The Ultimate and Complete Evolve Elsevier HESI Medical-Surgical Nursing
Study Guide 2024–2025, Covering Adult Health Assessment and Clinical
Judgment Skills, Cardiovascular Respiratory Neurological and
Gastrointestinal Disorders, Endocrine and Metabolic Imbalances, Renal and
Urinary System Conditions, Musculoskeletal and Integumentary Nursing Care,
Fluid and Electrolyte and Acid-Base Balance Management, Infection Control
and Sepsis Prevention Strategies, Perioperative and Postoperative Nursing
Care, Pharmacology and Medication Administration in Medical-Surgical
Settings, Prioritization and Delegation in Clinical Scenarios, HESI-Style
Practice Questions with Verified Answers and Detailed Rationales, Real
Clinical Case Studies, Step-by-Step Nursing Care Plans, and Proven
Strategies to Successfully Pass HESI Medical-Surgical Exams Using Evolve
Elsevier Resources
Question 1: A 68-year-old client with a history of chronic heart failure is admitted to the
medical-surgical unit with an acute exacerbation. The nurse notes bilateral crackles in the
lung bases, +3 pitting edema in the lower extremities, and jugular venous distention. Which
assessment finding should the nurse prioritize when evaluating the effectiveness of the
prescribed intravenous furosemide?
A. A decrease in the client's daily weight by 2 pounds. B. A reduction in the client's heart rate
from 102 beats per minute to 88 beats per minute. C. An increase in the client's urine output to
at least 30 mL per hour. D. A decrease in the client's respiratory rate and an improvement in
oxygen saturation levels.
CORRECT ANSWER: D. A decrease in the client's respiratory rate and an improvement in
oxygen saturation levels.
Rationale: In a client experiencing an acute exacerbation of heart failure with pulmonary
congestion, the primary life-threatening issue is impaired gas exchange due to fluid
accumulation in the alveolar spaces. While a reduction in weight and an increase in urine
output are expected outcomes of diuretic therapy, the immediate priority is respiratory status.
A decrease in respiratory rate and an improvement in oxygen saturation indicate that the
pulmonary edema is resolving and gas exchange is improving. Heart rate reduction may occur
secondary to decreased sympathetic nervous system activation, but it is not the most direct
indicator of resolving pulmonary congestion. Therefore, assessing the respiratory status and
oxygenation provides the most critical, real-time data regarding the immediate efficacy of the
diuretic intervention on the client's most vital organ system.
,Question 2: A client with a long-standing history of chronic obstructive pulmonary disease
(COPD) arrives at the emergency department reporting increased dyspnea and a productive
cough with thick, yellow-green sputum. The client's current oxygen saturation is 88% on room
air. Which intervention should the nurse implement first?
A. Administer the prescribed broad-spectrum intravenous antibiotic. B. Assist the client into a
high-Fowler's position and apply supplemental oxygen at 2 L/min via nasal cannula. C. Obtain a
sputum sample for culture and sensitivity testing. D. Administer the prescribed short-acting
beta-agonist via a metered-dose inhaler with a spacer.
CORRECT ANSWER: B. Assist the client into a high-Fowler's position and apply supplemental
oxygen at 2 L/min via nasal cannula.
Rationale: The client is presenting with signs of an acute COPD exacerbation likely triggered by
a respiratory infection, as evidenced by the change in sputum color and increased dyspnea. The
client is currently hypoxic (SpO2 88%). According to the ABCs (Airway, Breathing, Circulation) of
prioritization, addressing hypoxia is the immediate priority. Placing the client in a high-Fowler's
position maximizes lung expansion, and applying low-flow supplemental oxygen (2 L/min) helps
correct hypoxemia without eliminating the hypoxic drive in a client with chronic CO2 retention.
While antibiotics, sputum cultures, and bronchodilators are essential components of the
treatment plan for a COPD exacerbation, they will not immediately correct the life-threatening
hypoxia. Oxygenation and positioning must be addressed first to stabilize the client's
respiratory status.
Question 3: A client with advanced cirrhosis is admitted with ascites and esophageal varices.
The client suddenly reports feeling lightheaded and vomits a large amount of bright red
blood. The nurse assesses the client and notes a blood pressure of 80/50 mmHg and a heart
rate of 124 beats per minute. Which action is the nurse's immediate priority?
A. Administer the prescribed intravenous octreotide infusion. B. Prepare the client for an
emergent esophagogastroduodenoscopy (EGD). C. Establish two large-bore intravenous
accesses and initiate fluid resuscitation. D. Administer the prescribed intravenous vitamin K.
