HESI Critical Care Exam Official
Practice Exam Actual Exam 2026/2027
with Detailed Rationales | Complete
Exam-Style Questions | Pass
Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: HEMODYNAMICS & CARDIOVASCULAR CRITICAL CARE Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 67-year-old male admitted with an inferior wall MI develops sudden hypotension at 78/52
mmHg, heart rate 52 bpm, and crackles in bilateral lung bases. His 12-lead ECG now shows
sinus bradycardia with ST elevation in leads II, III, and aVF. The bedside nurse notes a new
holosystolic murmur at the left sternal border. Which intervention should the nurse prioritize
first?
A. Initiate a dopamine infusion at 5 mcg/kg/min to increase heart rate and blood pressure
B. Prepare the patient for emergent cardiac catheterization and possible revascularization
C. Obtain a stat transthoracic echocardiogram to evaluate for papillary muscle rupture or
ventricular septal defect
D. Administer atropine 0.5 mg IV push and prepare for temporary transvenous pacemaker
placement
Correct Answer: D
Rationale: In an inferior wall MI with sinus bradycardia and hypotension, the priority is
correcting the symptomatic bradycardia that is driving the low cardiac output. Atropine is the
first-line intervention for symptomatic bradycardia per ACLS protocols, and temporary pacing
may be needed if atropine fails. While the murmur suggests a mechanical complication, the
immediate threat is hemodynamic collapse from the bradycardia, not the murmur itself.
Emergent catheterization is important but secondary to stabilizing the rhythm and perfusion
pressure first.
Question 2 of 50
,A 54-year-old female with a history of dilated cardiomyopathy is admitted in acute
decompensated heart failure. Her arterial line shows a MAP of 58 mmHg, CVP 18 mmHg, and
PAOP 28 mmHg. She is cool and clammy with a urine output of 15 mL/hr. Her current
medications include furosemide 40 mg IV and carvedilol 25 mg PO BID. Which hemodynamic
profile best describes this patient and guides initial therapy?
A. Cold and wet profile requiring afterload reduction with nitroprusside
B. Cold and dry profile requiring cautious volume resuscitation
C. Warm and wet profile requiring diuresis and vasodilation
D. Cold and wet profile requiring inotropic support with dobutamine
Correct Answer: D
Rationale: This patient presents the classic cold and wet profile: low MAP (cold, poor
perfusion) with elevated CVP and PAOP (wet, volume overloaded), indicating cardiogenic
shock with pulmonary congestion. Inotropic support with dobutamine is indicated to improve
cardiac contractility and forward flow. Nitroprusside would further drop her already low MAP,
and volume resuscitation would worsen her pulmonary edema. While she is wet, she is not
warm; the cold extremities and low urine output confirm inadequate perfusion requiring
inotropes before diuresis.
Question 3 of 50
A 62-year-old male post-CABG x3 is on a pulmonary artery catheter. His readings show CI 1.8
L/min/m², SVR 1800 dynes/sec/cm⁻⁵, PAOP 8 mmHg, and SvO₂ 52%. He is on norepinephrine
at 12 mcg/min and vasopressin 0.04 units/min. His lactate is 4.2 mmol/L. Based on these
values, which adjustment to his hemodynamic management is most appropriate?
A. Add dobutamine to increase cardiac index and improve oxygen delivery
B. Increase norepinephrine to achieve a higher MAP and improve coronary perfusion
C. Administer a 500 mL bolus of lactated Ringer's to increase preload and PAOP
D. Initiate milrinone to reduce afterload and improve cardiac contractility
Correct Answer: A
Rationale: The low cardiac index (normal >2.5), elevated SVR, low PAOP, and critically low
SvO₂ indicate a primary problem of low cardiac output with adequate preload but poor oxygen
delivery. Dobutamine is the appropriate choice to increase contractility and cardiac index
without significantly increasing afterload. Further increasing norepinephrine would raise SVR
even more and worsen afterload. A fluid bolus is not indicated with a PAOP of 8 mmHg, which
is at the lower end of normal but not hypovolemic. Milrinone could cause excessive
hypotension in this postoperative patient already on high-dose vasopressors.
Question 4 of 50
, A 58-year-old male with a history of atrial fibrillation on warfarin presents to the ICU with
acute-onset chest pain, dyspnea, and syncope. His blood pressure is 86/54 mmHg, heart rate
118 bpm irregularly irregular, and SpO₂ 88% on 2L NC. CT angiography confirms a massive
saddle pulmonary embolism. The ICU team is preparing systemic thrombolysis. Which
intervention should the nurse anticipate administering immediately before the tPA infusion
begins?
