NR 224 – Fundamentals of Nursing: Vital Signs
& Basic Patient Assessment
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. Verify the patient’s identity
B. Document the findings immediately
C. Apply a blood pressure cuff
D. Position the patient for comfort
Answer: A. Verify the patient’s identity
Rationale: Patient identification is the first safety step before performing any
assessment or intervention.
2. A nurse is assessing a patient’s temperature. Which body temperature
measurement is considered most accurate?
A. Core temperature measurement
B. Skin temperature measurement
C. Room temperature assessment
D. Touching the forehead
Answer: A. Core temperature measurement
Rationale: Core temperature measurements most closely reflect the body’s
internal temperature.
,3. A nurse records a patient’s temperature as 38.5°C (101.3°F). How should the
nurse interpret this finding?
A. Fever
B. Hypothermia
C. Normal temperature
D. Bradycardia
Answer: A. Fever
Rationale: A temperature above the normal range indicates fever, which may
occur due to infection or inflammation.
4. A nurse is assessing a patient’s pulse. Which characteristic should the nurse
evaluate?
A. Rate, rhythm, and strength
B. Height and weight
C. Skin color only
D. Temperature only
Answer: A. Rate, rhythm, and strength
Rationale: Pulse assessment includes evaluating how fast, regular, and strong the
heartbeat is.
5. A nurse documents a patient’s pulse as 52 beats/min. How should the nurse
interpret this finding?
A. Bradycardia
B. Tachycardia
C. Normal pulse
D. Irregular breathing
Answer: A. Bradycardia
,Rationale: Bradycardia refers to a heart rate below the expected adult range,
commonly less than 60 beats/min.
6. A nurse is assessing a patient’s respirations. Which action provides the most
accurate respiratory assessment?
A. Observe chest movement without telling the patient
B. Ask the patient to breathe faster
C. Measure only oxygen saturation
D. Count respirations after exercise
Answer: A. Observe chest movement without telling the patient
Rationale: Patients may alter their breathing pattern if they know respirations are
being counted.
7. A nurse documents a respiratory rate of 8 breaths/min. Which term describes
this finding?
A. Bradypnea
B. Tachypnea
C. Apnea
D. Hyperventilation
Answer: A. Bradypnea
Rationale: Bradypnea refers to abnormally slow breathing.
8. A nurse assesses a patient’s respiratory rate as 30 breaths/min. How should this
finding be interpreted?
A. Tachypnea
B. Bradypnea
C. Normal respiration
D. Apnea
, Answer: A. Tachypnea
Rationale: Tachypnea is an abnormally increased respiratory rate.
9. A nurse is measuring blood pressure. Which action provides the most accurate
reading?
A. Use the correct cuff size.
B. Place the cuff over clothing.
C. Allow the patient to talk during measurement.
D. Keep the arm unsupported.
Answer: A. Use the correct cuff size.
Rationale: An incorrect cuff size can produce inaccurate blood pressure readings.
10. A nurse obtains a blood pressure reading of 88/54 mmHg. Which term
describes this finding?
A. Hypotension
B. Hypertension
C. Normal pressure
D. Tachycardia
Answer: A. Hypotension
Rationale: Hypotension refers to abnormally low blood pressure.
11. A nurse obtains a blood pressure reading of 150/95 mmHg. How should this
finding be interpreted?
A. Elevated blood pressure
B. Low blood pressure
C. Normal finding
D. Respiratory abnormality
& Basic Patient Assessment
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. Verify the patient’s identity
B. Document the findings immediately
C. Apply a blood pressure cuff
D. Position the patient for comfort
Answer: A. Verify the patient’s identity
Rationale: Patient identification is the first safety step before performing any
assessment or intervention.
2. A nurse is assessing a patient’s temperature. Which body temperature
measurement is considered most accurate?
A. Core temperature measurement
B. Skin temperature measurement
C. Room temperature assessment
D. Touching the forehead
Answer: A. Core temperature measurement
Rationale: Core temperature measurements most closely reflect the body’s
internal temperature.
,3. A nurse records a patient’s temperature as 38.5°C (101.3°F). How should the
nurse interpret this finding?
A. Fever
B. Hypothermia
C. Normal temperature
D. Bradycardia
Answer: A. Fever
Rationale: A temperature above the normal range indicates fever, which may
occur due to infection or inflammation.
4. A nurse is assessing a patient’s pulse. Which characteristic should the nurse
evaluate?
A. Rate, rhythm, and strength
B. Height and weight
C. Skin color only
D. Temperature only
Answer: A. Rate, rhythm, and strength
Rationale: Pulse assessment includes evaluating how fast, regular, and strong the
heartbeat is.
5. A nurse documents a patient’s pulse as 52 beats/min. How should the nurse
interpret this finding?
A. Bradycardia
B. Tachycardia
C. Normal pulse
D. Irregular breathing
Answer: A. Bradycardia
,Rationale: Bradycardia refers to a heart rate below the expected adult range,
commonly less than 60 beats/min.
6. A nurse is assessing a patient’s respirations. Which action provides the most
accurate respiratory assessment?
A. Observe chest movement without telling the patient
B. Ask the patient to breathe faster
C. Measure only oxygen saturation
D. Count respirations after exercise
Answer: A. Observe chest movement without telling the patient
Rationale: Patients may alter their breathing pattern if they know respirations are
being counted.
7. A nurse documents a respiratory rate of 8 breaths/min. Which term describes
this finding?
A. Bradypnea
B. Tachypnea
C. Apnea
D. Hyperventilation
Answer: A. Bradypnea
Rationale: Bradypnea refers to abnormally slow breathing.
8. A nurse assesses a patient’s respiratory rate as 30 breaths/min. How should this
finding be interpreted?
A. Tachypnea
B. Bradypnea
C. Normal respiration
D. Apnea
, Answer: A. Tachypnea
Rationale: Tachypnea is an abnormally increased respiratory rate.
9. A nurse is measuring blood pressure. Which action provides the most accurate
reading?
A. Use the correct cuff size.
B. Place the cuff over clothing.
C. Allow the patient to talk during measurement.
D. Keep the arm unsupported.
Answer: A. Use the correct cuff size.
Rationale: An incorrect cuff size can produce inaccurate blood pressure readings.
10. A nurse obtains a blood pressure reading of 88/54 mmHg. Which term
describes this finding?
A. Hypotension
B. Hypertension
C. Normal pressure
D. Tachycardia
Answer: A. Hypotension
Rationale: Hypotension refers to abnormally low blood pressure.
11. A nurse obtains a blood pressure reading of 150/95 mmHg. How should this
finding be interpreted?
A. Elevated blood pressure
B. Low blood pressure
C. Normal finding
D. Respiratory abnormality
