BSN 266 HESI MED SURG EXAM
2026-2027 | 100% Correct
Verified Q&A | Nightingale
College | Pass Guaranteed - A+
Grade
ART A – MULTIPLE CHOICE (Q1–85)
P
Q1 (Cardiovascular – Heart Failure): A 68-year-old male with HFrEF (EF 35%) presents with
worsening dyspnea, 3+ pitting edema, and JVD. Current meds include lisinopril, metoprolol, and
furosemide. According to 2026 GDMT guidelines, which medication should be added next?
A. Digoxin
B. Spironolactone
C. Dapagliflozin (SGLT2 inhibitor)
D. Hydralazine-isosorbide dinitrate
[CORRECT] C
Rationale: The 2026 AHA/ACC/HFSA heart failure guidelines recommend SGLT2 inhibitors
(dapagliflozin or empagliflozin) as foundational GDMT for HFrEF regardless of diabetes status,
reducing hospitalization and mortality. Spironolactone is indicated for NYHA Class II-IV with
persistent symptoms, but SGLT2i has broader Class I recommendation. Digoxin is reserved for
symptomatic control despite optimal therapy. Hydralazine-ISDN is for Black patients or
ACEI-intolerant individuals.
Q2 (Cardiovascular – MI): A 58-year-old woman presents with chest pressure, diaphoresis, and
nausea. ECG shows ST-elevation in leads V1-V4. Troponin I is 2.8 ng/mL (normal <0.04).
Which intervention is the priority?
A. Administer morphine 2 mg IV
B. Obtain a stat chest X-ray
C. Activate catheterization lab for primary PCI within 90 minutes
D. Begin heparin infusion before transport
[CORRECT] C
Rationale: STEMI management requires reperfusion therapy within 12 hours of symptom onset;
primary PCI is preferred with a door-to-balloon time of ≤90 minutes per ACC/AHA guidelines.
Morphine is no longer routinely recommended due to increased mortality risk. While heparin is
used adjunctively, it should not delay reperfusion. Chest X-ray is not priority in acute STEMI.
, 3 (Cardiovascular – Dysrhythmias): A patient with new-onset atrial fibrillation (HR 142, BP
Q
98/62) is hemodynamically unstable. Which intervention is indicated first?
A. Start amiodarone infusion
B. Administer IV metoprolol
C. Perform synchronized cardioversion at 100-200 J
D. Give IV digoxin loading dose
[CORRECT] C
Rationale: Unstable atrial fibrillation with hypotension (SBP <90 mmHg) or signs of shock
requires immediate synchronized cardioversion per ACLS 2026; electrical cardioversion is
preferred over pharmacologic rate control in unstable patients. Amiodarone is for stable patients
or chemical cardioversion. Beta-blockers and digoxin are contraindicated in hypotension as they
worsen hemodynamics.
Q4 (Cardiovascular – Hypertension): A 55-year-old African American male has BP 158/96
mmHg. He has no comorbidities. According to 2026 ACC/AHA guidelines, what is the first-line
pharmacologic therapy?
A. ACE inhibitor
B. Thiazide diuretic or calcium channel blocker
C. Beta-blocker
D. ARB plus thiazide combination
[CORRECT] B
Rationale: The 2026 ACC/AHA hypertension guidelines recommend thiazide diuretics or
calcium channel blockers as first-line for Black patients without compelling indications (CKD,
diabetes, HF), as ACE inhibitors/ARBs are less effective as monotherapy in this population.
Beta-blockers are not first-line for uncomplicated hypertension. Combination therapy is reserved
for Stage 2 hypertension (BP ≥140/90) or if BP >20/10 above goal.
Q5 (Cardiovascular – Shock): A patient post-CABG develops cool, clammy skin, narrowed pulse
pressure, and PCWP 24 mmHg. Cardiac output is 3.8 L/min. Which type of shock is most likely?
A. Hypovolemic
B. Cardiogenic
C. Distributive (septic)
D. Obstructive
[CORRECT] B
Rationale: Cardiogenic shock post-CABG presents with elevated PCWP (>18 mmHg indicates
left ventricular failure), low cardiac output (<4 L/min), and classic signs of poor perfusion (cool,
clammy skin, narrowed pulse pressure). Hypovolemic shock shows low PCWP. Septic shock
presents with warm, flushed skin and low SVR. Obstructive shock (tamponade, PE) shows
equalization of pressures.