CORRECT ANSWER: C. Establish two large-bore intravenous accesses and initiate fluid
resuscitation.
Rationale: The client is experiencing a life-threatening upper gastrointestinal hemorrhage
secondary to ruptured esophageal varices, leading to hypovolemic shock (evidenced by
hypotension, tachycardia, and lightheadedness). The absolute priority in a bleeding emergency
with hemodynamic instability is to restore intravascular volume to maintain tissue perfusion.
Establishing large-bore IV access and initiating rapid fluid resuscitation (with isotonic
crystalloids or blood products) is the most critical first step. While octreotide reduces
splanchnic blood flow and portal pressure, and an EGD is necessary to band or sclerose the
bleeding varices, these interventions cannot be effectively performed or will not be sufficient
,without first stabilizing the client's hemodynamic status. Vitamin K helps with coagulopathy but
does not address the immediate hypovolemia.
Question 4: A client admitted with acute kidney injury (AKI) in the oliguric phase has a serum
potassium level of 6.8 mEq/L. The nurse is reviewing the client's electrocardiogram (ECG).
Which ECG change is the most critical indicator of the severity of this electrolyte imbalance?
A. Presence of a U wave following the T wave. B. Prolonged QT interval and flattened T waves.
C. Peaked T waves and a widened QRS complex. D. ST segment depression and inverted T
waves.
CORRECT ANSWER: C. Peaked T waves and a widened QRS complex.
Rationale: A serum potassium level of 6.8 mEq/L indicates severe hyperkalemia, which poses an
immediate risk for life-threatening cardiac dysrhythmias, including ventricular fibrillation and
asystole. The classic and most dangerous ECG changes associated with severe hyperkalemia
include tall, peaked T waves, a prolonged PR interval, a widened QRS complex, and eventually a
sine wave pattern leading to cardiac arrest. U waves are characteristic of hypokalemia. A
prolonged QT interval and flattened T waves are seen in hypocalcemia and hypokalemia. ST
segment depression and inverted T waves are typically indicative of myocardial ischemia.
Therefore, peaked T waves and a widened QRS complex require the most immediate medical
intervention, such as the administration of calcium gluconate to stabilize the myocardium,
followed by insulin and glucose to shift potassium intracellularly.
Question 5: A client with a history of poorly controlled hypothyroidism is brought to the
emergency department by their family. The family reports that the client has been
increasingly confused, lethargic, and complaining of feeling very cold over the past few days.
The nurse assesses the client and notes a body temperature of 94.2°F (34.6°C), a heart rate of
52 beats per minute, and a blood pressure of 88/54 mmHg. Which condition should the nurse
suspect and prepare to treat immediately?
A. Thyroid storm. B. Myxedema coma. C. Hashimoto's thyroiditis. D. Sick euthyroid syndrome.
CORRECT ANSWER: B. Myxedema coma.
Rationale: Myxedema coma is a rare, life-threatening complication of severe, untreated, or
poorly managed hypothyroidism. It is characterized by profound hypothermia, bradycardia,
hypotension, altered mental status (ranging from lethargy to coma), and hypoventilation. The
client's presentation of confusion, lethargy, severe hypothermia, bradycardia, and hypotension
is classic for this endocrine emergency. Thyroid storm is a hypermetabolic crisis seen in severe
hyperthyroidism, presenting with hyperthermia, tachycardia, and hypertension. Hashimoto's
thyroiditis is an autoimmune cause of hypothyroidism, not an acute crisis. Sick euthyroid
syndrome refers to abnormal thyroid function tests in severely ill patients without preexisting
thyroid dysfunction. Immediate treatment for myxedema coma includes airway management,
, mechanical ventilation if necessary, intravenous levothyroxine, corticosteroids, and passive
rewarming.
Question 6: A client with type 1 diabetes mellitus is admitted to the intensive care unit with
diabetic ketoacidosis (DKA). The client's blood glucose is 480 mg/dL, and the arterial blood
gas (ABG) shows a pH of 7.18 and a bicarbonate level of 10 mEq/L. Which prescribed
intervention should the nurse implement first?
A. Administer an intravenous bolus of regular insulin. B. Initiate a continuous intravenous
infusion of 0.9% normal saline. C. Administer intravenous sodium bicarbonate to correct the
acidosis. D. Add potassium chloride to the intravenous fluids.
CORRECT ANSWER: B. Initiate a continuous intravenous infusion of 0.9% normal saline.
