HESI Elsevier Simulation Exam for Medical-Surgical
Nursing 2025/2026 - 75 Practice Questions with
Detailed Rationales for First-Time Exam Success
1. A patient with septic shock on norepinephrine and vasopressin has a mean arterial pressure of
58 mmHg, central venous pressure of 8 mmHg, ScvO2 of 65%, and lactate of 4.2 mmol/L. After
fluid resuscitation, the ScvO2 remains unchanged. Which intervention should the nurse anticipate
next?
A. Increase norepinephrine dose to achieve MAP >65 mmHg.
B. Administer a dobutamine infusion to improve cardiac output.
C. Initiate empiric broad-spectrum antibiotics if not already given.
D. Prepare for central line insertion to measure pulmonary artery pressures.
Answer: B
Rationale: Persistent low ScvO2 despite adequate MAP and CVP suggests inadequate oxygen delivery
due to myocardial depression (common in sepsis). Dobutamine increases cardiac contractility and
oxygen delivery. Increasing norepinephrine may worsen afterload and myocardial oxygen demand.
Antibiotics are critical but do not directly address low ScvO2. PA catheter is not routinely recommended
in sepsis.
2. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with FiO2 0.8, PEEP 14 cmH2O, plateau pressure 32 cmH2O, and tidal volume 6 mL/kg ideal
body weight. Arterial blood gas shows pH 7.25, PaCO2 55 mmHg, PaO2 68 mmHg. Which
adjustment should the nurse question?
A. Increase PEEP to 18 cmH2O to improve oxygenation.
B. Increase respiratory rate to 24 breaths/min to lower PaCO2.
C. Administer a neuromuscular blocking agent to improve chest wall compliance.
D. Consider prone positioning to enhance ventilation-perfusion matching.
Answer: B
Rationale: Increasing respiratory rate may cause auto-PEEP and further increase plateau pressure,
risking ventilator-induced lung injury. Permissive hypercapnia is accepted (pH >7.20). Increasing PEEP
to 18 is appropriate for severe ARDS (FiO2 >0.6). Neuromuscular blockade reduces oxygen
consumption and improves compliance. Prone positioning improves oxygenation in severe ARDS.
3. A patient with cirrhosis and ascites develops acute kidney injury. Urinalysis shows no
proteinuria, fractional excretion of sodium (FENa) <1%, and urine sodium <10 mEq/L. The
patient is not on diuretics. Which intervention is most appropriate?
A. Administer intravenous normal saline bolus 500 mL.
B. Start norepinephrine infusion to increase renal perfusion.
Page 1
,C. Prepare for large-volume paracentesis to reduce intra-abdominal pressure.
D. Discontinue all nephrotoxic medications and begin albumin infusion.
Answer: D
Rationale: FENa <1% indicates prerenal azotemia, but in cirrhosis, functional renal failure (hepatorenal
syndrome) is common. Volume expansion with albumin and avoidance of nephrotoxins are first-line.
Saline bolus may worsen ascites. Norepinephrine may be used if no response. Paracentesis can
precipitate HRS if not preceded by albumin. Discontinuing nephrotoxins is essential.
4. A patient with diabetic ketoacidosis (DKA) has an initial serum potassium of 5.8 mEq/L. After
starting insulin infusion and intravenous fluids, the nurse monitors potassium levels. At what
serum potassium level should the nurse begin potassium replacement?
A. When potassium falls below 5.0 mEq/L.
B. When potassium falls below 4.5 mEq/L.
C. When potassium falls below 4.0 mEq/L.
D. When potassium falls below 3.5 mEq/L.
Answer: C
Rationale: In DKA, total body potassium is depleted despite initial hyperkalemia. Insulin drives
potassium into cells, causing rapid decline. Replacement should begin when potassium is <4.0 mEq/L to
prevent hypokalemia, which can cause cardiac arrhythmias and respiratory arrest. Starting at 5.0 or 4.5
may lead to hyperkalemia. Waiting until 3.5 is too late.
5. A patient with acute ischemic stroke received alteplase 3 hours ago. The nurse assesses a sudden
severe headache, nausea, and blood pressure 180/110 mmHg. What is the priority action?