Q6 (Cardiovascular – Valvular): A patient with severe aortic stenosis reports syncope on
exertion. Which assessment finding is most consistent with this diagnosis?
A. Diastolic murmur at apex
B. Systolic crescendo-decrescendo murmur at right upper sternal border
C. Holosystolic murmur at left lower sternal border
D. Opening snap followed by diastolic rumble
[CORRECT] B
, ationale: Aortic stenosis produces a harsh systolic crescendo-decrescendo murmur best heard
R
at the right upper sternal border with radiation to the carotids; syncope on exertion occurs due to
fixed obstruction preventing increased cardiac output. Diastolic murmur at apex suggests mitral
stenosis. Holosystolic murmur at LLSB indicates tricuspid regurgitation. Opening snap with
rumble is classic for mitral stenosis.
Q7 (Respiratory – COPD): A patient with severe COPD (FEV1 45% predicted) presents with
acute exacerbation. SpO2 is 86% on room air. What is the appropriate oxygen titration target?
A. SpO2 94-98%
B. SpO2 88-92%
C. SpO2 >98%
D. SpO2 85-90%
[CORRECT] B
Rationale: GOLD 2026 guidelines target SpO2 88-92% in COPD patients with chronic
hypercapnia to avoid suppressing hypoxic respiratory drive and worsening hypercapnia;
high-flow oxygen can cause CO2 retention and respiratory acidosis. Targets >94% are for
patients without COPD. SpO2 >98% is dangerous in COPD. 85-90% is too low for stable
management.
Q8 (Respiratory – Asthma): A 24-year-old with moderate persistent asthma uses albuterol PRN
and fluticasone daily. She reports using albuterol 4 times weekly and waking with symptoms
twice monthly. Per GINA 2026 stepwise therapy, what adjustment is needed?
A. Increase fluticasone to high dose
B. Add long-acting muscarinic antagonist (LAMA)
C. Add low-dose inhaled corticosteroid-formoterol as reliever
D. Add oral prednisone daily
[CORRECT] C
Rationale: GINA 2026 recommends low-dose ICS-formoterol as both maintenance and reliever
(MART) for Step 3-4 asthma, reducing exacerbations compared to SABA-only reliever; this
patient's symptom frequency indicates inadequate control on Step 2. High-dose ICS is Step 4-5.
LAMA is add-on therapy for Step 4-5. Daily oral steroids are reserved for severe refractory
asthma.
Q9 (Respiratory – Pneumonia): A 72-year-old is admitted with community-acquired pneumonia.
CURB-65 score is 3. Which management is most appropriate?
A. Oral amoxicillin-clavulanate; discharge home
B. IV ceftriaxone plus azithromycin; admit to ICU
C. IV ceftriaxone plus azithromycin; admit to general medical floor
D. Oral doxycycline; outpatient management
[CORRECT] C
Rationale: CURB-65 score of 3 (confusion, urea >19, RR ≥30, BP <90/60, age ≥65) indicates
severe CAP requiring hospital admission and IV antibiotics (ceftriaxone + macrolide or
respiratory fluoroquinolone) per IDSA/ATS 2026; mortality risk is 15%. Score 0-1 allows
outpatient. Score 2 admits to floor. Score 4-5 requires ICU admission.
Q10 (Respiratory – PE): A patient with sudden dyspnea and pleuritic chest pain has HR 118, BP
104/68. Wells score is 6.5. D-dimer is 1,850 ng/mL. CT pulmonary angiography confirms
bilateral PE. BP then drops to 82/50. Which intervention is priority?
, . Start unfractionated heparin infusion
A
B. Administer systemic thrombolytics (alteplase)
C. Insert inferior vena cava filter
D. Begin warfarin 5 mg PO daily
[CORRECT] B
Rationale: Massive PE with hemodynamic instability (SBP <90 or drop ≥40 mmHg) requires
systemic thrombolysis (alteplase) per ACCP 2026; reperfusion restores RV function and
improves survival. Heparin alone is insufficient in massive PE. IVC filter is for anticoagulation
contraindications. Warfarin requires bridging and is not acute therapy.
Q11 (Respiratory – ARDS): A patient with ARDS is on mechanical ventilation. Which ventilator
strategy is consistent with the ARDSNet protocol?
