HESI Med-Surg V1 2025/2026 –
100% Verified & Updated Exam
Questions
1. A client with COPD exacerbation has PaCO₂ 68 mmHg and pH 7.28. Which
intervention is priority?Initiate BiPAP at 10/5 cm H₂O Rationale: Pathophysiology:
Chronic hypercapnia causes CO₂ narcosis; acute rise leads to respiratory acidosis (pH
<7.35). BiPAP reduces work of breathing, improves alveolar ventilation, and corrects
acidosis without intubation. Intubation is reserved for failure (pH <7.25).
2. A client post-pneumonectomy develops sudden dyspnea and tracheal deviation to
the opposite side. What is the emergency?Tension pneumothorax Rationale:
Pathophysiology: Air enters pleural space via bronchopleural fistula but cannot escape
→ mediastinal shift → vena cava compression → ↓ venous return. Immediate needle
decompression at 2nd ICS midclavicular line is lifesaving.
3. A client with asthma has peak flow 40% of personal best after albuterol. Next
action?Administer magnesium sulfate 2 g IV over 20 min Rationale: Pathophysiology:
Severe bronchospasm → ↓ FEV1; magnesium relaxes smooth muscle by blocking
calcium influx. Used in refractory status asthmaticus per GINA guidelines.
4. A client with pulmonary embolism (PE) has RV strain on ECG. Which thrombolytic
is indicated?Alteplase 100 mg IV over 2 hours Rationale: Pathophysiology: Massive PE
→ acute cor pulmonale; RV dilation → ↓ cardiac output. Thrombolysis dissolves clot,
restores pulmonary perfusion; contraindicated in recent surgery.
5. A client with ARDS has plateau pressure 34 cm H₂O on volume control.
Adjustment needed?Reduce tidal volume to 4 mL/kg IBW Rationale: Pathophysiology:
Alveolar overdistension → barotrauma, VILI. ARDSNet protocol: TV 4–6 mL/kg, plateau
<30 cm H₂O to prevent lung injury.
6. A client with heart failure has S3 gallop and BNP 1200 pg/mL. Which diuretic is
first-line?Furosemide 40 mg IV Rationale: Pathophysiology: Systolic dysfunction → ↑
LVEDP → pulmonary edema; S3 from rapid ventricular filling. Loop diuretics reduce
preload via natriuresis.
7. A client post-MI develops new holosystolic murmur at apex. Diagnosis?Papillary
muscle rupture → mitral regurgitation Rationale: Pathophysiology: Inferior MI →
posteromedial papillary muscle ischemia (RCA supply) → chordae tendineae rupture →
acute MR → pulmonary edema, cardiogenic shock.
8. A client with atrial fibrillation has HR 148 bpm. First medication?Diltiazem 0.25
mg/kg IV over 2 min Rationale: Pathophysiology: Rapid ventricular response → ↓
diastolic filling → ↓ CO. Non-dihydropyridine CCB slows AV node conduction.
, 9. A client with aortic dissection type A has SBP 180 mmHg. Target BP?SBP 100–120
mmHg with esmolol + nitroprusside Rationale: Pathophysiology: Intimal tear → false
lumen propagation driven by dP/dt. Beta-blocker reduces shear force; vasodilator lowers
BP.
10.A client with pericarditis has PR depression and diffuse ST elevation.
Treatment?Ibuprofen 600 mg q8h + colchicine 0.6 mg BID Rationale: Pathophysiology:
Inflammatory pericardial effusion → friction rub, ECG changes. NSAIDs + colchicine
reduce recurrence (COPE trial).
11.A client with CKD stage 4 has K⁺ 6.2 mEq/L and peaked T waves. Priority?Calcium
gluconate 1 g IV over 3 min Rationale: Pathophysiology: ↓ GFR → K⁺ retention →
membrane depolarization → arrhythmias. Calcium stabilizes cardiac membrane.
12.A client on hemodialysis misses a session; weight gain 5 kg. Finding?Pulmonary
edema with crackles Rationale: Pathophysiology: Fluid overload → ↑ hydrostatic
pressure → transudative edema in alveoli. Ultrafiltration required.
13.A client with nephrotic syndrome has 4+ proteinuria and albumin 1.8 g/dL.
Complication?Hypercoagulability → renal vein thrombosis Rationale: Pathophysiology:
Urinary loss of antithrombin III, protein C/S → prothrombotic state.
