HESI Clinical Judgment Case Studies, 7th Edition by
Sandra L. Upchurch & Frances A. Sills:
Comprehensive Practice Exam Questions to Ensure
First-Attempt Success
1. A patient with a history of chronic heart failure (HFrEF) presents with acute dyspnea, oxygen
saturation 88% on room air, and crackles halfway up the lung fields. The patient has been
adherent to medications including lisinopril, metoprolol, and furosemide. Which intervention
should the nurse implement first?
A. Administer intravenous furosemide 40 mg bolus.
B. Place the patient in high Fowler's position and apply high-flow oxygen via non-rebreather mask.
C. Obtain a stat electrocardiogram to rule out acute coronary syndrome.
D. Notify the healthcare provider for possible noninvasive positive pressure ventilation.
Answer: B
Rationale: The priority is to optimize oxygenation and reduce preload. High Fowler's position promotes
ventilation-perfusion matching, and high-flow oxygen addresses hypoxemia. While diuretics and NIPPV
may be needed, immediate positioning and oxygen are the first-line interventions. ECG is important but
not the priority.
2. A patient receiving mechanical ventilation in the ICU has a sudden drop in oxygen saturation
from 95% to 82%. The ventilator high-pressure alarm is sounding. Which action should the nurse
take first?
A. Suction the endotracheal tube.
B. Disconnect the patient and manually ventilate with a bag-valve-mask.
C. Check the ventilator circuit for kinks or condensation.
D. Administer a sedative to reduce patient-ventilator dyssynchrony.
Answer: B
Rationale: A sudden desaturation with high-pressure alarm indicates possible obstruction (e.g., mucus
plug, kinked tube, or pneumothorax). The immediate priority is to ensure oxygenation by disconnecting
the ventilator and manually ventilating. If manual ventilation is difficult, the obstruction is likely in the
tube; if easy, the problem is in the circuit. Suctioning and checking the circuit are subsequent steps.
3. A patient with septic shock is receiving norepinephrine at 15 mcg/min and has a mean arterial
pressure of 58 mm Hg. The healthcare provider orders a fluid bolus of 500 mL normal saline over
15 minutes. Which assessment finding most suggests that the patient is developing fluid overload?
A. Heart rate increases from 88 to 96 bpm.
B. Central venous pressure rises from 8 to 14 mm Hg.
Page 1
,C. Urine output decreases from 30 mL/hr to 15 mL/hr.
D. Serum lactate level decreases from 4.2 to 3.1 mmol/L.
Answer: B
Rationale: A rapid increase in CVP above 12-15 mm Hg indicates fluid overload and risk of pulmonary
edema. Tachycardia may reflect ongoing shock or fluid responsiveness. Decreasing urine output
suggests worsening renal perfusion, not overload. Decreasing lactate is a positive sign of resuscitation.
CVP elevation is the most direct indicator of excessive preload.
4. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor reading of
22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. Which intervention should the
nurse implement to improve CPP?
A. Administer mannitol 0.5 g/kg IV.
B. Elevate the head of bed to 30 degrees.
C. Increase the rate of propofol infusion.
D. Administer a bolus of normal saline.
Answer: D
Rationale: CPP = MAP - ICP. With ICP 22 and CPP 55, MAP is 77. To improve CPP, either increase
MAP or decrease ICP. The patient's MAP is low (77), so a fluid bolus (isotonic crystalloid) can increase
MAP and thus CPP. Mannitol and head elevation decrease ICP, but the primary issue here is low MAP.
Propofol may lower ICP but also can lower MAP.
5. A patient with acute kidney injury (AKI) stage 3 has a serum potassium of 6.2 mEq/L and a
widened QRS complex on ECG. Which order should the nurse question?
A. Administer intravenous calcium gluconate.
B. Administer regular insulin 10 units IV with 50 mL of 50% dextrose.
C. Administer sodium polystyrene sulfonate 30 grams orally.
D. Prepare for emergent hemodialysis.
Answer: C
Rationale: Sodium polystyrene sulfonate (Kayexalate) works slowly (hours) and is not appropriate for
life-threatening hyperkalemia with ECG changes. Calcium gluconate stabilizes the cardiac membrane,
insulin+dextrose shifts potassium into cells, and hemodialysis removes potassium rapidly. Therefore, the
oral medication should be questioned as it delays definitive treatment.