Rationale: In the initial management of diabetic ketoacidosis (DKA), the client is profoundly
dehydrated due to osmotic diuresis caused by severe hyperglycemia. The absolute first priority
is aggressive fluid resuscitation to restore intravascular volume, improve tissue perfusion, and
help lower blood glucose levels through renal excretion. Isotonic fluids, such as 0.9% normal
saline, are administered rapidly in the first 1 to 2 hours. While insulin therapy is essential to halt
ketogenesis and correct hyperglycemia, it should be initiated after or concurrently with fluid
replacement, as giving insulin to a severely volume-depleted client can lead to cardiovascular
collapse. Potassium replacement is crucial but is only added once urine output is established
and serum potassium levels are known to be within a safe range (usually < 5.2 mEq/L) to
prevent hyperkalemia. Sodium bicarbonate is rarely used and only considered in severe, life-
threatening acidosis (pH < 6.9) due to the risk of paradoxical central nervous system acidosis.
Question 7: A 72-year-old client arrives at the emergency department exhibiting right-sided
hemiplegia and aphasia that began 45 minutes ago. A non-contrast computed tomography
(CT) scan of the head shows no evidence of hemorrhage. The healthcare provider prescribes
intravenous alteplase (tPA). Which finding in the client's medical history is an absolute
contraindication for this therapy?
A. A history of hypertension managed with lisinopril and amlodipine. B. A myocardial infarction
4 months ago. C. A recent episode of gastrointestinal bleeding 3 weeks ago. D. A history of type
2 diabetes mellitus managed with metformin.
CORRECT ANSWER: C. A recent episode of gastrointestinal bleeding 3 weeks ago.
Rationale: Intravenous alteplase (tPA) is a potent thrombolytic agent used to dissolve the clot
causing an acute ischemic stroke, but it carries a high risk of severe hemorrhage. Absolute
contraindications for tPA include any active internal bleeding, a history of recent significant
internal bleeding (such as gastrointestinal or intracranial bleeding within the past 3 weeks to 3
months, depending on specific guidelines), a recent major surgery or trauma (within 14 days), a
history of hemorrhagic stroke, or a current severe uncontrolled hypertension (e.g., systolic >
185 mmHg or diastolic > 110 mmHg). A gastrointestinal bleed 3 weeks ago poses an
Study Guide 2024–2025, Covering Adult Health Assessment and Clinical
Judgment Skills, Cardiovascular Respiratory Neurological and
Gastrointestinal Disorders, Endocrine and Metabolic Imbalances, Renal and
Urinary System Conditions, Musculoskeletal and Integumentary Nursing Care,
Fluid and Electrolyte and Acid-Base Balance Management, Infection Control
and Sepsis Prevention Strategies, Perioperative and Postoperative Nursing
Care, Pharmacology and Medication Administration in Medical-Surgical
Settings, Prioritization and Delegation in Clinical Scenarios, HESI-Style
Practice Questions with Verified Answers and Detailed Rationales, Real
Clinical Case Studies, Step-by-Step Nursing Care Plans, and Proven
Strategies to Successfully Pass HESI Medical-Surgical Exams Using Evolve
Elsevier Resources
Question 1: A 68-year-old client with a history of chronic heart failure is admitted to the
medical-surgical unit with an acute exacerbation. The nurse notes bilateral crackles in the
lung bases, +3 pitting edema in the lower extremities, and jugular venous distention. Which
assessment finding should the nurse prioritize when evaluating the effectiveness of the
prescribed intravenous furosemide?
A. A decrease in the client's daily weight by 2 pounds. B. A reduction in the client's heart rate
from 102 beats per minute to 88 beats per minute. C. An increase in the client's urine output to
at least 30 mL per hour. D. A decrease in the client's respiratory rate and an improvement in
oxygen saturation levels.
CORRECT ANSWER: D. A decrease in the client's respiratory rate and an improvement in
oxygen saturation levels.
Rationale: In a client experiencing an acute exacerbation of heart failure with pulmonary
congestion, the primary life-threatening issue is impaired gas exchange due to fluid
accumulation in the alveolar spaces. While a reduction in weight and an increase in urine
output are expected outcomes of diuretic therapy, the immediate priority is respiratory status.
A decrease in respiratory rate and an improvement in oxygen saturation indicate that the
pulmonary edema is resolving and gas exchange is improving. Heart rate reduction may occur
secondary to decreased sympathetic nervous system activation, but it is not the most direct
indicator of resolving pulmonary congestion. Therefore, assessing the respiratory status and
oxygenation provides the most critical, real-time data regarding the immediate efficacy of the
diuretic intervention on the client's most vital organ system.