14.A client post-cystoscopy has fever and flank pain. Diagnosis?Acute pyelonephritis
Rationale: Pathophysiology: Instrumentation → ascending UTI → renal abscess
possible. Ceftriaxone + fluids.
15.A client with SIADH has Na⁺ 122 mEq/L and urine osmolality 600 mOsm/kg.
Treatment?Fluid restriction to 800 mL/day + demeclocycline Rationale:
Pathophysiology: ↑ ADH → water retention → dilutional hyponatremia. Demeclocycline
induces nephrogenic DI.
16.A client with DKA has pH 7.1, glucose 580 mg/dL. Initial fluid?Normal saline 1
L/hour x 2 hours Rationale: Pathophysiology: Osmotic diuresis → volume depletion 6–10
L. Isotonic saline restores intravascular volume before insulin.
17.A client with hypothyroidism has myxedema coma. Priority
medication?Levothyroxine 200–500 mcg IV bolus Rationale: Pathophysiology: Severe
T3/T4 deficiency → ↓ metabolism, hypothermia, coma. Rapid repletion needed; support
ventilation.
18.A client with Cushing’s syndrome has moon face, buffalo hump. Cause?Excess
cortisol → protein catabolism, fat redistribution Rationale: Pathophysiology: ↑ ACTH or
adrenal tumor → glucocorticoid excess → central obesity, muscle wasting.
19.A client with Addison’s disease has Na⁺ 128, K⁺ 5.8, BP 80/50.
Treatment?Hydrocortisone 100 mg IV + NS bolus Rationale: Pathophysiology:
Cortisol/aldosterone deficiency → shock, hyponatremia, hyperkalemia. Steroids restore
vascular tone.
20.A client with pheochromocytoma has paroxysmal HTN. Preoperative
drug?Phenoxybenzamine (alpha-blocker) Rationale: Pathophysiology: Catecholamine
surges → vasoconstriction. Alpha-blockade prevents intraoperative crisis.
21.A client with cirrhosis has ascites and SBP 18 g/dL - 5 g/dL = 13. Next
step?Diagnostic paracentesis Rationale: Pathophysiology: SAAG >1.1 → portal HTN.
PMNs >250 → spontaneous bacterial peritonitis (SBP).
100% Verified & Updated Exam
Questions
1. A client with COPD exacerbation has PaCO₂ 68 mmHg and pH 7.28. Which
intervention is priority?Initiate BiPAP at 10/5 cm H₂O Rationale: Pathophysiology:
Chronic hypercapnia causes CO₂ narcosis; acute rise leads to respiratory acidosis (pH
<7.35). BiPAP reduces work of breathing, improves alveolar ventilation, and corrects
acidosis without intubation. Intubation is reserved for failure (pH <7.25).
2. A client post-pneumonectomy develops sudden dyspnea and tracheal deviation to
the opposite side. What is the emergency?Tension pneumothorax Rationale:
Pathophysiology: Air enters pleural space via bronchopleural fistula but cannot escape
→ mediastinal shift → vena cava compression → ↓ venous return. Immediate needle
decompression at 2nd ICS midclavicular line is lifesaving.
3. A client with asthma has peak flow 40% of personal best after albuterol. Next
action?Administer magnesium sulfate 2 g IV over 20 min Rationale: Pathophysiology:
Severe bronchospasm → ↓ FEV1; magnesium relaxes smooth muscle by blocking
calcium influx. Used in refractory status asthmaticus per GINA guidelines.
4. A client with pulmonary embolism (PE) has RV strain on ECG. Which thrombolytic
is indicated?Alteplase 100 mg IV over 2 hours Rationale: Pathophysiology: Massive PE
→ acute cor pulmonale; RV dilation → ↓ cardiac output. Thrombolysis dissolves clot,
restores pulmonary perfusion; contraindicated in recent surgery.
5. A client with ARDS has plateau pressure 34 cm H₂O on volume control.
Adjustment needed?Reduce tidal volume to 4 mL/kg IBW Rationale: Pathophysiology:
Alveolar overdistension → barotrauma, VILI. ARDSNet protocol: TV 4–6 mL/kg, plateau
<30 cm H₂O to prevent lung injury.
6. A client with heart failure has S3 gallop and BNP 1200 pg/mL. Which diuretic is
first-line?Furosemide 40 mg IV Rationale: Pathophysiology: Systolic dysfunction → ↑
LVEDP → pulmonary edema; S3 from rapid ventricular filling. Loop diuretics reduce
preload via natriuresis.