A. Administer vitamin K 10 mg IV to reverse warfarin anticoagulation
B. Draw and type & screen for 4 units of packed red blood cells
C. Prepare a heparin infusion at 18 units/kg/hr to run concurrently with tPA
D. Obtain a stat coagulation panel and prepare for possible fresh frozen plasma
administration
Correct Answer: D
Rationale: Before thrombolysis in a patient on warfarin, the nurse must assess baseline
coagulation status because the risk of hemorrhagic conversion is significantly elevated with
an elevated INR. A stat coagulation panel guides whether FFP is needed to correct
coagulopathy before or during lysis. Vitamin K takes hours to days to work and is not
appropriate for immediate reversal. Heparin should be held during and immediately after tPA
administration due to bleeding risk. While blood typing is prudent, it is not the most critical
immediate action before initiating a high-bleeding-risk therapy.
Question 5 of 50
A 45-year-old female with septic shock from a perforated viscus is on norepinephrine 20
mcg/min, vasopressin 0.04 units/min, and epinephrine 8 mcg/min. Her MAP remains 58
mmHg despite these interventions. Her lactate is 6.8 mmol/L, ScvO₂ 48%, and she has
mottling to her knees. Bedside echocardiography reveals an LVEF of 65% with a small,
hyperdynamic left ventricle. Which additional intervention is most appropriate at this time?
A. Add phenylephrine to increase systemic vascular resistance and improve MAP
B. Initiate hydrocortisone 50 mg IV q6h for refractory vasopressor-dependent shock
C. Begin dobutamine to augment cardiac contractility in the setting of sepsis-induced
cardiomyopathy
D. Administer a 30 mL/kg crystalloid bolus to increase preload and stroke volume
Correct Answer: B
Rationale: This patient has refractory septic shock with persistent hypotension despite three
vasopressors, meeting criteria for corticosteroid replacement per Surviving Sepsis Campaign
guidelines. Hydrocortisone is indicated when vasopressor requirements are high and shock
is refractory. Phenylephrine is pure alpha-agonism and would further reduce already
compromised tissue perfusion. Dobutamine is contraindicated because the echocardiogram
shows a hyperdynamic heart with preserved EF, not sepsis-induced cardiomyopathy.
Practice Exam Actual Exam 2026/2027
with Detailed Rationales | Complete
Exam-Style Questions | Pass
Guaranteed – A+ Graded
══════════════════════════════════════
SECTION 1: HEMODYNAMICS & CARDIOVASCULAR CRITICAL CARE Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 67-year-old male admitted with an inferior wall MI develops sudden hypotension at 78/52
mmHg, heart rate 52 bpm, and crackles in bilateral lung bases. His 12-lead ECG now shows
sinus bradycardia with ST elevation in leads II, III, and aVF. The bedside nurse notes a new
holosystolic murmur at the left sternal border. Which intervention should the nurse prioritize
first?
A. Initiate a dopamine infusion at 5 mcg/kg/min to increase heart rate and blood pressure
B. Prepare the patient for emergent cardiac catheterization and possible revascularization
C. Obtain a stat transthoracic echocardiogram to evaluate for papillary muscle rupture or
ventricular septal defect
D. Administer atropine 0.5 mg IV push and prepare for temporary transvenous pacemaker
placement
Correct Answer: D
Rationale: In an inferior wall MI with sinus bradycardia and hypotension, the priority is
correcting the symptomatic bradycardia that is driving the low cardiac output. Atropine is the
first-line intervention for symptomatic bradycardia per ACLS protocols, and temporary pacing
may be needed if atropine fails. While the murmur suggests a mechanical complication, the
immediate threat is hemodynamic collapse from the bradycardia, not the murmur itself.
Emergent catheterization is important but secondary to stabilizing the rhythm and perfusion
pressure first.
Question 2 of 50
,A 54-year-old female with a history of dilated cardiomyopathy is admitted in acute
decompensated heart failure. Her arterial line shows a MAP of 58 mmHg, CVP 18 mmHg, and
PAOP 28 mmHg. She is cool and clammy with a urine output of 15 mL/hr. Her current
medications include furosemide 40 mg IV and carvedilol 25 mg PO BID. Which hemodynamic
profile best describes this patient and guides initial therapy?
