BSN 266 HESI Exam Med-Surg Exam 4 150
Verified Q&A ACTUAL EXAM 2026/2027 |
BSN 266 HESI Med Surg 4 | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1–25)
Q1: A 68-year-old male is admitted with acute decompensated heart failure. Vital signs: BP 88/52
mmHg, HR 118 bpm (irregular), RR 28/min, SpO2 89% on room air. BNP 1,850 pg/mL. Crackles
bilaterally, JVD +4 cm, 3+ pitting edema. Which intervention is the priority?
A. Administer IV furosemide 40 mg push
B. Initiate continuous positive airway pressure (CPAP)
C. Administer IV dobutamine for inotropic support [CORRECT]
D. Insert a Foley catheter for strict intake and output
Correct Answer: C
Rationale: This patient presents with cardiogenic shock secondary to acute decompensated heart failure
evidenced by hypotension (BP 88/52), tachycardia, and signs of poor perfusion. According to the
ADHERE registry and heart failure guidelines, patients with low-output cold/wet profiles require
inotropic support with dobutamine or milrinone to improve cardiac output before diuresis. Diuresis in a
hypotensive patient can worsen perfusion and precipitate renal failure.
Q2: A patient with a history of atrial fibrillation is receiving warfarin. The INR is 6.8, and the patient
reports dark tarry stools. Which intervention is most appropriate?
A. Administer vitamin K 10 mg orally
B. Hold warfarin and administer fresh frozen plasma [CORRECT]
C. Continue warfarin at a reduced dose
D. Administer protamine sulfate
Correct Answer: B
Rationale: An INR of 6.8 with signs of gastrointestinal bleeding (melena) indicates life-threatening
hemorrhage requiring immediate reversal of anticoagulation. Holding warfarin and administering fresh
,frozen plasma provides rapid replacement of clotting factors. Vitamin K works too slowly for acute
bleeding, and protamine sulfate reverses heparin, not warfarin.
Q3: A patient is admitted with chest pain. ECG shows ST elevation in leads V1–V4. Troponin I is 12.5
ng/mL. Which complication is the nurse most concerned about in the first 24 hours?
A. Papillary muscle rupture
B. Ventricular fibrillation [CORRECT]
C. Dressler syndrome
D. Ventricular aneurysm
Correct Answer: B
Rationale: This ECG pattern indicates an anterior ST-elevation myocardial infarction (STEMI), which
carries the highest risk of lethal ventricular dysrhythmias within the first 24 hours due to extensive
myocardial irritability and ischemia. Ventricular fibrillation is the most common cause of death in the
immediate post-MI period and requires continuous cardiac monitoring and crash cart readiness.
Q4: A patient with third-degree AV block has a heart rate of 32 bpm, BP 70/40 mmHg, and altered
mental status. Which intervention is the priority?
A. Administer atropine 0.5 mg IV
B. Prepare for transcutaneous pacing [CORRECT]
C. Administer dopamine infusion
D. Insert a temporary pacemaker via the femoral vein
Correct Answer: B
Rationale: Third-degree AV block with hemodynamic compromise (hypotension, altered mental status)
requires immediate transcutaneous pacing according to ACLS guidelines. Atropine is ineffective in third-
degree blocks because the block is below the AV node. Transcutaneous pacing provides rapid
stabilization while preparing for transvenous pacemaker insertion.
Q5: A patient post-aortic valve replacement develops a new harsh systolic murmur, hypotension, and
pulmonary edema. Which complication is most likely?
A. Pericardial tamponade
B. Paravalvular leak [CORRECT]
C. Prosthetic valve endocarditis
D. Cardiac tamponade
,Correct Answer: B
Rationale: A new harsh systolic murmur with acute heart failure following valve surgery strongly
suggests a paravalvular leak, which occurs when the prosthetic valve does not seal properly against the
annulus. This complication causes acute valvular regurgitation, volume overload, and cardiogenic shock
requiring urgent surgical intervention.
Q6: A patient with infective endocarditis is receiving IV antibiotics. Which assessment finding indicates a
serious complication requiring immediate notification of the provider?
A. Temperature 38.2°C
B. New onset of hemiparesis [CORRECT]
C. Mild fatigue
D. Anorexia
Correct Answer: B
Rationale: New onset hemiparesis in a patient with infective endocarditis indicates a systemic
embolization, most likely a cerebral embolus from vegetation on the heart valve. This is a life-
threatening complication that requires immediate evaluation for stroke and possible surgical
intervention. Cerebral emboli occur in 20-50% of endocarditis cases and are a major cause of morbidity
and mortality.
Q7: A patient with pericarditis reports severe chest pain that worsens with inspiration and lying flat.
Which positioning provides the most relief?
