Vital signs NCLEX-RN Practice Questions

Vital signs NCLEX-RN Practice Questions

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Vital Signs NCLEX-RN Practice Questions

Mastering vital signs is essential for reducing risk and identifying complications early. This topic-wise NCLEX-RN practice set focuses on Reduction of Risk Potential through accurate measurement, interpretation, and prioritization of care based on vital sign trends across the lifespan. You’ll encounter real exam-level scenarios covering temperature routes, blood pressure technique and cuff sizing, orthostatic hypotension, pulse oximetry pitfalls, pediatric and obstetric norms, shock, sepsis, increased intracranial pressure, COPD oxygen targets, capnography, and post-operative safety. Each question emphasizes clinical reasoning, safe practice, and next best nursing actions. Use these 30 MCQs to refine critical thinking and decision-making so you can confidently recognize normal from dangerous, intervene promptly, and document accurately for optimal patient outcomes.

Q1. Which set of adult vital signs is within expected limits for a stable, resting client?

  • Temperature 36.8°C (98.2°F), HR 78/min, RR 16/min, BP 118/72 mm Hg, SpO₂ 98%
  • Temperature 38.6°C (101.5°F), HR 54/min, RR 8/min, BP 92/56 mm Hg, SpO₂ 88%
  • Temperature 35.6°C (96.1°F), HR 110/min, RR 28/min, BP 160/100 mm Hg, SpO₂ 90%
  • Temperature 37.2°C (99.0°F), HR 120/min, RR 24/min, BP 86/50 mm Hg, SpO₂ 94%

Correct Answer: Temperature 36.8°C (98.2°F), HR 78/min, RR 16/min, BP 118/72 mm Hg, SpO₂ 98%

Q2. A post-operative client on 2 L/min oxygen by nasal cannula has the following vital signs: HR 104/min, RR 8/min, BP 106/64 mm Hg, SpO₂ 88%. Which finding requires immediate intervention?

  • Respiratory rate 8/min with SpO₂ 88% on oxygen
  • Heart rate 104/min after ambulation
  • Blood pressure 106/64 mm Hg
  • Mild incisional pain rated 4/10

Correct Answer: Respiratory rate 8/min with SpO₂ 88% on oxygen

Q3. Which set of measurements indicates orthostatic hypotension in an adult?

  • Lying: 128/78 mm Hg, HR 76/min; Standing: 108/66 mm Hg, HR 98/min
  • Lying: 122/80 mm Hg, HR 70/min; Standing: 120/78 mm Hg, HR 74/min
  • Lying: 118/76 mm Hg, HR 68/min; Standing: 118/74 mm Hg, HR 68/min
  • Lying: 136/84 mm Hg, HR 82/min; Standing: 132/86 mm Hg, HR 84/min

Correct Answer: Lying: 128/78 mm Hg, HR 76/min; Standing: 108/66 mm Hg, HR 98/min

Q4. Which factor is most likely to cause a falsely low pulse oximetry reading?

  • Black nail polish on the finger being assessed
  • Carbon monoxide exposure
  • Hyperbilirubinemia
  • Receiving oxygen via nonrebreather mask

Correct Answer: Black nail polish on the finger being assessed

Q5. Which respiratory rate is expected for a resting 2-year-old child?

  • 18 breaths/min
  • 24 breaths/min
  • 44 breaths/min
  • 10 breaths/min

Correct Answer: 24 breaths/min

Q6. Which heart rate is expected in a newborn immediately after birth?

  • 156/min
  • 86/min
  • 68/min
  • 180/min sustained for 10 minutes

Correct Answer: 156/min

Q7. For a client with severe COPD and chronic CO₂ retention, which oxygen saturation goal is most appropriate unless otherwise prescribed?

  • 88%–92%
  • 94%–96%
  • 97%–99%
  • 80%–85%

Correct Answer: 88%–92%

Q8. An adult has a temperature of 39.4°C (103.0°F) and is placed on a hypothermia (cooling) blanket. Which nursing action is appropriate?