A. Administer intravenous labetalol to lower blood pressure.
B. Stop any anticoagulants and obtain a stat noncontrast head CT.
C. Administer ondansetron for nausea and reassess in 15 minutes.
D. Increase the rate of intravenous fluids to maintain cerebral perfusion.
Answer: B
Rationale: Sudden severe headache after thrombolysis suggests intracranial hemorrhage. Stopping
anticoagulants and obtaining head CT is critical. Lowering BP with labetalol is indicated if hemorrhage
confirmed, but CT must come first. Antiemetics may mask symptoms. Increasing fluids could worsen
edema or hemorrhage.
6. A patient with a history of heart failure with reduced ejection fraction (HFrEF) presents with
dyspnea, JVD, and lower extremity edema. Vital signs: BP 100/60 mmHg, HR 110 bpm, RR 22,
SpO2 94% on room air. Initial labs show BNP 1200 pg/mL, creatinine 1.8 mg/dL, potassium 5.2
mEq/L. Which medication should the nurse question?
A. Furosemide 40 mg IV push.
B. Lisinopril 5 mg PO.
C. Metoprolol succinate 25 mg PO.
D. Spironolactone 25 mg PO.
Answer: D
Page 2
,Rationale: Spironolactone is a potassium-sparing diuretic. With potassium 5.2 mEq/L (hyperkalemia) and acute kidney
injury (creatinine 1.8), spironolactone increases risk of life-threatening hyperkalemia. Furosemide is appropriate for volume
overload. Lisinopril can be used cautiously but may worsen hyperkalemia; however, spironolactone is more contraindicated.
Metoprolol is indicated for HFrEF.
7. A patient with a new diagnosis of type 2 diabetes has an HbA1c of 9.2%. The provider orders
metformin 500 mg BID and lifestyle modifications. The patient also has chronic kidney disease
stage 3 (eGFR 45 mL/min/1.73m2). Which intervention is most appropriate?
A. Hold metformin and consult nephrology before starting.
B. Start metformin as ordered but reduce dose to 500 mg daily.
C. Start metformin as ordered and monitor eGFR every 3 months.
D. Start metformin as ordered and add a second agent like glipizide.
Answer: A
Rationale: Metformin is contraindicated when eGFR <30, but caution is advised for eGFR 30-45.
Current guidelines recommend holding metformin in patients with eGFR <45 due to risk of lactic
acidosis. Consultation with nephrology is warranted. Reducing dose to 500 mg daily is not
recommended without specialist input. Adding glipizide may be considered after nephrology clearance.
8. A patient with acute pancreatitis has a Ranson score of 4. The nurse notes increasing abdominal
pain, distention, and a drop in hematocrit from 40% to 30% over 8 hours. What complication
should the nurse suspect?
A. Pancreatic pseudocyst.
B. Hemorrhagic pancreatitis.
C. Acute respiratory distress syndrome.
D. Hypovolemic shock due to third spacing.
Answer: B
Rationale: A significant drop in hematocrit without fluid resuscitation suggests bleeding, indicating
hemorrhagic pancreatitis. This is a severe complication with high mortality. Pseudocyst develops weeks
later. ARDS presents with respiratory distress, not hematocrit drop. Hypovolemic shock can occur from
third spacing but would not cause such a rapid hematocrit drop.
9. A patient with neutropenic fever (absolute neutrophil count 200/mm3, temperature 38.9°C) is
started on cefepime. After 48 hours, the fever persists and blood cultures grow
vancomycin-resistant Enterococcus faecium. Which additional antibiotic should the nurse
anticipate?
A. Daptomycin.
B. Vancomycin.
C. Linezolid.
D. Gentamicin.
Answer: C
Rationale: Vancomycin-resistant Enterococcus faecium (VRE) is resistant to vancomycin. Linezolid is
effective against VRE, including faecium. Daptomycin can be used but is not first-line for VRE faecium
due to potential resistance. Vancomycin is ineffective. Gentamicin is not active against VRE as
monotherapy.
Page 3
, 10. A patient with a history of opioid use disorder is admitted for acute pain management after
abdominal surgery. The patient is on buprenorphine/naloxone maintenance therapy. Which pain
management strategy is most appropriate?
A. Discontinue buprenorphine/naloxone and start full opioid agonists.
B. Continue buprenorphine/naloxone and add non-opioid analgesics and regional anesthesia.
C. Increase the dose of buprenorphine/naloxone to provide additional analgesia.
D. Administer naloxone to reverse buprenorphine effects before starting opioids.
Answer: B
Rationale: Continuing buprenorphine/naloxone prevents withdrawal and provides baseline analgesia.
