proper fit with the device snug on the lower leg from ankle to below the
knee
Rationale: SCDs should be applied snugly on the lower extremity from the ankle to below the knee to
promote venous return through intermittent pneumatic compression, reducing stasis and DVT risk. A
proper fit ensures effective graduated compression. Removing SCDs during sleep (A) is incorrect; they
should remain on continuously except during ambulation or bathing. Applying over clothing (B) reduces
compression effectiveness and is improper technique. Applying to only the unaffected leg (D) provides
incomplete prophylaxis, as the surgical leg is at highest risk for DVT due to immobility, vessel injury, and
hypercoagulability (Virchow triad). The nurse should assess skin integrity, neurovascular status, and
device function hourly. Additional DVT prophylaxis may include subcutaneous enoxaparin (Lovenox) and
early ambulation. (Lewis et al., Ch. 32; HESI RN Review Module, Cardiovascular System)
7. A 45-year-old woman who is 5 days postpartum suddenly develops severe dyspnea, sharp
pleuritic chest pain, and tachycardia. Oxygen saturation is 88% on room air. She appears anxious
and diaphoretic. Which condition should the nurse suspect, and what is the likely underlying
cause?
A. Myocardial infarction secondary to coronary artery spasm
B. Pulmonary embolism from deep vein thrombosis in the lower extremity
C. Pneumothorax from ruptured blebs in the lung parenchyma
D. Aspiration pneumonia from gastroesophageal reflux during labor
✓ Correct: B. Pulmonary embolism from deep vein thrombosis in the lower extremity
Rationale: This patient's presentation is classic for pulmonary embolism (PE), with the triad of dyspnea,
pleuritic chest pain, and tachycardia. Postpartum women are at high risk for DVT and PE due to venous
stasis, pelvic vessel compression during pregnancy, hypercoagulable state (increased fibrinogen and
clotting factors), and decreased mobility. The pleuritic chest pain (worsens with inspiration) results from
pulmonary infarction and inflammation of the pleura. MI (A) is less likely in a young postpartum woman
without cardiac risk factors and would typically present with substernal pressure. Spontaneous
pneumothorax (C) causes sudden dyspnea and pleuritic pain but is not associated with the postpartum
period. Aspiration pneumonia (D) typically presents with fever and productive cough over hours to days,
not sudden onset. The nurse should immediately initiate oxygen, elevate the head of bed, and prepare for
CT pulmonary angiography and anticoagulation. (Ignatavicius & Workman, Ch. 34; HESI RN Review
Module, Cardiovascular System)
8. A 52-year-old man with a history of hypertension presents to the emergency department with a
blood pressure of 210/130 mmHg, severe occipital headache, blurred vision, and confusion. He
reports epistaxis earlier in the day. Which assessment finding would best indicate end-organ
damage requiring immediate intervention?
A. Heart rate of 98 beats/minute with regular rhythm
B. Complaint of mild bilateral ankle edema at the end of the day
C. New-onset slurred speech and right-sided facial droop
D. Blood glucose level of 142 mg/dL on random sampling
✓ Correct: C. New-onset slurred speech and right-sided facial droop
Rationale: This patient is in hypertensive crisis with BP 210/130 mmHg. The presence of neurological
changes (confusion) with severe headache and visual disturbances suggests hypertensive emergency with
end-organ damage. New-onset slurred speech and facial droop (C) indicate acute neurological injury,
likely a hypertensive hemorrhagic stroke or encephalopathy, requiring immediate BP reduction in a
4