,Question 2: A client with a long-standing history of chronic obstructive pulmonary disease
(COPD) arrives at the emergency department reporting increased dyspnea and a productive
cough with thick, yellow-green sputum. The client's current oxygen saturation is 88% on room
air. Which intervention should the nurse implement first?
A. Administer the prescribed broad-spectrum intravenous antibiotic. B. Assist the client into a
high-Fowler's position and apply supplemental oxygen at 2 L/min via nasal cannula. C. Obtain a
sputum sample for culture and sensitivity testing. D. Administer the prescribed short-acting
beta-agonist via a metered-dose inhaler with a spacer.
CORRECT ANSWER: B. Assist the client into a high-Fowler's position and apply supplemental
oxygen at 2 L/min via nasal cannula.
Rationale: The client is presenting with signs of an acute COPD exacerbation likely triggered by
a respiratory infection, as evidenced by the change in sputum color and increased dyspnea. The
client is currently hypoxic (SpO2 88%). According to the ABCs (Airway, Breathing, Circulation) of
prioritization, addressing hypoxia is the immediate priority. Placing the client in a high-Fowler's
position maximizes lung expansion, and applying low-flow supplemental oxygen (2 L/min) helps
correct hypoxemia without eliminating the hypoxic drive in a client with chronic CO2 retention.
While antibiotics, sputum cultures, and bronchodilators are essential components of the
treatment plan for a COPD exacerbation, they will not immediately correct the life-threatening
hypoxia. Oxygenation and positioning must be addressed first to stabilize the client's
respiratory status.
Question 3: A client with advanced cirrhosis is admitted with ascites and esophageal varices.
The client suddenly reports feeling lightheaded and vomits a large amount of bright red
blood. The nurse assesses the client and notes a blood pressure of 80/50 mmHg and a heart
rate of 124 beats per minute. Which action is the nurse's immediate priority?
A. Administer the prescribed intravenous octreotide infusion. B. Prepare the client for an
emergent esophagogastroduodenoscopy (EGD). C. Establish two large-bore intravenous
accesses and initiate fluid resuscitation. D. Administer the prescribed intravenous vitamin K.
CORRECT ANSWER: C. Establish two large-bore intravenous accesses and initiate fluid
resuscitation.
Rationale: The client is experiencing a life-threatening upper gastrointestinal hemorrhage
secondary to ruptured esophageal varices, leading to hypovolemic shock (evidenced by
hypotension, tachycardia, and lightheadedness). The absolute priority in a bleeding emergency
with hemodynamic instability is to restore intravascular volume to maintain tissue perfusion.
Establishing large-bore IV access and initiating rapid fluid resuscitation (with isotonic
crystalloids or blood products) is the most critical first step. While octreotide reduces
splanchnic blood flow and portal pressure, and an EGD is necessary to band or sclerose the
bleeding varices, these interventions cannot be effectively performed or will not be sufficient
,without first stabilizing the client's hemodynamic status. Vitamin K helps with coagulopathy but
does not address the immediate hypovolemia.
Question 4: A client admitted with acute kidney injury (AKI) in the oliguric phase has a serum
potassium level of 6.8 mEq/L. The nurse is reviewing the client's electrocardiogram (ECG).
Which ECG change is the most critical indicator of the severity of this electrolyte imbalance?
A. Presence of a U wave following the T wave. B. Prolonged QT interval and flattened T waves.
C. Peaked T waves and a widened QRS complex. D. ST segment depression and inverted T
waves.
CORRECT ANSWER: C. Peaked T waves and a widened QRS complex.
Rationale: A serum potassium level of 6.8 mEq/L indicates severe hyperkalemia, which poses an
immediate risk for life-threatening cardiac dysrhythmias, including ventricular fibrillation and
asystole. The classic and most dangerous ECG changes associated with severe hyperkalemia
include tall, peaked T waves, a prolonged PR interval, a widened QRS complex, and eventually a
sine wave pattern leading to cardiac arrest. U waves are characteristic of hypokalemia. A
prolonged QT interval and flattened T waves are seen in hypocalcemia and hypokalemia. ST
segment depression and inverted T waves are typically indicative of myocardial ischemia.
Therefore, peaked T waves and a widened QRS complex require the most immediate medical
intervention, such as the administration of calcium gluconate to stabilize the myocardium,
followed by insulin and glucose to shift potassium intracellularly.