A. Tidal volume 10 mL/kg ideal body weight, PEEP 5 cm H2O
B. Tidal volume 6 mL/kg ideal body weight, plateau pressure <30 cm H2O
C. Tidal volume 8 mL/kg actual body weight, high PEEP strategy
D. Tidal volume 4 mL/kg, no PEEP
[CORRECT] B
Rationale: ARDSNet low tidal volume ventilation (6 mL/kg IBW) with plateau pressure <30 cm
H2O reduces mortality by preventing volutrauma and barotrauma per ARDSNet 2026 updates.
10 mL/kg causes lung injury. Actual body weight overestimates volume in obesity. No PEEP
causes alveolar collapse. Prone positioning is added for severe ARDS (P/F <150).
Q12 (Endocrine – DKA): A 22-year-old with T1DM presents with Kussmaul respirations, fruity
breath, glucose 486 mg/dL, pH 7.18, HCO3 8 mEq/L. Which is the priority initial intervention?
A. Start regular insulin infusion at 0.1 units/kg/hr
B. Administer 1-2 L 0.9% NS over first hour
C. Give IV potassium 40 mEq immediately
D. Administer sodium bicarbonate 50 mEq IV
[CORRECT] B
Rationale: DKA management prioritizes aggressive isotonic fluid resuscitation (0.9% NS 1-2 L
first hour) to restore perfusion and correct dehydration before insulin administration; insulin
before fluids risks worsening hypotension and shock. Potassium is given only if K+ <3.3 mEq/L
or after insulin starts and K+ declines. Bicarbonate is reserved for pH <6.9 per ADA 2026.
Q13 (Endocrine – HHS): A 78-year-old with T2DM has glucose 920 mg/dL, serum osmolality
340 mOsm/kg, pH 7.35, and minimal ketones. Which nursing assessment is most critical?
A. Monitor for signs of cerebral edema
B. Assess for Kussmaul respirations
C. Check for acetone breath
D. Evaluate for abdominal pain severity
[CORRECT] A
Rationale: HHS (hyperosmolar hyperglycemic state) carries high risk of cerebral edema during
treatment due to rapid osmolar shifts; fluid replacement must be gradual with frequent neuro
checks. Kussmaul respirations and acetone breath are DKA findings. Abdominal pain is more
common in DKA. HHS has higher mortality than DKA due to severe dehydration and thrombosis
risk.
2026-2027 | 100% Correct
Verified Q&A | Nightingale
College | Pass Guaranteed - A+
Grade
ART A – MULTIPLE CHOICE (Q1–85)
P
Q1 (Cardiovascular – Heart Failure): A 68-year-old male with HFrEF (EF 35%) presents with
worsening dyspnea, 3+ pitting edema, and JVD. Current meds include lisinopril, metoprolol, and
furosemide. According to 2026 GDMT guidelines, which medication should be added next?
A. Digoxin
B. Spironolactone
C. Dapagliflozin (SGLT2 inhibitor)
D. Hydralazine-isosorbide dinitrate
[CORRECT] C
Rationale: The 2026 AHA/ACC/HFSA heart failure guidelines recommend SGLT2 inhibitors
(dapagliflozin or empagliflozin) as foundational GDMT for HFrEF regardless of diabetes status,
reducing hospitalization and mortality. Spironolactone is indicated for NYHA Class II-IV with
persistent symptoms, but SGLT2i has broader Class I recommendation. Digoxin is reserved for
symptomatic control despite optimal therapy. Hydralazine-ISDN is for Black patients or
ACEI-intolerant individuals.
Q2 (Cardiovascular – MI): A 58-year-old woman presents with chest pressure, diaphoresis, and
nausea. ECG shows ST-elevation in leads V1-V4. Troponin I is 2.8 ng/mL (normal <0.04).
Which intervention is the priority?
A. Administer morphine 2 mg IV
B. Obtain a stat chest X-ray
C. Activate catheterization lab for primary PCI within 90 minutes
D. Begin heparin infusion before transport
[CORRECT] C
Rationale: STEMI management requires reperfusion therapy within 12 hours of symptom onset;
primary PCI is preferred with a door-to-balloon time of ≤90 minutes per ACC/AHA guidelines.
Morphine is no longer routinely recommended due to increased mortality risk. While heparin is
used adjunctively, it should not delay reperfusion. Chest X-ray is not priority in acute STEMI.
, 3 (Cardiovascular – Dysrhythmias): A patient with new-onset atrial fibrillation (HR 142, BP
Q
98/62) is hemodynamically unstable. Which intervention is indicated first?