A. High Fowler's position
B. Sitting upright and leaning forward [CORRECT]
C. Supine with legs elevated
D. Left lateral decubitus
Correct Answer: B
Rationale: The characteristic pain of pericarditis is positional and worsens with inspiration and supine
positioning due to increased contact between the inflamed pericardial layers. Sitting upright and leaning
forward reduces pressure on the pericardium and minimizes friction between the visceral and parietal
layers, providing significant pain relief.
Q8: A patient with a blood pressure of 220/130 mmHg reports a severe headache and blurred vision.
Fundoscopic exam shows papilledema. Which diagnosis is most appropriate?
, A. Hypertensive urgency
B. Hypertensive emergency [CORRECT]
C. Primary hypertension
D. Malignant hypertension
Correct Answer: B
Rationale: Hypertensive emergency is defined by severely elevated blood pressure with evidence of
acute target organ damage, in this case papilledema indicating hypertensive encephalopathy. This
requires immediate but controlled reduction of blood pressure using IV agents such as nicardipine or
labetalol to prevent cerebral hypoperfusion from overly rapid correction.
Q9: A patient with acute MI develops a loud holosystolic murmur at the apex radiating to the axilla,
pulmonary edema, and hypotension. Which complication has occurred?
A. Ventricular septal defect
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Free wall rupture
D. Left ventricular aneurysm
Correct Answer: B
Rationale: Papillary muscle rupture is a catastrophic mechanical complication of acute MI, typically
occurring 2-7 days post-infarction, that causes acute severe mitral regurgitation. The apical holosystolic
murmur radiating to the axilla, combined with acute pulmonary edema and hypotension, is the classic
presentation requiring emergent surgical repair.
Q10: A patient is receiving IV heparin for DVT prophylaxis. The platelet count drops from 250,000 to
85,000 on day 7. Which action is the priority?
A. Continue heparin and monitor platelets
B. Discontinue all heparin immediately [CORRECT]
C. Switch to warfarin
D. Administer platelet transfusion
Correct Answer: B
Rationale: A 50% or greater decrease in platelet count while receiving heparin is highly suggestive of
heparin-induced thrombocytopenia (HIT) type II, an immune-mediated prothrombotic condition. All
heparin must be discontinued immediately, including heparin flushes and IV line locks, and an
alternative anticoagulant such as argatroban or fondaparinux must be initiated.
Verified Q&A ACTUAL EXAM 2026/2027 |
BSN 266 HESI Med Surg 4 | Verified Q&A |
Pass Guaranteed - A+ Graded
Section 1: Cardiovascular Disorders (Questions 1–25)
Q1: A 68-year-old male is admitted with acute decompensated heart failure. Vital signs: BP 88/52
mmHg, HR 118 bpm (irregular), RR 28/min, SpO2 89% on room air. BNP 1,850 pg/mL. Crackles
bilaterally, JVD +4 cm, 3+ pitting edema. Which intervention is the priority?
A. Administer IV furosemide 40 mg push
B. Initiate continuous positive airway pressure (CPAP)
C. Administer IV dobutamine for inotropic support [CORRECT]
D. Insert a Foley catheter for strict intake and output
Correct Answer: C
Rationale: This patient presents with cardiogenic shock secondary to acute decompensated heart failure
evidenced by hypotension (BP 88/52), tachycardia, and signs of poor perfusion. According to the
ADHERE registry and heart failure guidelines, patients with low-output cold/wet profiles require
inotropic support with dobutamine or milrinone to improve cardiac output before diuresis. Diuresis in a
hypotensive patient can worsen perfusion and precipitate renal failure.
Q2: A patient with a history of atrial fibrillation is receiving warfarin. The INR is 6.8, and the patient
reports dark tarry stools. Which intervention is most appropriate?
A. Administer vitamin K 10 mg orally
B. Hold warfarin and administer fresh frozen plasma [CORRECT]
C. Continue warfarin at a reduced dose
D. Administer protamine sulfate
Correct Answer: B
Rationale: An INR of 6.8 with signs of gastrointestinal bleeding (melena) indicates life-threatening
hemorrhage requiring immediate reversal of anticoagulation. Holding warfarin and administering fresh
,frozen plasma provides rapid replacement of clotting factors. Vitamin K works too slowly for acute
bleeding, and protamine sulfate reverses heparin, not warfarin.
Q3: A patient is admitted with chest pain. ECG shows ST elevation in leads V1–V4. Troponin I is 12.5
ng/mL. Which complication is the nurse most concerned about in the first 24 hours?
A. Papillary muscle rupture
B. Ventricular fibrillation [CORRECT]
C. Dressler syndrome
D. Ventricular aneurysm
Correct Answer: B
Rationale: This ECG pattern indicates an anterior ST-elevation myocardial infarction (STEMI), which
carries the highest risk of lethal ventricular dysrhythmias within the first 24 hours due to extensive
myocardial irritability and ischemia. Ventricular fibrillation is the most common cause of death in the
immediate post-MI period and requires continuous cardiac monitoring and crash cart readiness.