  • Administer an antipyretic and cover the client lightly to minimize shivering
  • Apply ice packs to axillae and groin for rapid cooling
  • Give an ice-water enema to decrease core temperature quickly
  • Turn off the cooling blanket when the temperature is 38.9°C (102.0°F)

Correct Answer: Administer an antipyretic and cover the client lightly to minimize shivering

Q9. Which statement reflects correct blood pressure cuff selection for an adult?

  • The cuff width should be about 40% of the arm’s circumference and bladder length 80%
  • The cuff should cover the entire arm length from shoulder to wrist
  • Using a cuff slightly smaller than recommended improves accuracy
  • Cuff size does not affect readings if calibrated equipment is used

Correct Answer: The cuff width should be about 40% of the arm’s circumference and bladder length 80%

Q10. A client’s blood pressure is 90/60 mm Hg. What is the approximate mean arterial pressure (MAP)?

  • 60 mm Hg
  • 70 mm Hg
  • 75 mm Hg
  • 80 mm Hg

Correct Answer: 70 mm Hg

Q11. Which set of findings is most consistent with increased intracranial pressure (Cushing triad)?

  • BP 190/60 mm Hg, HR 48/min, irregular respirations
  • BP 86/50 mm Hg, HR 128/min, RR 28/min
  • BP 120/80 mm Hg, HR 100/min, RR 24/min
  • BP 150/90 mm Hg, HR 110/min, RR 16/min

Correct Answer: BP 190/60 mm Hg, HR 48/min, irregular respirations

Q12. Before administering digoxin 0.125 mg to an adult client, which assessment is the priority?

  • Auscultate the apical heart rate for a full minute
  • Measure blood pressure in both arms
  • Assess capillary refill in the fingers
  • Obtain a pain rating on a 0–10 scale

Correct Answer: Auscultate the apical heart rate for a full minute

Q13. A sedated client on PCA morphine shows SpO₂ 96% but ETCO₂ rising from 38 to 54 mm Hg. What is the best interpretation?

  • Hypoventilation is developing despite normal SpO₂
  • Hyperventilation requires immediate naloxone
  • Normal ventilation with adequate analgesia
  • Pulse oximeter malfunction

Correct Answer: Hypoventilation is developing despite normal SpO₂

Q14. Which change is typically the earliest indicator of hypovolemic shock?

  • Tachycardia
  • Hypotension
  • Cyanosis
  • Anuria

Correct Answer: Tachycardia

Q15. After working outdoors in high heat, a client presents with confusion, temperature 41.1°C (106.0°F), and dry skin. What does this most likely indicate?

  • Heat stroke
  • Heat exhaustion
  • Febrile illness
  • Malignant hyperthermia

Correct Answer: Heat stroke

Q16. A client is moderately hypothermic with a core temperature of 33.5°C (92.3°F). Which intervention is appropriate?

  • Active external rewarming with forced-air warming and warmed IV fluids
  • Rapid hot-water immersion bath
  • Vigorous massage of cold extremities
  • Infuse cold normal saline to prevent afterdrop

Correct Answer: Active external rewarming with forced-air warming and warmed IV fluids

Q17. Which vital signs are most concerning for severe preeclampsia in a 32-week pregnant client?

  • BP 162/112 mm Hg, HR 60/min
  • BP 138/86 mm Hg, HR 90/min
  • BP 110/70 mm Hg, HR 100/min
  • BP 146/88 mm Hg, HR 78/min

Correct Answer: BP 162/112 mm Hg, HR 60/min

Q18. Which statement about pain and vital signs is most accurate?

  • Pain is what the client says it is; vital signs may be normal, especially in chronic pain
  • Elevated blood pressure is required to validate severe pain
  • Absence of tachycardia rules out significant pain
  • Respiratory rate is the most reliable indicator of pain severity

Correct Answer: Pain is what the client says it is; vital signs may be normal, especially in chronic pain

Q19. Which postoperative vital sign pattern most strongly suggests hemorrhage?