6. A patient with a history of type 2 diabetes mellitus is admitted with a serum glucose of 480
mg/dL, pH 7.28, bicarbonate 18 mEq/L, and positive serum ketones. The nurse administers an IV
bolus of normal saline and initiates an insulin drip at 0.1 units/kg/hr. One hour later, the serum
glucose is 320 mg/dL. What is the nurse's priority action?
A. Continue the insulin drip at the same rate and monitor glucose hourly.
B. Decrease the insulin drip to 0.05 units/kg/hr and add 5% dextrose to IV fluids.
C. Increase the insulin drip to 0.15 units/kg/hr to prevent recurrence of ketosis.
D. Obtain a stat serum potassium level and administer potassium if needed.
Answer: B
Page 2
,Rationale: In DKA, when glucose falls to 250-300 mg/dL, dextrose should be added to prevent hypoglycemia while
continuing insulin to clear ketones. The insulin rate should be reduced to 0.05 units/kg/hr. Continuing the same rate risks
hypoglycemia. Increasing the rate is unnecessary. Potassium monitoring is important but not the priority action at this
glucose level.
7. A patient with cirrhosis and ascites is receiving spironolactone and furosemide. The nurse notes
a serum sodium of 128 mEq/L, potassium 3.2 mEq/L, and creatinine 1.2 mg/dL. Which
intervention is most appropriate?
A. Hold furosemide and administer sodium chloride tablets.
B. Hold spironolactone and administer potassium chloride supplements.
C. Administer both diuretics as prescribed and restrict fluid intake.
D. Hold both diuretics and administer hypertonic saline.
Answer: B
Rationale: The patient has hyponatremia and hypokalemia. Spironolactone is a potassium-sparing
diuretic, which can contribute to hyperkalemia; however, here potassium is low. Furosemide causes
potassium loss. The hypokalemia is likely due to furosemide, so holding spironolactone is not indicated.
Instead, hold furosemide and replace potassium. Sodium chloride tablets would worsen ascites. Fluid
restriction is appropriate but not the immediate intervention.
8. A patient with a pulmonary embolism is receiving a heparin infusion. The aPTT is 95 seconds
(therapeutic range 60-80 seconds). Which action should the nurse take?
A. Continue the infusion at the same rate and recheck aPTT in 6 hours.
B. Decrease the infusion rate by 2 units/kg/hr and recheck aPTT in 6 hours.
C. Stop the infusion for 1 hour, then restart at a lower rate.
D. Administer protamine sulfate to reverse the heparin effect.
Answer: B
Rationale: An aPTT of 95 is supratherapeutic and increases bleeding risk. The appropriate action is to
decrease the infusion rate per protocol (typically reduce by 2 units/kg/hr) and recheck aPTT in 6 hours.
Stopping the infusion may be too aggressive unless the aPTT is critically high. Protamine is reserved for
severe bleeding or reversal needed.
9. A patient with acute pancreatitis has a nasogastric tube to low continuous suction. The nurse
assesses the patient and notes absent bowel sounds, abdominal distension, and a serum calcium of
7.8 mg/dL. Which complication should the nurse suspect?
A. Hypocalcemia due to fat necrosis and saponification.
B. Paralytic ileus secondary to pancreatic inflammation.
C. Gastric outlet obstruction from pancreatic pseudocyst.
D. Acute respiratory distress syndrome from systemic inflammation.
Answer: B
Rationale: Absent bowel sounds and abdominal distension in acute pancreatitis indicate paralytic ileus, a
common complication due to inflammation of the pancreas and surrounding tissues. Hypocalcemia is
also common but is not the cause of the ileus. Gastric outlet obstruction and ARDS are possible but less
likely given the presentation.
Page 3
, 10. A patient with a history of myasthenia gravis is admitted with respiratory distress. The nurse
notes ptosis, dysphagia, and a forced vital capacity of 15 mL/kg. Which intervention should the
nurse anticipate?
A. Administer edrophonium to differentiate between myasthenic and cholinergic crisis.
B. Prepare for immediate endotracheal intubation and mechanical ventilation.
C. Administer atropine to reduce excessive muscarinic side effects.
D. Increase the dose of pyridostigmine as ordered for myasthenic crisis.
Answer: B
Rationale: A forced vital capacity < 15 mL/kg indicates impending respiratory failure requiring
intubation. While edrophonium may be used to differentiate crisis type, the priority is securing the
airway. Atropine is for cholinergic crisis. Increasing pyridostigmine could worsen a cholinergic crisis.