A. Cold and wet profile requiring afterload reduction with nitroprusside
B. Cold and dry profile requiring cautious volume resuscitation
C. Warm and wet profile requiring diuresis and vasodilation
D. Cold and wet profile requiring inotropic support with dobutamine
Correct Answer: D
Rationale: This patient presents the classic cold and wet profile: low MAP (cold, poor
perfusion) with elevated CVP and PAOP (wet, volume overloaded), indicating cardiogenic
shock with pulmonary congestion. Inotropic support with dobutamine is indicated to improve
cardiac contractility and forward flow. Nitroprusside would further drop her already low MAP,
and volume resuscitation would worsen her pulmonary edema. While she is wet, she is not
warm; the cold extremities and low urine output confirm inadequate perfusion requiring
inotropes before diuresis.
Question 3 of 50
A 62-year-old male post-CABG x3 is on a pulmonary artery catheter. His readings show CI 1.8
L/min/m², SVR 1800 dynes/sec/cm⁻⁵, PAOP 8 mmHg, and SvO₂ 52%. He is on norepinephrine
at 12 mcg/min and vasopressin 0.04 units/min. His lactate is 4.2 mmol/L. Based on these
values, which adjustment to his hemodynamic management is most appropriate?
A. Add dobutamine to increase cardiac index and improve oxygen delivery
B. Increase norepinephrine to achieve a higher MAP and improve coronary perfusion
C. Administer a 500 mL bolus of lactated Ringer's to increase preload and PAOP
D. Initiate milrinone to reduce afterload and improve cardiac contractility
Correct Answer: A
Rationale: The low cardiac index (normal >2.5), elevated SVR, low PAOP, and critically low
SvO₂ indicate a primary problem of low cardiac output with adequate preload but poor oxygen
delivery. Dobutamine is the appropriate choice to increase contractility and cardiac index
without significantly increasing afterload. Further increasing norepinephrine would raise SVR
even more and worsen afterload. A fluid bolus is not indicated with a PAOP of 8 mmHg, which
is at the lower end of normal but not hypovolemic. Milrinone could cause excessive
hypotension in this postoperative patient already on high-dose vasopressors.
Question 4 of 50
, A 58-year-old male with a history of atrial fibrillation on warfarin presents to the ICU with
acute-onset chest pain, dyspnea, and syncope. His blood pressure is 86/54 mmHg, heart rate
118 bpm irregularly irregular, and SpO₂ 88% on 2L NC. CT angiography confirms a massive
saddle pulmonary embolism. The ICU team is preparing systemic thrombolysis. Which
intervention should the nurse anticipate administering immediately before the tPA infusion
begins?
A. Administer vitamin K 10 mg IV to reverse warfarin anticoagulation
B. Draw and type & screen for 4 units of packed red blood cells
C. Prepare a heparin infusion at 18 units/kg/hr to run concurrently with tPA
D. Obtain a stat coagulation panel and prepare for possible fresh frozen plasma
administration
Correct Answer: D
Rationale: Before thrombolysis in a patient on warfarin, the nurse must assess baseline
coagulation status because the risk of hemorrhagic conversion is significantly elevated with
an elevated INR. A stat coagulation panel guides whether FFP is needed to correct
coagulopathy before or during lysis. Vitamin K takes hours to days to work and is not
appropriate for immediate reversal. Heparin should be held during and immediately after tPA
administration due to bleeding risk. While blood typing is prudent, it is not the most critical
immediate action before initiating a high-bleeding-risk therapy.
Question 5 of 50
A 45-year-old female with septic shock from a perforated viscus is on norepinephrine 20
mcg/min, vasopressin 0.04 units/min, and epinephrine 8 mcg/min. Her MAP remains 58
mmHg despite these interventions. Her lactate is 6.8 mmol/L, ScvO₂ 48%, and she has
mottling to her knees. Bedside echocardiography reveals an LVEF of 65% with a small,
hyperdynamic left ventricle. Which additional intervention is most appropriate at this time?
A. Add phenylephrine to increase systemic vascular resistance and improve MAP
B. Initiate hydrocortisone 50 mg IV q6h for refractory vasopressor-dependent shock
C. Begin dobutamine to augment cardiac contractility in the setting of sepsis-induced
cardiomyopathy
D. Administer a 30 mL/kg crystalloid bolus to increase preload and stroke volume
Correct Answer: B
Rationale: This patient has refractory septic shock with persistent hypotension despite three
vasopressors, meeting criteria for corticosteroid replacement per Surviving Sepsis Campaign
guidelines. Hydrocortisone is indicated when vasopressor requirements are high and shock
is refractory. Phenylephrine is pure alpha-agonism and would further reduce already
compromised tissue perfusion. Dobutamine is contraindicated because the echocardiogram
shows a hyperdynamic heart with preserved EF, not sepsis-induced cardiomyopathy.