Question 5: A client with a history of poorly controlled hypothyroidism is brought to the
emergency department by their family. The family reports that the client has been
increasingly confused, lethargic, and complaining of feeling very cold over the past few days.
The nurse assesses the client and notes a body temperature of 94.2°F (34.6°C), a heart rate of
52 beats per minute, and a blood pressure of 88/54 mmHg. Which condition should the nurse
suspect and prepare to treat immediately?
A. Thyroid storm. B. Myxedema coma. C. Hashimoto's thyroiditis. D. Sick euthyroid syndrome.
CORRECT ANSWER: B. Myxedema coma.
Rationale: Myxedema coma is a rare, life-threatening complication of severe, untreated, or
poorly managed hypothyroidism. It is characterized by profound hypothermia, bradycardia,
hypotension, altered mental status (ranging from lethargy to coma), and hypoventilation. The
client's presentation of confusion, lethargy, severe hypothermia, bradycardia, and hypotension
is classic for this endocrine emergency. Thyroid storm is a hypermetabolic crisis seen in severe
hyperthyroidism, presenting with hyperthermia, tachycardia, and hypertension. Hashimoto's
thyroiditis is an autoimmune cause of hypothyroidism, not an acute crisis. Sick euthyroid
syndrome refers to abnormal thyroid function tests in severely ill patients without preexisting
thyroid dysfunction. Immediate treatment for myxedema coma includes airway management,
, mechanical ventilation if necessary, intravenous levothyroxine, corticosteroids, and passive
rewarming.
Question 6: A client with type 1 diabetes mellitus is admitted to the intensive care unit with
diabetic ketoacidosis (DKA). The client's blood glucose is 480 mg/dL, and the arterial blood
gas (ABG) shows a pH of 7.18 and a bicarbonate level of 10 mEq/L. Which prescribed
intervention should the nurse implement first?
A. Administer an intravenous bolus of regular insulin. B. Initiate a continuous intravenous
infusion of 0.9% normal saline. C. Administer intravenous sodium bicarbonate to correct the
acidosis. D. Add potassium chloride to the intravenous fluids.
CORRECT ANSWER: B. Initiate a continuous intravenous infusion of 0.9% normal saline.
Rationale: In the initial management of diabetic ketoacidosis (DKA), the client is profoundly
dehydrated due to osmotic diuresis caused by severe hyperglycemia. The absolute first priority
is aggressive fluid resuscitation to restore intravascular volume, improve tissue perfusion, and
help lower blood glucose levels through renal excretion. Isotonic fluids, such as 0.9% normal
saline, are administered rapidly in the first 1 to 2 hours. While insulin therapy is essential to halt
ketogenesis and correct hyperglycemia, it should be initiated after or concurrently with fluid
replacement, as giving insulin to a severely volume-depleted client can lead to cardiovascular
collapse. Potassium replacement is crucial but is only added once urine output is established
and serum potassium levels are known to be within a safe range (usually < 5.2 mEq/L) to
prevent hyperkalemia. Sodium bicarbonate is rarely used and only considered in severe, life-
threatening acidosis (pH < 6.9) due to the risk of paradoxical central nervous system acidosis.
Question 7: A 72-year-old client arrives at the emergency department exhibiting right-sided
hemiplegia and aphasia that began 45 minutes ago. A non-contrast computed tomography
(CT) scan of the head shows no evidence of hemorrhage. The healthcare provider prescribes
intravenous alteplase (tPA). Which finding in the client's medical history is an absolute
contraindication for this therapy?
A. A history of hypertension managed with lisinopril and amlodipine. B. A myocardial infarction
4 months ago. C. A recent episode of gastrointestinal bleeding 3 weeks ago. D. A history of type
2 diabetes mellitus managed with metformin.
CORRECT ANSWER: C. A recent episode of gastrointestinal bleeding 3 weeks ago.
Rationale: Intravenous alteplase (tPA) is a potent thrombolytic agent used to dissolve the clot
causing an acute ischemic stroke, but it carries a high risk of severe hemorrhage. Absolute
contraindications for tPA include any active internal bleeding, a history of recent significant
internal bleeding (such as gastrointestinal or intracranial bleeding within the past 3 weeks to 3
months, depending on specific guidelines), a recent major surgery or trauma (within 14 days), a
history of hemorrhagic stroke, or a current severe uncontrolled hypertension (e.g., systolic >
185 mmHg or diastolic > 110 mmHg). A gastrointestinal bleed 3 weeks ago poses an