Q4: A patient with third-degree AV block has a heart rate of 32 bpm, BP 70/40 mmHg, and altered
mental status. Which intervention is the priority?
A. Administer atropine 0.5 mg IV
B. Prepare for transcutaneous pacing [CORRECT]
C. Administer dopamine infusion
D. Insert a temporary pacemaker via the femoral vein
Correct Answer: B
Rationale: Third-degree AV block with hemodynamic compromise (hypotension, altered mental status)
requires immediate transcutaneous pacing according to ACLS guidelines. Atropine is ineffective in third-
degree blocks because the block is below the AV node. Transcutaneous pacing provides rapid
stabilization while preparing for transvenous pacemaker insertion.
Q5: A patient post-aortic valve replacement develops a new harsh systolic murmur, hypotension, and
pulmonary edema. Which complication is most likely?
A. Pericardial tamponade
B. Paravalvular leak [CORRECT]
C. Prosthetic valve endocarditis
D. Cardiac tamponade
,Correct Answer: B
Rationale: A new harsh systolic murmur with acute heart failure following valve surgery strongly
suggests a paravalvular leak, which occurs when the prosthetic valve does not seal properly against the
annulus. This complication causes acute valvular regurgitation, volume overload, and cardiogenic shock
requiring urgent surgical intervention.
Q6: A patient with infective endocarditis is receiving IV antibiotics. Which assessment finding indicates a
serious complication requiring immediate notification of the provider?
A. Temperature 38.2°C
B. New onset of hemiparesis [CORRECT]
C. Mild fatigue
D. Anorexia
Correct Answer: B
Rationale: New onset hemiparesis in a patient with infective endocarditis indicates a systemic
embolization, most likely a cerebral embolus from vegetation on the heart valve. This is a life-
threatening complication that requires immediate evaluation for stroke and possible surgical
intervention. Cerebral emboli occur in 20-50% of endocarditis cases and are a major cause of morbidity
and mortality.
Q7: A patient with pericarditis reports severe chest pain that worsens with inspiration and lying flat.
Which positioning provides the most relief?
A. High Fowler's position
B. Sitting upright and leaning forward [CORRECT]
C. Supine with legs elevated
D. Left lateral decubitus
Correct Answer: B
Rationale: The characteristic pain of pericarditis is positional and worsens with inspiration and supine
positioning due to increased contact between the inflamed pericardial layers. Sitting upright and leaning
forward reduces pressure on the pericardium and minimizes friction between the visceral and parietal
layers, providing significant pain relief.
Q8: A patient with a blood pressure of 220/130 mmHg reports a severe headache and blurred vision.
Fundoscopic exam shows papilledema. Which diagnosis is most appropriate?
, A. Hypertensive urgency
B. Hypertensive emergency [CORRECT]
C. Primary hypertension
D. Malignant hypertension
Correct Answer: B
Rationale: Hypertensive emergency is defined by severely elevated blood pressure with evidence of
acute target organ damage, in this case papilledema indicating hypertensive encephalopathy. This
requires immediate but controlled reduction of blood pressure using IV agents such as nicardipine or
labetalol to prevent cerebral hypoperfusion from overly rapid correction.
Q9: A patient with acute MI develops a loud holosystolic murmur at the apex radiating to the axilla,
pulmonary edema, and hypotension. Which complication has occurred?
A. Ventricular septal defect
B. Papillary muscle rupture with acute mitral regurgitation [CORRECT]
C. Free wall rupture
D. Left ventricular aneurysm
Correct Answer: B
Rationale: Papillary muscle rupture is a catastrophic mechanical complication of acute MI, typically
occurring 2-7 days post-infarction, that causes acute severe mitral regurgitation. The apical holosystolic
murmur radiating to the axilla, combined with acute pulmonary edema and hypotension, is the classic
presentation requiring emergent surgical repair.
Q10: A patient is receiving IV heparin for DVT prophylaxis. The platelet count drops from 250,000 to
85,000 on day 7. Which action is the priority?
A. Continue heparin and monitor platelets
B. Discontinue all heparin immediately [CORRECT]
C. Switch to warfarin
D. Administer platelet transfusion
Correct Answer: B
Rationale: A 50% or greater decrease in platelet count while receiving heparin is highly suggestive of
heparin-induced thrombocytopenia (HIT) type II, an immune-mediated prothrombotic condition. All
heparin must be discontinued immediately, including heparin flushes and IV line locks, and an
alternative anticoagulant such as argatroban or fondaparinux must be initiated.