Therefore, intubation is the immediate priority.
11. A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with
acute respiratory failure. Arterial blood gas results show pH 7.28, PaCO2 65 mm Hg, PaO2 50 mm
Hg on room air. The provider prescribes noninvasive positive pressure ventilation (NIPPV). Which
assessment finding indicates a need for immediate endotracheal intubation?
A. Patient is unable to tolerate the mask and requests a break every 30 minutes.
B. PaCO2 increases to 70 mm Hg after 2 hours of NIPPV.
C. Respiratory rate decreases from 32 to 24 breaths per minute.
D. Patient becomes agitated and attempts to remove the mask.
Answer: B
Rationale: A rising PaCO2 despite NIPPV indicates worsening ventilation and is a criterion for
intubation. Option A (mask intolerance) may be managed with sedation or mask adjustments. Option C
(decreased respiratory rate) could indicate improvement. Option D (agitation) may be due to anxiety or
hypoxia and does not necessarily require intubation.
12. A patient is receiving a continuous infusion of heparin for the treatment of a deep vein
thrombosis (DVT). The activated partial thromboplastin time (aPTT) is 120 seconds. The current
infusion rate is 18 units/kg/hour. The provider's order states: 'Adjust heparin infusion per DVT
protocol: if aPTT > 100 seconds, decrease infusion by 2 units/kg/hour; if aPTT 60-100 seconds,
maintain current rate; if aPTT < 60 seconds, increase by 2 units/kg/hour.' The patient weighs 70
kg. What is the new infusion rate in units/hour?
A. 1120 units/hour
B. 1260 units/hour
C. 1400 units/hour
D. 1540 units/hour
Answer: A
Rationale: Current infusion rate is 18 units/kg/hour × 70 kg = 1260 units/hour. Since aPTT > 100
seconds, decrease by 2 units/kg/hour: new rate = (18 - 2) = 16 units/kg/hour × 70 kg = 1120 units/hour.
Option B is the current rate. Option C is if no change. Option D is if increased.
Page 4
Sandra L. Upchurch & Frances A. Sills:
Comprehensive Practice Exam Questions to Ensure
First-Attempt Success
1. A patient with a history of chronic heart failure (HFrEF) presents with acute dyspnea, oxygen
saturation 88% on room air, and crackles halfway up the lung fields. The patient has been
adherent to medications including lisinopril, metoprolol, and furosemide. Which intervention
should the nurse implement first?
A. Administer intravenous furosemide 40 mg bolus.
B. Place the patient in high Fowler's position and apply high-flow oxygen via non-rebreather mask.
C. Obtain a stat electrocardiogram to rule out acute coronary syndrome.
D. Notify the healthcare provider for possible noninvasive positive pressure ventilation.
Answer: B
Rationale: The priority is to optimize oxygenation and reduce preload. High Fowler's position promotes
ventilation-perfusion matching, and high-flow oxygen addresses hypoxemia. While diuretics and NIPPV
may be needed, immediate positioning and oxygen are the first-line interventions. ECG is important but
not the priority.
2. A patient receiving mechanical ventilation in the ICU has a sudden drop in oxygen saturation
from 95% to 82%. The ventilator high-pressure alarm is sounding. Which action should the nurse
take first?
A. Suction the endotracheal tube.
B. Disconnect the patient and manually ventilate with a bag-valve-mask.
C. Check the ventilator circuit for kinks or condensation.
D. Administer a sedative to reduce patient-ventilator dyssynchrony.
Answer: B
Rationale: A sudden desaturation with high-pressure alarm indicates possible obstruction (e.g., mucus
plug, kinked tube, or pneumothorax). The immediate priority is to ensure oxygenation by disconnecting
the ventilator and manually ventilating. If manual ventilation is difficult, the obstruction is likely in the
tube; if easy, the problem is in the circuit. Suctioning and checking the circuit are subsequent steps.
3. A patient with septic shock is receiving norepinephrine at 15 mcg/min and has a mean arterial
pressure of 58 mm Hg. The healthcare provider orders a fluid bolus of 500 mL normal saline over
15 minutes. Which assessment finding most suggests that the patient is developing fluid overload?
