Exam Bank
SAUNDERS NCLEX-PN VITAL SIGNS: 50 HIGH-YIELD PRACTICE QUESTIONS
WITH RATIONALES – 9TH EDITION TEST BANK
By Linda Anne Silvestri, PhD, RN, ANEF, FAAN (Author) – Paperback, June 2026
1. The nurse is assessing an adult client’s temperature. Which temperature is
considered normal?
A. 35.8°C (96.4°F)
B. 37°C (98.6°F)
C. 38.2°C (100.8°F)
D. 39°C (102.2°F)
✅Correct Answer: B
Rationale:
Normal adult body temperature averages 37°C (98.6°F). Temperatures above this indicate fever,
while lower values suggest hypothermia.
2. Which site is most accurate for measuring core body temperature?
A. Axillary
B. Oral
C. Rectal
D. Tympanic
✅Correct Answer: C
Rationale:
The rectal route best reflects core body temperature. Axillary is least accurate and used
mainly for screening.
3. A client’s oral temperature is 100.4°F (38°C). How should the nurse
interpret this finding?
A. Normal finding
B. Hypothermia
C. Fever
D. Heat stroke
✅Correct Answer: C
,Exam Bank
Rationale:
A temperature ≥38°C (100.4°F) is classified as fever.
4. Which factor can falsely elevate an oral temperature reading?
A. Fasting
B. Drinking hot liquids
C. Smoking cessation
D. Sitting quietly
✅Correct Answer: B
Rationale:
Hot liquids, smoking, or chewing gum increase oral temperature readings. The nurse should
wait 15–30 minutes before measurement.
5. The nurse is measuring a pulse and notes an irregular rhythm. What is the
priority action?
A. Document and reassess in 1 hour
B. Notify family
C. Assess apical pulse for 1 full minute
D. Ignore if rate is normal
✅Correct Answer: C
Rationale:
An irregular pulse requires assessment of the apical pulse for a full minute to determine rate
and rhythm accurately.
6. Normal resting heart rate for an adult is:
A. 40–60 bpm
B. 60–100 bpm
C. 100–120 bpm
D. 120–160 bpm
✅Correct Answer: B
, Exam Bank
Rationale:
The normal adult pulse range is 60–100 beats per minute.
7. A pulse rate of 52 bpm in an adult is documented as:
A. Tachycardia
B. Dysrhythmia
C. Bradycardia
D. Normal
✅Correct Answer: C
Rationale:
Bradycardia is defined as a heart rate below 60 bpm in adults.
8. The nurse notes a bounding pulse. This finding is most commonly
associated with:
A. Hypovolemia
B. Fever
C. Shock
D. Dehydration
✅Correct Answer: B
Rationale:
A bounding pulse may occur with fever, anxiety, or exercise due to increased cardiac output.
9. Which pulse site is assessed during cardiopulmonary resuscitation (CPR) in
adults?
A. Radial
B. Brachial
C. Carotid
D. Femoral
✅Correct Answer: C
SAUNDERS NCLEX-PN VITAL SIGNS: 50 HIGH-YIELD PRACTICE QUESTIONS
WITH RATIONALES – 9TH EDITION TEST BANK
By Linda Anne Silvestri, PhD, RN, ANEF, FAAN (Author) – Paperback, June 2026
1. The nurse is assessing an adult client’s temperature. Which temperature is
considered normal?
A. 35.8°C (96.4°F)
B. 37°C (98.6°F)
C. 38.2°C (100.8°F)
D. 39°C (102.2°F)
✅Correct Answer: B
Rationale:
Normal adult body temperature averages 37°C (98.6°F). Temperatures above this indicate fever,
while lower values suggest hypothermia.
2. Which site is most accurate for measuring core body temperature?
A. Axillary
B. Oral
C. Rectal
D. Tympanic
✅Correct Answer: C
Rationale:
The rectal route best reflects core body temperature. Axillary is least accurate and used
mainly for screening.
3. A client’s oral temperature is 100.4°F (38°C). How should the nurse
interpret this finding?
A. Normal finding
B. Hypothermia
C. Fever
D. Heat stroke
✅Correct Answer: C
,Exam Bank
Rationale:
A temperature ≥38°C (100.4°F) is classified as fever.
4. Which factor can falsely elevate an oral temperature reading?
A. Fasting
B. Drinking hot liquids
C. Smoking cessation
D. Sitting quietly
✅Correct Answer: B
Rationale:
Hot liquids, smoking, or chewing gum increase oral temperature readings. The nurse should
wait 15–30 minutes before measurement.
5. The nurse is measuring a pulse and notes an irregular rhythm. What is the
priority action?
A. Document and reassess in 1 hour
B. Notify family
C. Assess apical pulse for 1 full minute
D. Ignore if rate is normal
✅Correct Answer: C
Rationale:
An irregular pulse requires assessment of the apical pulse for a full minute to determine rate
and rhythm accurately.
6. Normal resting heart rate for an adult is:
A. 40–60 bpm
B. 60–100 bpm
C. 100–120 bpm
D. 120–160 bpm
✅Correct Answer: B
, Exam Bank
Rationale:
The normal adult pulse range is 60–100 beats per minute.
7. A pulse rate of 52 bpm in an adult is documented as:
A. Tachycardia
B. Dysrhythmia
C. Bradycardia
D. Normal
✅Correct Answer: C
Rationale:
Bradycardia is defined as a heart rate below 60 bpm in adults.
8. The nurse notes a bounding pulse. This finding is most commonly
associated with:
A. Hypovolemia
B. Fever
C. Shock
D. Dehydration
✅Correct Answer: B
Rationale:
A bounding pulse may occur with fever, anxiety, or exercise due to increased cardiac output.
9. Which pulse site is assessed during cardiopulmonary resuscitation (CPR) in
adults?
A. Radial
B. Brachial
C. Carotid
D. Femoral
✅Correct Answer: C