7. A client post-MI develops new holosystolic murmur at apex. Diagnosis?Papillary
muscle rupture → mitral regurgitation Rationale: Pathophysiology: Inferior MI →
posteromedial papillary muscle ischemia (RCA supply) → chordae tendineae rupture →
acute MR → pulmonary edema, cardiogenic shock.
8. A client with atrial fibrillation has HR 148 bpm. First medication?Diltiazem 0.25
mg/kg IV over 2 min Rationale: Pathophysiology: Rapid ventricular response → ↓
diastolic filling → ↓ CO. Non-dihydropyridine CCB slows AV node conduction.
, 9. A client with aortic dissection type A has SBP 180 mmHg. Target BP?SBP 100–120
mmHg with esmolol + nitroprusside Rationale: Pathophysiology: Intimal tear → false
lumen propagation driven by dP/dt. Beta-blocker reduces shear force; vasodilator lowers
BP.
10.A client with pericarditis has PR depression and diffuse ST elevation.
Treatment?Ibuprofen 600 mg q8h + colchicine 0.6 mg BID Rationale: Pathophysiology:
Inflammatory pericardial effusion → friction rub, ECG changes. NSAIDs + colchicine
reduce recurrence (COPE trial).
11.A client with CKD stage 4 has K⁺ 6.2 mEq/L and peaked T waves. Priority?Calcium
gluconate 1 g IV over 3 min Rationale: Pathophysiology: ↓ GFR → K⁺ retention →
membrane depolarization → arrhythmias. Calcium stabilizes cardiac membrane.
12.A client on hemodialysis misses a session; weight gain 5 kg. Finding?Pulmonary
edema with crackles Rationale: Pathophysiology: Fluid overload → ↑ hydrostatic
pressure → transudative edema in alveoli. Ultrafiltration required.
13.A client with nephrotic syndrome has 4+ proteinuria and albumin 1.8 g/dL.
Complication?Hypercoagulability → renal vein thrombosis Rationale: Pathophysiology:
Urinary loss of antithrombin III, protein C/S → prothrombotic state.
14.A client post-cystoscopy has fever and flank pain. Diagnosis?Acute pyelonephritis
Rationale: Pathophysiology: Instrumentation → ascending UTI → renal abscess
possible. Ceftriaxone + fluids.
15.A client with SIADH has Na⁺ 122 mEq/L and urine osmolality 600 mOsm/kg.
Treatment?Fluid restriction to 800 mL/day + demeclocycline Rationale:
Pathophysiology: ↑ ADH → water retention → dilutional hyponatremia. Demeclocycline
induces nephrogenic DI.
16.A client with DKA has pH 7.1, glucose 580 mg/dL. Initial fluid?Normal saline 1
L/hour x 2 hours Rationale: Pathophysiology: Osmotic diuresis → volume depletion 6–10
L. Isotonic saline restores intravascular volume before insulin.
17.A client with hypothyroidism has myxedema coma. Priority
medication?Levothyroxine 200–500 mcg IV bolus Rationale: Pathophysiology: Severe
T3/T4 deficiency → ↓ metabolism, hypothermia, coma. Rapid repletion needed; support
ventilation.
18.A client with Cushing’s syndrome has moon face, buffalo hump. Cause?Excess
cortisol → protein catabolism, fat redistribution Rationale: Pathophysiology: ↑ ACTH or
adrenal tumor → glucocorticoid excess → central obesity, muscle wasting.
19.A client with Addison’s disease has Na⁺ 128, K⁺ 5.8, BP 80/50.
Treatment?Hydrocortisone 100 mg IV + NS bolus Rationale: Pathophysiology:
Cortisol/aldosterone deficiency → shock, hyponatremia, hyperkalemia. Steroids restore
vascular tone.
20.A client with pheochromocytoma has paroxysmal HTN. Preoperative
drug?Phenoxybenzamine (alpha-blocker) Rationale: Pathophysiology: Catecholamine
surges → vasoconstriction. Alpha-blockade prevents intraoperative crisis.
21.A client with cirrhosis has ascites and SBP 18 g/dL - 5 g/dL = 13. Next
step?Diagnostic paracentesis Rationale: Pathophysiology: SAAG >1.1 → portal HTN.
PMNs >250 → spontaneous bacterial peritonitis (SBP).