A. Heart rate increases from 88 to 96 bpm.
B. Central venous pressure rises from 8 to 14 mm Hg.
Page 1
,C. Urine output decreases from 30 mL/hr to 15 mL/hr.
D. Serum lactate level decreases from 4.2 to 3.1 mmol/L.
Answer: B
Rationale: A rapid increase in CVP above 12-15 mm Hg indicates fluid overload and risk of pulmonary
edema. Tachycardia may reflect ongoing shock or fluid responsiveness. Decreasing urine output
suggests worsening renal perfusion, not overload. Decreasing lactate is a positive sign of resuscitation.
CVP elevation is the most direct indicator of excessive preload.
4. A patient with a traumatic brain injury has an intracranial pressure (ICP) monitor reading of
22 mm Hg and cerebral perfusion pressure (CPP) of 55 mm Hg. Which intervention should the
nurse implement to improve CPP?
A. Administer mannitol 0.5 g/kg IV.
B. Elevate the head of bed to 30 degrees.
C. Increase the rate of propofol infusion.
D. Administer a bolus of normal saline.
Answer: D
Rationale: CPP = MAP - ICP. With ICP 22 and CPP 55, MAP is 77. To improve CPP, either increase
MAP or decrease ICP. The patient's MAP is low (77), so a fluid bolus (isotonic crystalloid) can increase
MAP and thus CPP. Mannitol and head elevation decrease ICP, but the primary issue here is low MAP.
Propofol may lower ICP but also can lower MAP.
5. A patient with acute kidney injury (AKI) stage 3 has a serum potassium of 6.2 mEq/L and a
widened QRS complex on ECG. Which order should the nurse question?
A. Administer intravenous calcium gluconate.
B. Administer regular insulin 10 units IV with 50 mL of 50% dextrose.
C. Administer sodium polystyrene sulfonate 30 grams orally.
D. Prepare for emergent hemodialysis.
Answer: C
Rationale: Sodium polystyrene sulfonate (Kayexalate) works slowly (hours) and is not appropriate for
life-threatening hyperkalemia with ECG changes. Calcium gluconate stabilizes the cardiac membrane,
insulin+dextrose shifts potassium into cells, and hemodialysis removes potassium rapidly. Therefore, the
oral medication should be questioned as it delays definitive treatment.
6. A patient with a history of type 2 diabetes mellitus is admitted with a serum glucose of 480
mg/dL, pH 7.28, bicarbonate 18 mEq/L, and positive serum ketones. The nurse administers an IV
bolus of normal saline and initiates an insulin drip at 0.1 units/kg/hr. One hour later, the serum
glucose is 320 mg/dL. What is the nurse's priority action?
A. Continue the insulin drip at the same rate and monitor glucose hourly.
B. Decrease the insulin drip to 0.05 units/kg/hr and add 5% dextrose to IV fluids.
C. Increase the insulin drip to 0.15 units/kg/hr to prevent recurrence of ketosis.
D. Obtain a stat serum potassium level and administer potassium if needed.
Answer: B
Page 2
,Rationale: In DKA, when glucose falls to 250-300 mg/dL, dextrose should be added to prevent hypoglycemia while
continuing insulin to clear ketones. The insulin rate should be reduced to 0.05 units/kg/hr. Continuing the same rate risks
hypoglycemia. Increasing the rate is unnecessary. Potassium monitoring is important but not the priority action at this
glucose level.
7. A patient with cirrhosis and ascites is receiving spironolactone and furosemide. The nurse notes
a serum sodium of 128 mEq/L, potassium 3.2 mEq/L, and creatinine 1.2 mg/dL. Which
intervention is most appropriate?
A. Hold furosemide and administer sodium chloride tablets.
B. Hold spironolactone and administer potassium chloride supplements.
C. Administer both diuretics as prescribed and restrict fluid intake.
D. Hold both diuretics and administer hypertonic saline.
Answer: B
Rationale: The patient has hyponatremia and hypokalemia. Spironolactone is a potassium-sparing
diuretic, which can contribute to hyperkalemia; however, here potassium is low. Furosemide causes
potassium loss. The hypokalemia is likely due to furosemide, so holding spironolactone is not indicated.
Instead, hold furosemide and replace potassium. Sodium chloride tablets would worsen ascites. Fluid
restriction is appropriate but not the immediate intervention.
8. A patient with a pulmonary embolism is receiving a heparin infusion. The aPTT is 95 seconds
(therapeutic range 60-80 seconds). Which action should the nurse take?