Adding non-opioid analgesics and regional anesthesia optimizes pain control without disrupting
maintenance therapy. Discontinuing buprenorphine risks withdrawal and relapse. Increasing dose may
not provide sufficient acute pain relief. Naloxone would precipitate withdrawal and is contraindicated.
11. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with a set tidal volume of 6 mL/kg ideal body weight. The plateau pressure is 32 cm H2O, and the
PaCO2 is 55 mm Hg with a pH of 7.25. Which intervention should the nurse anticipate to improve
oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg to improve minute ventilation and reduce PaCO2.
B. Increase positive end-expiratory pressure (PEEP) to recruit alveoli and improve oxygenation.
C. Decrease respiratory rate to allow more time for exhalation and reduce auto-PEEP.
D. Switch to pressure-controlled ventilation with a high inspiratory pressure to increase mean airway pressure.
Answer: B
Rationale: In ARDS, lung-protective ventilation uses low tidal volumes (6 mL/kg) to prevent volutrauma.
Plateau pressure above 30 cm H2O indicates risk of barotrauma; increasing PEEP can recruit
collapsed alveoli, improve oxygenation, and reduce shunt fraction. Increasing tidal volume would
worsen lung injury. Decreasing respiratory rate would not improve oxygenation and might worsen
hypercapnia. Pressure-controlled ventilation with high pressures could cause barotrauma.
12. A patient with type 2 diabetes mellitus and chronic kidney disease (stage 4) is prescribed
metformin. The nurse reviews the patient's laboratory results: eGFR 28 mL/min/1.73 m², serum
creatinine 2.4 mg/dL. Which action is most appropriate?
A. Administer the metformin as prescribed, but monitor renal function weekly.
B. Hold the metformin and notify the prescriber because it is contraindicated.
C. Reduce the metformin dose by 50% and monitor for lactic acidosis.
D. Administer the metformin with a sulfonylurea to enhance glycemic control.
Answer: B
Rationale: Metformin is contraindicated when eGFR is below 30 mL/min/1.73 m² due to increased risk of
lactic acidosis. The nurse should hold the medication and notify the prescriber for an alternative agent.
Dose reduction is not sufficient at this level of renal impairment. Adding a sulfonylurea does not address
the contraindication.
Page 4
Nursing 2025/2026 - 75 Practice Questions with
Detailed Rationales for First-Time Exam Success
1. A patient with septic shock on norepinephrine and vasopressin has a mean arterial pressure of
58 mmHg, central venous pressure of 8 mmHg, ScvO2 of 65%, and lactate of 4.2 mmol/L. After
fluid resuscitation, the ScvO2 remains unchanged. Which intervention should the nurse anticipate
next?
A. Increase norepinephrine dose to achieve MAP >65 mmHg.
B. Administer a dobutamine infusion to improve cardiac output.
C. Initiate empiric broad-spectrum antibiotics if not already given.
D. Prepare for central line insertion to measure pulmonary artery pressures.
Answer: B
Rationale: Persistent low ScvO2 despite adequate MAP and CVP suggests inadequate oxygen delivery
due to myocardial depression (common in sepsis). Dobutamine increases cardiac contractility and
oxygen delivery. Increasing norepinephrine may worsen afterload and myocardial oxygen demand.
Antibiotics are critical but do not directly address low ScvO2. PA catheter is not routinely recommended
in sepsis.
2. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with FiO2 0.8, PEEP 14 cmH2O, plateau pressure 32 cmH2O, and tidal volume 6 mL/kg ideal
body weight. Arterial blood gas shows pH 7.25, PaCO2 55 mmHg, PaO2 68 mmHg. Which
adjustment should the nurse question?
A. Increase PEEP to 18 cmH2O to improve oxygenation.
B. Increase respiratory rate to 24 breaths/min to lower PaCO2.
C. Administer a neuromuscular blocking agent to improve chest wall compliance.
D. Consider prone positioning to enhance ventilation-perfusion matching.
Answer: B
Rationale: Increasing respiratory rate may cause auto-PEEP and further increase plateau pressure,
risking ventilator-induced lung injury. Permissive hypercapnia is accepted (pH >7.20). Increasing PEEP
to 18 is appropriate for severe ARDS (FiO2 >0.6). Neuromuscular blockade reduces oxygen
consumption and improves compliance. Prone positioning improves oxygenation in severe ARDS.
3. A patient with cirrhosis and ascites develops acute kidney injury. Urinalysis shows no
proteinuria, fractional excretion of sodium (FENa) <1%, and urine sodium <10 mEq/L. The
patient is not on diuretics. Which intervention is most appropriate?