  • HR 118/min, BP 86/54 mm Hg, cool clammy skin
  • HR 64/min, BP 122/80 mm Hg, warm dry skin
  • HR 96/min, BP 138/88 mm Hg, mild incisional pain
  • HR 80/min, BP 100/70 mm Hg, nausea

Correct Answer: HR 118/min, BP 86/54 mm Hg, cool clammy skin

Q20. Which oxygen saturation change is most concerning in a client with suspected sepsis?

  • SpO₂ decreases from 96% to 90% on room air with RR 26/min
  • SpO₂ increases from 90% to 96% after deep breathing
  • SpO₂ remains 94% with RR 16/min
  • SpO₂ 98% after 2 L/min via nasal cannula

Correct Answer: SpO₂ decreases from 96% to 90% on room air with RR 26/min

Q21. Thirty minutes after IV morphine, which finding requires immediate action?

  • RR 8/min and ETCO₂ 55 mm Hg
  • RR 18/min and SpO₂ 96%
  • Mild dizziness with RR 14/min
  • HR 88/min and BP 118/70 mm Hg

Correct Answer: RR 8/min and ETCO₂ 55 mm Hg

Q22. Parents call about their 2-month-old with a rectal temperature of 38.2°C (100.8°F). What is the best advice?

  • Seek immediate medical evaluation
  • Give aspirin and recheck in 4 hours
  • Offer fluids and monitor at home for 24 hours
  • Bundle the infant to promote sweating

Correct Answer: Seek immediate medical evaluation

Q23. Which situation contraindicates taking an oral temperature?

  • The client drank hot coffee 5 minutes ago
  • The client is receiving 2 L/min oxygen via nasal cannula
  • The client is afebrile and alert
  • The client has an intact cough reflex

Correct Answer: The client drank hot coffee 5 minutes ago

Q24. The nurse palpates an irregular radial pulse. What is the best next action?

  • Auscultate the apical pulse for a full minute
  • Document and reassess in 4 hours
  • Immediately obtain a 12-lead ECG without further assessment
  • Measure blood pressure in both arms

Correct Answer: Auscultate the apical pulse for a full minute

Q25. Which blood pressure pattern suggests a narrowed pulse pressure commonly seen with hypovolemia?

  • 110/90 mm Hg
  • 140/80 mm Hg
  • 132/72 mm Hg
  • 150/70 mm Hg

Correct Answer: 110/90 mm Hg

Q26. During a blood transfusion, which change most suggests a febrile reaction?

  • Temperature rises from 37.0°C to 38.2°C with chills
  • Pulse decreases from 88/min to 72/min
  • Blood pressure increases from 118/70 to 130/78 mm Hg
  • Respiratory rate decreases from 18/min to 14/min

Correct Answer: Temperature rises from 37.0°C to 38.2°C with chills

Q27. Which set of findings indicates severe dehydration in a 10-month-old?

  • Lethargy, HR 178/min, BP 70/40 mm Hg
  • Alert, HR 120/min, BP 100/60 mm Hg
  • Irritable, HR 140/min, BP 90/60 mm Hg
  • Playful, HR 110/min, BP 96/60 mm Hg

Correct Answer: Lethargy, HR 178/min, BP 70/40 mm Hg

Q28. To reduce risk when evaluating vital signs, which nursing action is best?

  • Compare current values to the client’s baseline and trends
  • Rely on single measurements to guide interventions
  • Use estimated values if the client is sleeping
  • Delay documentation until the end of the shift

Correct Answer: Compare current values to the client’s baseline and trends

Q29. Which site is contraindicated for blood pressure measurement?

  • Arm with an arteriovenous (AV) fistula
  • Arm at heart level while seated
  • Opposite arm of a peripheral IV
  • Forearm using a validated cuff

Correct Answer: Arm with an arteriovenous (AV) fistula

Q30. Which temperature site is most reliable for a diaphoretic adult immediately after exertion?

  • Tympanic membrane
  • Temporal artery scan across a sweaty forehead
  • Axillary
  • Oral immediately after cold water intake

Correct Answer: Tympanic membrane

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