NR 224 – Fundamentals of Nursing: Vital
Signs & Basic Assessment Skills
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is assessing a patient’s vital signs. Which statement best describes the
purpose of obtaining vital signs?
A. To determine a patient’s financial needs
B. To assess basic body functions and detect changes in health status
C. To replace a complete physical assessment
D. To determine a patient’s diagnosis independently
Answer: B. To assess basic body functions and detect changes in health status
Rationale: Vital signs provide important information about the body’s
physiological status and can reveal early signs of deterioration.
2. A nurse is preparing to measure a patient’s temperature. Which factor should
the nurse consider?
A. The method and site of measurement affect the reading
B. All temperature sites provide identical results
C. Temperature does not change throughout the day
D. Patient activity has no effect on temperature
Answer: A. The method and site of measurement affect the reading
Rationale: Temperature varies depending on the measurement site and technique
used.
,3. A nurse obtains a patient’s temperature and records 38.5°C (101.3°F). How
should the nurse interpret this finding?
A. Hypothermia
B. Fever
C. Normal temperature
D. Bradycardia
Answer: B. Fever
Rationale: A temperature above the expected range indicates an elevated
temperature or fever.
4. A nurse is assessing an adult patient’s pulse. Which finding requires further
assessment?
A. Pulse rate of 110 beats/min
B. Pulse rate of 76 beats/min
C. Regular rhythm
D. Strong pulse quality
Answer: A. Pulse rate of 110 beats/min
Rationale: A heart rate above the expected adult range may indicate tachycardia
and requires assessment.
5. A nurse is measuring a patient’s radial pulse. Which technique is correct?
A. Use fingertips to palpate the pulse
B. Use the thumb to measure the pulse
C. Press firmly until the pulse disappears
D. Count for only 5 seconds
Answer: A. Use fingertips to palpate the pulse
Rationale: The fingertips are more sensitive for detecting pulsations; the thumb
has its own pulse that can interfere with accuracy.
,6. A nurse assesses a patient’s respiratory rate. Which action provides the most
accurate measurement?
A. Observe respirations without telling the patient
B. Ask the patient to breathe faster
C. Count respirations immediately after exercise
D. Measure only after the patient talks
Answer: A. Observe respirations without telling the patient
Rationale: Patients may consciously alter breathing patterns if they know
respirations are being counted.
7. A nurse documents a patient’s respiratory rate as 8 breaths/min. How should
this finding be interpreted?
A. Tachypnea
B. Bradypnea
C. Normal respiration
D. Hyperventilation
Answer: B. Bradypnea
Rationale: Bradypnea refers to an abnormally slow respiratory rate.
8. A nurse assesses a patient’s blood pressure. Which factor can affect the
accuracy of the reading?
A. Incorrect cuff size
B. Patient’s eye color
C. Height of the nurse
D. Room decoration
Answer: A. Incorrect cuff size
, Rationale: An improperly sized cuff can produce inaccurate blood pressure
measurements.
9. A nurse uses a blood pressure cuff that is too small for the patient’s arm.
What result is likely?
A. Falsely elevated blood pressure reading
B. Falsely low blood pressure reading
C. No change in reading
D. Accurate reading every time
Answer: A. Falsely elevated blood pressure reading
Rationale: A cuff that is too small may overestimate blood pressure.
10. A nurse is measuring blood pressure. Which action is appropriate?
A. Keep the patient’s arm supported at heart level
B. Allow the arm to hang unsupported
C. Measure immediately after exercise
D. Place the cuff over clothing
Answer: A. Keep the patient’s arm supported at heart level
Rationale: Proper positioning improves accuracy of blood pressure measurement.
11. A nurse assesses a patient’s oxygen saturation. Which value requires
attention?
A. 88%
B. 98%
C. 97%
D. 96%
Answer: A. 88%
Signs & Basic Assessment Skills
100 NCLEX®-Style Practice Questions with
Detailed Rationales
1. A nurse is assessing a patient’s vital signs. Which statement best describes the
purpose of obtaining vital signs?
A. To determine a patient’s financial needs
B. To assess basic body functions and detect changes in health status
C. To replace a complete physical assessment
D. To determine a patient’s diagnosis independently
Answer: B. To assess basic body functions and detect changes in health status
Rationale: Vital signs provide important information about the body’s
physiological status and can reveal early signs of deterioration.
2. A nurse is preparing to measure a patient’s temperature. Which factor should
the nurse consider?
A. The method and site of measurement affect the reading
B. All temperature sites provide identical results
C. Temperature does not change throughout the day
D. Patient activity has no effect on temperature
Answer: A. The method and site of measurement affect the reading
Rationale: Temperature varies depending on the measurement site and technique
used.
,3. A nurse obtains a patient’s temperature and records 38.5°C (101.3°F). How
should the nurse interpret this finding?
A. Hypothermia
B. Fever
C. Normal temperature
D. Bradycardia
Answer: B. Fever
Rationale: A temperature above the expected range indicates an elevated
temperature or fever.
4. A nurse is assessing an adult patient’s pulse. Which finding requires further
assessment?
A. Pulse rate of 110 beats/min
B. Pulse rate of 76 beats/min
C. Regular rhythm
D. Strong pulse quality
Answer: A. Pulse rate of 110 beats/min
Rationale: A heart rate above the expected adult range may indicate tachycardia
and requires assessment.
5. A nurse is measuring a patient’s radial pulse. Which technique is correct?
A. Use fingertips to palpate the pulse
B. Use the thumb to measure the pulse
C. Press firmly until the pulse disappears
D. Count for only 5 seconds
Answer: A. Use fingertips to palpate the pulse
Rationale: The fingertips are more sensitive for detecting pulsations; the thumb
has its own pulse that can interfere with accuracy.
,6. A nurse assesses a patient’s respiratory rate. Which action provides the most
accurate measurement?
A. Observe respirations without telling the patient
B. Ask the patient to breathe faster
C. Count respirations immediately after exercise
D. Measure only after the patient talks
Answer: A. Observe respirations without telling the patient
Rationale: Patients may consciously alter breathing patterns if they know
respirations are being counted.
7. A nurse documents a patient’s respiratory rate as 8 breaths/min. How should
this finding be interpreted?
A. Tachypnea
B. Bradypnea
C. Normal respiration
D. Hyperventilation
Answer: B. Bradypnea
Rationale: Bradypnea refers to an abnormally slow respiratory rate.
8. A nurse assesses a patient’s blood pressure. Which factor can affect the
accuracy of the reading?
A. Incorrect cuff size
B. Patient’s eye color
C. Height of the nurse
D. Room decoration
Answer: A. Incorrect cuff size
, Rationale: An improperly sized cuff can produce inaccurate blood pressure
measurements.
9. A nurse uses a blood pressure cuff that is too small for the patient’s arm.
What result is likely?
A. Falsely elevated blood pressure reading
B. Falsely low blood pressure reading
C. No change in reading
D. Accurate reading every time
Answer: A. Falsely elevated blood pressure reading
Rationale: A cuff that is too small may overestimate blood pressure.
10. A nurse is measuring blood pressure. Which action is appropriate?
A. Keep the patient’s arm supported at heart level
B. Allow the arm to hang unsupported
C. Measure immediately after exercise
D. Place the cuff over clothing
Answer: A. Keep the patient’s arm supported at heart level
Rationale: Proper positioning improves accuracy of blood pressure measurement.
11. A nurse assesses a patient’s oxygen saturation. Which value requires
attention?
A. 88%
B. 98%
C. 97%
D. 96%
Answer: A. 88%
