NR 224 – Fundamentals of Nursing: Vital Signs
& Basic Assessment Skills
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is preparing to assess a patient’s vital signs. Which action should the
nurse perform first?
A. Document the findings immediately.
B. Verify the patient’s identity using two identifiers.
C. Ask the patient to describe symptoms.
D. Apply oxygen therapy.
Answer: B. Verify the patient’s identity using two identifiers.
Rationale: Correct patient identification is the first step before
performing any assessment or intervention to prevent errors.
2. A nurse is assessing a patient’s temperature. Which route provides the most
accurate measurement of core body temperature?
A. Oral.
B. Axillary.
C. Rectal.
D. Temporal.
Answer: C. Rectal.
,Rationale: Rectal temperature is considered one of the most
accurate indicators of core body temperature, although it may
not be appropriate for some patients.
3. A nurse is assessing a patient’s temperature and obtains a reading of 39°C
(102.2°F). How should the nurse interpret this finding?
A. Hypothermia.
B. Normal temperature.
C. Fever.
D. Bradycardia.
Answer: C. Fever.
Rationale: A temperature above the expected range indicates
fever, which may occur due to infection, inflammation, or other
conditions.
4. A nurse is assessing a patient’s pulse. Which finding should the nurse report?
A. Pulse rate of 76 beats/min in an adult.
B. Pulse rate of 48 beats/min with dizziness.
C. Regular pulse rhythm.
D. Strong pulse quality.
Answer: B. Pulse rate of 48 beats/min with dizziness.
Rationale: Bradycardia with symptoms such as dizziness may
indicate inadequate cardiac output and requires further
assessment.
5. A nurse is assessing respirations. Which factor should the nurse evaluate?
,A. Rate, rhythm, and depth.
B. Height and weight only.
C. Skin color only.
D. Blood glucose level.
Answer: A. Rate, rhythm, and depth.
Rationale: Respiratory assessment includes evaluating how often
the patient breathes, the pattern, and the depth of breathing.
6. A nurse counts a patient’s respirations at 28 breaths/min. How should this
finding be interpreted?
A. Bradypnea.
B. Normal respirations.
C. Tachypnea.
D. Apnea.
Answer: C. Tachypnea.
Rationale: Tachypnea refers to an increased respiratory rate,
commonly greater than 20 breaths/min in adults.
7. A nurse is assessing blood pressure. Which action provides the most accurate
reading?
A. Use a cuff that fits the patient’s arm correctly.
B. Place the cuff over thick clothing.
C. Measure blood pressure immediately after exercise.
D. Allow the patient to talk during measurement.
Answer: A. Use a cuff that fits the patient’s arm correctly.
, Rationale: An appropriately sized cuff is essential for accurate
blood pressure measurement.
8. A nurse obtains a blood pressure reading of 88/54 mmHg. Which action should
the nurse take?
A. Document as normal.
B. Assess the patient for symptoms of hypotension.
C. Ignore the finding.
D. Encourage rapid standing.
Answer: B. Assess the patient for symptoms of hypotension.
Rationale: Low blood pressure may reduce tissue perfusion. The
nurse should assess for dizziness, weakness, or other symptoms.
9. A nurse is teaching a patient about oxygen saturation monitoring. Which
statement indicates understanding?
A. "The device measures how much oxygen is carried in my blood."
B. "The device measures my blood pressure."
C. "The device replaces respiratory assessment."
D. "The device measures body temperature."
Answer: A. "The device measures how much oxygen is carried in my blood."
Rationale: Pulse oximetry measures peripheral oxygen saturation
(SpO₂), indicating the percentage of hemoglobin carrying
oxygen.
10. A nurse is assessing a patient’s oxygen saturation and obtains 88%. Which
action is appropriate?
& Basic Assessment Skills
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is preparing to assess a patient’s vital signs. Which action should the
nurse perform first?
A. Document the findings immediately.
B. Verify the patient’s identity using two identifiers.
C. Ask the patient to describe symptoms.
D. Apply oxygen therapy.
Answer: B. Verify the patient’s identity using two identifiers.
Rationale: Correct patient identification is the first step before
performing any assessment or intervention to prevent errors.
2. A nurse is assessing a patient’s temperature. Which route provides the most
accurate measurement of core body temperature?
A. Oral.
B. Axillary.
C. Rectal.
D. Temporal.
Answer: C. Rectal.
,Rationale: Rectal temperature is considered one of the most
accurate indicators of core body temperature, although it may
not be appropriate for some patients.
3. A nurse is assessing a patient’s temperature and obtains a reading of 39°C
(102.2°F). How should the nurse interpret this finding?
A. Hypothermia.
B. Normal temperature.
C. Fever.
D. Bradycardia.
Answer: C. Fever.
Rationale: A temperature above the expected range indicates
fever, which may occur due to infection, inflammation, or other
conditions.
4. A nurse is assessing a patient’s pulse. Which finding should the nurse report?
A. Pulse rate of 76 beats/min in an adult.
B. Pulse rate of 48 beats/min with dizziness.
C. Regular pulse rhythm.
D. Strong pulse quality.
Answer: B. Pulse rate of 48 beats/min with dizziness.
Rationale: Bradycardia with symptoms such as dizziness may
indicate inadequate cardiac output and requires further
assessment.
5. A nurse is assessing respirations. Which factor should the nurse evaluate?
,A. Rate, rhythm, and depth.
B. Height and weight only.
C. Skin color only.
D. Blood glucose level.
Answer: A. Rate, rhythm, and depth.
Rationale: Respiratory assessment includes evaluating how often
the patient breathes, the pattern, and the depth of breathing.
6. A nurse counts a patient’s respirations at 28 breaths/min. How should this
finding be interpreted?
A. Bradypnea.
B. Normal respirations.
C. Tachypnea.
D. Apnea.
Answer: C. Tachypnea.
Rationale: Tachypnea refers to an increased respiratory rate,
commonly greater than 20 breaths/min in adults.
7. A nurse is assessing blood pressure. Which action provides the most accurate
reading?
A. Use a cuff that fits the patient’s arm correctly.
B. Place the cuff over thick clothing.
C. Measure blood pressure immediately after exercise.
D. Allow the patient to talk during measurement.
Answer: A. Use a cuff that fits the patient’s arm correctly.
, Rationale: An appropriately sized cuff is essential for accurate
blood pressure measurement.
8. A nurse obtains a blood pressure reading of 88/54 mmHg. Which action should
the nurse take?
A. Document as normal.
B. Assess the patient for symptoms of hypotension.
C. Ignore the finding.
D. Encourage rapid standing.
Answer: B. Assess the patient for symptoms of hypotension.
Rationale: Low blood pressure may reduce tissue perfusion. The
nurse should assess for dizziness, weakness, or other symptoms.
9. A nurse is teaching a patient about oxygen saturation monitoring. Which
statement indicates understanding?
A. "The device measures how much oxygen is carried in my blood."
B. "The device measures my blood pressure."
C. "The device replaces respiratory assessment."
D. "The device measures body temperature."
Answer: A. "The device measures how much oxygen is carried in my blood."
Rationale: Pulse oximetry measures peripheral oxygen saturation
(SpO₂), indicating the percentage of hemoglobin carrying
oxygen.
10. A nurse is assessing a patient’s oxygen saturation and obtains 88%. Which
action is appropriate?