A. Administer intravenous normal saline bolus 500 mL.
B. Start norepinephrine infusion to increase renal perfusion.
Page 1
,C. Prepare for large-volume paracentesis to reduce intra-abdominal pressure.
D. Discontinue all nephrotoxic medications and begin albumin infusion.
Answer: D
Rationale: FENa <1% indicates prerenal azotemia, but in cirrhosis, functional renal failure (hepatorenal
syndrome) is common. Volume expansion with albumin and avoidance of nephrotoxins are first-line.
Saline bolus may worsen ascites. Norepinephrine may be used if no response. Paracentesis can
precipitate HRS if not preceded by albumin. Discontinuing nephrotoxins is essential.
4. A patient with diabetic ketoacidosis (DKA) has an initial serum potassium of 5.8 mEq/L. After
starting insulin infusion and intravenous fluids, the nurse monitors potassium levels. At what
serum potassium level should the nurse begin potassium replacement?
A. When potassium falls below 5.0 mEq/L.
B. When potassium falls below 4.5 mEq/L.
C. When potassium falls below 4.0 mEq/L.
D. When potassium falls below 3.5 mEq/L.
Answer: C
Rationale: In DKA, total body potassium is depleted despite initial hyperkalemia. Insulin drives
potassium into cells, causing rapid decline. Replacement should begin when potassium is <4.0 mEq/L to
prevent hypokalemia, which can cause cardiac arrhythmias and respiratory arrest. Starting at 5.0 or 4.5
may lead to hyperkalemia. Waiting until 3.5 is too late.
5. A patient with acute ischemic stroke received alteplase 3 hours ago. The nurse assesses a sudden
severe headache, nausea, and blood pressure 180/110 mmHg. What is the priority action?
A. Administer intravenous labetalol to lower blood pressure.
B. Stop any anticoagulants and obtain a stat noncontrast head CT.
C. Administer ondansetron for nausea and reassess in 15 minutes.
D. Increase the rate of intravenous fluids to maintain cerebral perfusion.
Answer: B
Rationale: Sudden severe headache after thrombolysis suggests intracranial hemorrhage. Stopping
anticoagulants and obtaining head CT is critical. Lowering BP with labetalol is indicated if hemorrhage
confirmed, but CT must come first. Antiemetics may mask symptoms. Increasing fluids could worsen
edema or hemorrhage.
6. A patient with a history of heart failure with reduced ejection fraction (HFrEF) presents with
dyspnea, JVD, and lower extremity edema. Vital signs: BP 100/60 mmHg, HR 110 bpm, RR 22,
SpO2 94% on room air. Initial labs show BNP 1200 pg/mL, creatinine 1.8 mg/dL, potassium 5.2
mEq/L. Which medication should the nurse question?
A. Furosemide 40 mg IV push.
B. Lisinopril 5 mg PO.
C. Metoprolol succinate 25 mg PO.
D. Spironolactone 25 mg PO.
Answer: D
Page 2
,Rationale: Spironolactone is a potassium-sparing diuretic. With potassium 5.2 mEq/L (hyperkalemia) and acute kidney
injury (creatinine 1.8), spironolactone increases risk of life-threatening hyperkalemia. Furosemide is appropriate for volume
overload. Lisinopril can be used cautiously but may worsen hyperkalemia; however, spironolactone is more contraindicated.
Metoprolol is indicated for HFrEF.
7. A patient with a new diagnosis of type 2 diabetes has an HbA1c of 9.2%. The provider orders
metformin 500 mg BID and lifestyle modifications. The patient also has chronic kidney disease
stage 3 (eGFR 45 mL/min/1.73m2). Which intervention is most appropriate?
A. Hold metformin and consult nephrology before starting.
B. Start metformin as ordered but reduce dose to 500 mg daily.
C. Start metformin as ordered and monitor eGFR every 3 months.
D. Start metformin as ordered and add a second agent like glipizide.
Answer: A
Rationale: Metformin is contraindicated when eGFR <30, but caution is advised for eGFR 30-45.
Current guidelines recommend holding metformin in patients with eGFR <45 due to risk of lactic
acidosis. Consultation with nephrology is warranted. Reducing dose to 500 mg daily is not
recommended without specialist input. Adding glipizide may be considered after nephrology clearance.
