, NU 136: Fundamentals of Nursing – HESI
Questions and Answers with Rationales
2026/2027 update
Question 1
A nurse is assessing an older adult client who is admitted with
confusion and lethargy. The family reports that the client has
been increasingly forgetful and unsteady over the past week.
Which preliminary action is most important for the nurse to
perform first?
A. Restrain the client wrists to prevent accidental pulling on
lines.
B. Obtain a complete baseline neurological assessment and
vital signs, including oxygen saturation.
C. Administer a prescribed sleeping pill to calm the client.
D. Discharge the client back home with family instructions.
Correct Answer: B. Obtain a complete baseline neurological
assessment and vital signs, including oxygen saturation.
Expert Rationale: Acute confusion in an older adult requires
immediate clinical investigation to rule out physiological
stressors such as hypoxia, infection, or metabolic imbalance.
Establishing a baseline through vital signs and a neuro check
guides appropriate medical interventions before considering
restrictive measures.
Question 2
,A nurse is preparing to administer an intramuscular injection
into the ventrogluteal site of an adult client. Which anatomical
landmarks should the nurse use to properly locate this site?
A. Place the palm on the greater trochanter, point the index
finger toward the anterior superior iliac spine, and stretch
the middle finger back along the iliac crest.
B. Divide the buttocks into four equal quadrants and inject
into the upper outer quadrant.
C. Locate the acromion process and measure three
fingerbreadths down.
D. Pinch the skin of the anterior thigh firmly.
Correct Answer: A. Place the palm on the greater
trochanter, point the index finger toward the anterior
superior iliac spine, and stretch the middle finger back along
the iliac crest.
Expert Rationale: The ventrogluteal site is the safest and most
preferred intramuscular injection site for adults because it is free
of major nerves and blood vessels. Using the greater trochanter,
anterior superior iliac spine, and iliac crest ensures accurate
landmarking.
Question 3
A client is admitted to the medical-surgical unit with severe
dehydration and electrolyte imbalances. The primary healthcare
provider prescribes an intravenous infusion of 0.9\% sodium
, chloride at 150 milliliters per hour. What classification of
intravenous solution is 0.9\% sodium chloride?
A. Hypotonic solution
B. Isotonic solution
C. Hypertonic solution
D. Colloid solution
Correct Answer: B. Isotonic solution
Expert Rationale: Normal saline (0.9\% sodium chloride) is an
isotonic solution with an osmolality close to extracellular fluid.
It expands intravascular volume without causing fluid shifts into
or out of cells, making it ideal for fluid resuscitation and
dehydration.
Question 4
A nurse is monitoring a client receiving a blood transfusion.
Within 15 minutes of starting the transfusion, the client develops
chills, lower back pain, tachycardia, and apprehension. What is
the nurse's immediate priority action?
A. Slow down the transfusion rate and continue to monitor
vital signs every 10 minutes.
B. Stop the blood transfusion immediately, disconnect the
tubing, infuse normal saline through a separate new line,
and notify the healthcare provider and blood bank.
Questions and Answers with Rationales
2026/2027 update
Question 1
A nurse is assessing an older adult client who is admitted with
confusion and lethargy. The family reports that the client has
been increasingly forgetful and unsteady over the past week.
Which preliminary action is most important for the nurse to
perform first?
A. Restrain the client wrists to prevent accidental pulling on
lines.
B. Obtain a complete baseline neurological assessment and
vital signs, including oxygen saturation.
C. Administer a prescribed sleeping pill to calm the client.
D. Discharge the client back home with family instructions.
Correct Answer: B. Obtain a complete baseline neurological
assessment and vital signs, including oxygen saturation.
Expert Rationale: Acute confusion in an older adult requires
immediate clinical investigation to rule out physiological
stressors such as hypoxia, infection, or metabolic imbalance.
Establishing a baseline through vital signs and a neuro check
guides appropriate medical interventions before considering
restrictive measures.
Question 2
,A nurse is preparing to administer an intramuscular injection
into the ventrogluteal site of an adult client. Which anatomical
landmarks should the nurse use to properly locate this site?
A. Place the palm on the greater trochanter, point the index
finger toward the anterior superior iliac spine, and stretch
the middle finger back along the iliac crest.
B. Divide the buttocks into four equal quadrants and inject
into the upper outer quadrant.
C. Locate the acromion process and measure three
fingerbreadths down.
D. Pinch the skin of the anterior thigh firmly.
Correct Answer: A. Place the palm on the greater
trochanter, point the index finger toward the anterior
superior iliac spine, and stretch the middle finger back along
the iliac crest.
Expert Rationale: The ventrogluteal site is the safest and most
preferred intramuscular injection site for adults because it is free
of major nerves and blood vessels. Using the greater trochanter,
anterior superior iliac spine, and iliac crest ensures accurate
landmarking.
Question 3
A client is admitted to the medical-surgical unit with severe
dehydration and electrolyte imbalances. The primary healthcare
provider prescribes an intravenous infusion of 0.9\% sodium
, chloride at 150 milliliters per hour. What classification of
intravenous solution is 0.9\% sodium chloride?
A. Hypotonic solution
B. Isotonic solution
C. Hypertonic solution
D. Colloid solution
Correct Answer: B. Isotonic solution
Expert Rationale: Normal saline (0.9\% sodium chloride) is an
isotonic solution with an osmolality close to extracellular fluid.
It expands intravascular volume without causing fluid shifts into
or out of cells, making it ideal for fluid resuscitation and
dehydration.
Question 4
A nurse is monitoring a client receiving a blood transfusion.
Within 15 minutes of starting the transfusion, the client develops
chills, lower back pain, tachycardia, and apprehension. What is
the nurse's immediate priority action?
A. Slow down the transfusion rate and continue to monitor
vital signs every 10 minutes.
B. Stop the blood transfusion immediately, disconnect the
tubing, infuse normal saline through a separate new line,
and notify the healthcare provider and blood bank.