A. Start amiodarone infusion
B. Administer IV metoprolol
C. Perform synchronized cardioversion at 100-200 J
D. Give IV digoxin loading dose
[CORRECT] C
Rationale: Unstable atrial fibrillation with hypotension (SBP <90 mmHg) or signs of shock
requires immediate synchronized cardioversion per ACLS 2026; electrical cardioversion is
preferred over pharmacologic rate control in unstable patients. Amiodarone is for stable patients
or chemical cardioversion. Beta-blockers and digoxin are contraindicated in hypotension as they
worsen hemodynamics.
Q4 (Cardiovascular – Hypertension): A 55-year-old African American male has BP 158/96
mmHg. He has no comorbidities. According to 2026 ACC/AHA guidelines, what is the first-line
pharmacologic therapy?
A. ACE inhibitor
B. Thiazide diuretic or calcium channel blocker
C. Beta-blocker
D. ARB plus thiazide combination
[CORRECT] B
Rationale: The 2026 ACC/AHA hypertension guidelines recommend thiazide diuretics or
calcium channel blockers as first-line for Black patients without compelling indications (CKD,
diabetes, HF), as ACE inhibitors/ARBs are less effective as monotherapy in this population.
Beta-blockers are not first-line for uncomplicated hypertension. Combination therapy is reserved
for Stage 2 hypertension (BP ≥140/90) or if BP >20/10 above goal.
Q5 (Cardiovascular – Shock): A patient post-CABG develops cool, clammy skin, narrowed pulse
pressure, and PCWP 24 mmHg. Cardiac output is 3.8 L/min. Which type of shock is most likely?
A. Hypovolemic
B. Cardiogenic
C. Distributive (septic)
D. Obstructive
[CORRECT] B
Rationale: Cardiogenic shock post-CABG presents with elevated PCWP (>18 mmHg indicates
left ventricular failure), low cardiac output (<4 L/min), and classic signs of poor perfusion (cool,
clammy skin, narrowed pulse pressure). Hypovolemic shock shows low PCWP. Septic shock
presents with warm, flushed skin and low SVR. Obstructive shock (tamponade, PE) shows
equalization of pressures.
Q6 (Cardiovascular – Valvular): A patient with severe aortic stenosis reports syncope on
exertion. Which assessment finding is most consistent with this diagnosis?
A. Diastolic murmur at apex
B. Systolic crescendo-decrescendo murmur at right upper sternal border
C. Holosystolic murmur at left lower sternal border
D. Opening snap followed by diastolic rumble
[CORRECT] B
, ationale: Aortic stenosis produces a harsh systolic crescendo-decrescendo murmur best heard
R
at the right upper sternal border with radiation to the carotids; syncope on exertion occurs due to
fixed obstruction preventing increased cardiac output. Diastolic murmur at apex suggests mitral
stenosis. Holosystolic murmur at LLSB indicates tricuspid regurgitation. Opening snap with
rumble is classic for mitral stenosis.
Q7 (Respiratory – COPD): A patient with severe COPD (FEV1 45% predicted) presents with
acute exacerbation. SpO2 is 86% on room air. What is the appropriate oxygen titration target?
A. SpO2 94-98%
B. SpO2 88-92%
C. SpO2 >98%
D. SpO2 85-90%
[CORRECT] B
Rationale: GOLD 2026 guidelines target SpO2 88-92% in COPD patients with chronic
hypercapnia to avoid suppressing hypoxic respiratory drive and worsening hypercapnia;
high-flow oxygen can cause CO2 retention and respiratory acidosis. Targets >94% are for
patients without COPD. SpO2 >98% is dangerous in COPD. 85-90% is too low for stable
management.
Q8 (Respiratory – Asthma): A 24-year-old with moderate persistent asthma uses albuterol PRN
and fluticasone daily. She reports using albuterol 4 times weekly and waking with symptoms
twice monthly. Per GINA 2026 stepwise therapy, what adjustment is needed?
A. Increase fluticasone to high dose
B. Add long-acting muscarinic antagonist (LAMA)
C. Add low-dose inhaled corticosteroid-formoterol as reliever
D. Add oral prednisone daily
[CORRECT] C
Rationale: GINA 2026 recommends low-dose ICS-formoterol as both maintenance and reliever
(MART) for Step 3-4 asthma, reducing exacerbations compared to SABA-only reliever; this
patient's symptom frequency indicates inadequate control on Step 2. High-dose ICS is Step 4-5.