8. A patient with acute pancreatitis has a Ranson score of 4. The nurse notes increasing abdominal
pain, distention, and a drop in hematocrit from 40% to 30% over 8 hours. What complication
should the nurse suspect?
A. Pancreatic pseudocyst.
B. Hemorrhagic pancreatitis.
C. Acute respiratory distress syndrome.
D. Hypovolemic shock due to third spacing.
Answer: B
Rationale: A significant drop in hematocrit without fluid resuscitation suggests bleeding, indicating
hemorrhagic pancreatitis. This is a severe complication with high mortality. Pseudocyst develops weeks
later. ARDS presents with respiratory distress, not hematocrit drop. Hypovolemic shock can occur from
third spacing but would not cause such a rapid hematocrit drop.
9. A patient with neutropenic fever (absolute neutrophil count 200/mm3, temperature 38.9°C) is
started on cefepime. After 48 hours, the fever persists and blood cultures grow
vancomycin-resistant Enterococcus faecium. Which additional antibiotic should the nurse
anticipate?
A. Daptomycin.
B. Vancomycin.
C. Linezolid.
D. Gentamicin.
Answer: C
Rationale: Vancomycin-resistant Enterococcus faecium (VRE) is resistant to vancomycin. Linezolid is
effective against VRE, including faecium. Daptomycin can be used but is not first-line for VRE faecium
due to potential resistance. Vancomycin is ineffective. Gentamicin is not active against VRE as
monotherapy.
Page 3
, 10. A patient with a history of opioid use disorder is admitted for acute pain management after
abdominal surgery. The patient is on buprenorphine/naloxone maintenance therapy. Which pain
management strategy is most appropriate?
A. Discontinue buprenorphine/naloxone and start full opioid agonists.
B. Continue buprenorphine/naloxone and add non-opioid analgesics and regional anesthesia.
C. Increase the dose of buprenorphine/naloxone to provide additional analgesia.
D. Administer naloxone to reverse buprenorphine effects before starting opioids.
Answer: B
Rationale: Continuing buprenorphine/naloxone prevents withdrawal and provides baseline analgesia.
Adding non-opioid analgesics and regional anesthesia optimizes pain control without disrupting
maintenance therapy. Discontinuing buprenorphine risks withdrawal and relapse. Increasing dose may
not provide sufficient acute pain relief. Naloxone would precipitate withdrawal and is contraindicated.
11. A patient with acute respiratory distress syndrome (ARDS) is on volume-controlled ventilation
with a set tidal volume of 6 mL/kg ideal body weight. The plateau pressure is 32 cm H2O, and the
PaCO2 is 55 mm Hg with a pH of 7.25. Which intervention should the nurse anticipate to improve
oxygenation while minimizing ventilator-induced lung injury?
A. Increase tidal volume to 8 mL/kg to improve minute ventilation and reduce PaCO2.
B. Increase positive end-expiratory pressure (PEEP) to recruit alveoli and improve oxygenation.
C. Decrease respiratory rate to allow more time for exhalation and reduce auto-PEEP.
D. Switch to pressure-controlled ventilation with a high inspiratory pressure to increase mean airway pressure.
Answer: B
Rationale: In ARDS, lung-protective ventilation uses low tidal volumes (6 mL/kg) to prevent volutrauma.
Plateau pressure above 30 cm H2O indicates risk of barotrauma; increasing PEEP can recruit
collapsed alveoli, improve oxygenation, and reduce shunt fraction. Increasing tidal volume would
worsen lung injury. Decreasing respiratory rate would not improve oxygenation and might worsen
hypercapnia. Pressure-controlled ventilation with high pressures could cause barotrauma.
12. A patient with type 2 diabetes mellitus and chronic kidney disease (stage 4) is prescribed
metformin. The nurse reviews the patient's laboratory results: eGFR 28 mL/min/1.73 m², serum
creatinine 2.4 mg/dL. Which action is most appropriate?
A. Administer the metformin as prescribed, but monitor renal function weekly.
B. Hold the metformin and notify the prescriber because it is contraindicated.
C. Reduce the metformin dose by 50% and monitor for lactic acidosis.
D. Administer the metformin with a sulfonylurea to enhance glycemic control.
Answer: B
Rationale: Metformin is contraindicated when eGFR is below 30 mL/min/1.73 m² due to increased risk of
lactic acidosis. The nurse should hold the medication and notify the prescriber for an alternative agent.
Dose reduction is not sufficient at this level of renal impairment. Adding a sulfonylurea does not address
the contraindication.
Page 4