A. Continue the infusion at the same rate and recheck aPTT in 6 hours.
B. Decrease the infusion rate by 2 units/kg/hr and recheck aPTT in 6 hours.
C. Stop the infusion for 1 hour, then restart at a lower rate.
D. Administer protamine sulfate to reverse the heparin effect.
Answer: B
Rationale: An aPTT of 95 is supratherapeutic and increases bleeding risk. The appropriate action is to
decrease the infusion rate per protocol (typically reduce by 2 units/kg/hr) and recheck aPTT in 6 hours.
Stopping the infusion may be too aggressive unless the aPTT is critically high. Protamine is reserved for
severe bleeding or reversal needed.
9. A patient with acute pancreatitis has a nasogastric tube to low continuous suction. The nurse
assesses the patient and notes absent bowel sounds, abdominal distension, and a serum calcium of
7.8 mg/dL. Which complication should the nurse suspect?
A. Hypocalcemia due to fat necrosis and saponification.
B. Paralytic ileus secondary to pancreatic inflammation.
C. Gastric outlet obstruction from pancreatic pseudocyst.
D. Acute respiratory distress syndrome from systemic inflammation.
Answer: B
Rationale: Absent bowel sounds and abdominal distension in acute pancreatitis indicate paralytic ileus, a
common complication due to inflammation of the pancreas and surrounding tissues. Hypocalcemia is
also common but is not the cause of the ileus. Gastric outlet obstruction and ARDS are possible but less
likely given the presentation.
Page 3
, 10. A patient with a history of myasthenia gravis is admitted with respiratory distress. The nurse
notes ptosis, dysphagia, and a forced vital capacity of 15 mL/kg. Which intervention should the
nurse anticipate?
A. Administer edrophonium to differentiate between myasthenic and cholinergic crisis.
B. Prepare for immediate endotracheal intubation and mechanical ventilation.
C. Administer atropine to reduce excessive muscarinic side effects.
D. Increase the dose of pyridostigmine as ordered for myasthenic crisis.
Answer: B
Rationale: A forced vital capacity < 15 mL/kg indicates impending respiratory failure requiring
intubation. While edrophonium may be used to differentiate crisis type, the priority is securing the
airway. Atropine is for cholinergic crisis. Increasing pyridostigmine could worsen a cholinergic crisis.
Therefore, intubation is the immediate priority.
11. A patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with
acute respiratory failure. Arterial blood gas results show pH 7.28, PaCO2 65 mm Hg, PaO2 50 mm
Hg on room air. The provider prescribes noninvasive positive pressure ventilation (NIPPV). Which
assessment finding indicates a need for immediate endotracheal intubation?
A. Patient is unable to tolerate the mask and requests a break every 30 minutes.
B. PaCO2 increases to 70 mm Hg after 2 hours of NIPPV.
C. Respiratory rate decreases from 32 to 24 breaths per minute.
D. Patient becomes agitated and attempts to remove the mask.
Answer: B
Rationale: A rising PaCO2 despite NIPPV indicates worsening ventilation and is a criterion for
intubation. Option A (mask intolerance) may be managed with sedation or mask adjustments. Option C
(decreased respiratory rate) could indicate improvement. Option D (agitation) may be due to anxiety or
hypoxia and does not necessarily require intubation.
12. A patient is receiving a continuous infusion of heparin for the treatment of a deep vein
thrombosis (DVT). The activated partial thromboplastin time (aPTT) is 120 seconds. The current
infusion rate is 18 units/kg/hour. The provider's order states: 'Adjust heparin infusion per DVT
protocol: if aPTT > 100 seconds, decrease infusion by 2 units/kg/hour; if aPTT 60-100 seconds,
maintain current rate; if aPTT < 60 seconds, increase by 2 units/kg/hour.' The patient weighs 70
kg. What is the new infusion rate in units/hour?
A. 1120 units/hour
B. 1260 units/hour
C. 1400 units/hour
D. 1540 units/hour
Answer: A
Rationale: Current infusion rate is 18 units/kg/hour × 70 kg = 1260 units/hour. Since aPTT > 100
seconds, decrease by 2 units/kg/hour: new rate = (18 - 2) = 16 units/kg/hour × 70 kg = 1120 units/hour.
Option B is the current rate. Option C is if no change. Option D is if increased.
Page 4