LAMA is add-on therapy for Step 4-5. Daily oral steroids are reserved for severe refractory
asthma.
Q9 (Respiratory – Pneumonia): A 72-year-old is admitted with community-acquired pneumonia.
CURB-65 score is 3. Which management is most appropriate?
A. Oral amoxicillin-clavulanate; discharge home
B. IV ceftriaxone plus azithromycin; admit to ICU
C. IV ceftriaxone plus azithromycin; admit to general medical floor
D. Oral doxycycline; outpatient management
[CORRECT] C
Rationale: CURB-65 score of 3 (confusion, urea >19, RR ≥30, BP <90/60, age ≥65) indicates
severe CAP requiring hospital admission and IV antibiotics (ceftriaxone + macrolide or
respiratory fluoroquinolone) per IDSA/ATS 2026; mortality risk is 15%. Score 0-1 allows
outpatient. Score 2 admits to floor. Score 4-5 requires ICU admission.
Q10 (Respiratory – PE): A patient with sudden dyspnea and pleuritic chest pain has HR 118, BP
104/68. Wells score is 6.5. D-dimer is 1,850 ng/mL. CT pulmonary angiography confirms
bilateral PE. BP then drops to 82/50. Which intervention is priority?
, . Start unfractionated heparin infusion
A
B. Administer systemic thrombolytics (alteplase)
C. Insert inferior vena cava filter
D. Begin warfarin 5 mg PO daily
[CORRECT] B
Rationale: Massive PE with hemodynamic instability (SBP <90 or drop ≥40 mmHg) requires
systemic thrombolysis (alteplase) per ACCP 2026; reperfusion restores RV function and
improves survival. Heparin alone is insufficient in massive PE. IVC filter is for anticoagulation
contraindications. Warfarin requires bridging and is not acute therapy.
Q11 (Respiratory – ARDS): A patient with ARDS is on mechanical ventilation. Which ventilator
strategy is consistent with the ARDSNet protocol?
A. Tidal volume 10 mL/kg ideal body weight, PEEP 5 cm H2O
B. Tidal volume 6 mL/kg ideal body weight, plateau pressure <30 cm H2O
C. Tidal volume 8 mL/kg actual body weight, high PEEP strategy
D. Tidal volume 4 mL/kg, no PEEP
[CORRECT] B
Rationale: ARDSNet low tidal volume ventilation (6 mL/kg IBW) with plateau pressure <30 cm
H2O reduces mortality by preventing volutrauma and barotrauma per ARDSNet 2026 updates.
10 mL/kg causes lung injury. Actual body weight overestimates volume in obesity. No PEEP
causes alveolar collapse. Prone positioning is added for severe ARDS (P/F <150).
Q12 (Endocrine – DKA): A 22-year-old with T1DM presents with Kussmaul respirations, fruity
breath, glucose 486 mg/dL, pH 7.18, HCO3 8 mEq/L. Which is the priority initial intervention?
A. Start regular insulin infusion at 0.1 units/kg/hr
B. Administer 1-2 L 0.9% NS over first hour
C. Give IV potassium 40 mEq immediately
D. Administer sodium bicarbonate 50 mEq IV
[CORRECT] B
Rationale: DKA management prioritizes aggressive isotonic fluid resuscitation (0.9% NS 1-2 L
first hour) to restore perfusion and correct dehydration before insulin administration; insulin
before fluids risks worsening hypotension and shock. Potassium is given only if K+ <3.3 mEq/L
or after insulin starts and K+ declines. Bicarbonate is reserved for pH <6.9 per ADA 2026.
Q13 (Endocrine – HHS): A 78-year-old with T2DM has glucose 920 mg/dL, serum osmolality
340 mOsm/kg, pH 7.35, and minimal ketones. Which nursing assessment is most critical?
A. Monitor for signs of cerebral edema
B. Assess for Kussmaul respirations
C. Check for acetone breath
D. Evaluate for abdominal pain severity
[CORRECT] A
Rationale: HHS (hyperosmolar hyperglycemic state) carries high risk of cerebral edema during
treatment due to rapid osmolar shifts; fluid replacement must be gradual with frequent neuro
checks. Kussmaul respirations and acetone breath are DKA findings. Abdominal pain is more
common in DKA. HHS has higher mortality than DKA due to severe dehydration and thrombosis
risk.
