9.1 Adult Vital-Sign Ranges and When to Report
Key Takeaways
- Typical adult study ranges used in CNA training are oral temperature about 97.6–99.6°F (36.4–37.6°C), pulse 60–100, and respirations 12–20 — Credentia does not publish those numbers as a written cut score.
- For blood pressure, report the values the licensed nurse has flagged and any large change from that client's own baseline; hypotension and hypertension are report-worthy.
- Temperature sites are oral, axillary, tympanic, temporal, and rectal; take a rectal temperature only if trained and ordered, never on a cardiac client without nurse direction, and always follow facility policy.
- Report an abnormal vital sign to the licensed nurse first, then document; never write machine error and walk away without a recheck and a nurse report if the number is still abnormal.
- Pain is the fifth vital sign: report location, a 0–10 rating, and what makes it worse.
9.1 Adult Vital-Sign Ranges and When to Report
Quick Answer: Typical adult study ranges used in CNA training are oral temperature about 97.6–99.6°F (36.4–37.6°C), pulse 60–100 beats per minute, and respirations 12–20 breaths per minute. Credentia does not publish those numbers as a written-exam cut score — they are training references. For blood pressure, report the values the licensed nurse has flagged and any large change from the client's own baseline. Hypotension and hypertension are report-worthy. Pain is the fifth vital sign: report location, a 0–10 rating, and what makes it worse. Report first, then document. Never ignore a machine error without a recheck and a nurse report if the number is still abnormal.
Why this section is on the exam
On the 2024 National Nurse Aide Assessment Program (NNAAP) outline Colorado uses, Data Collection and Reporting is leaf I.B.4 inside Basic Nursing Skills (I.B). Basic nursing skills are 35% of the 60 scored written items — about 21 questions that also cover infection control, safety, and technical procedures. Data-collection stems still show up as temperature, pulse, respiration, blood pressure, and pain items that ask one thing: what do you do with the number?
The Skills Evaluation always includes one measurement skill among the four random skills (plus hand hygiene). Radial pulse, respirations, and electronic blood pressure are three of those five measurement skills. Written items test the ranges and the report rule. Skills items test whether you can produce a number the evaluator will accept. This section is the ranges and the report rule. Skills 6, 7, 12, and 23 get their own handbook steps in 9.2 and 9.3.
Study ranges — not a Credentia cut score
Memorize these as typical adult references used in training. They are not a number Credentia prints as a written passing score, and they are not a critical-element tolerance on the skills test. A client can have a pulse of 88 — inside the study range — and still need an immediate report if that person's usual pulse is 56. Baseline beats textbook.
| Measurement | Typical adult study range | Report-worthy examples |
|---|---|---|
| Oral temperature | About 97.6–99.6°F (36.4–37.6°C) | 102.4°F oral; a sudden drop below the person's usual |
| Radial pulse | 60–100 beats per minute | 48, 124, newly irregular, or a large change from baseline |
| Respirations | 12–20 breaths per minute | 8, 28, noisy, labored, or a large change from baseline |
| Blood pressure | Follow the nurse's flagged limits and the client's baseline | Hypotension, hypertension, or a large change from that person's usual |
| Pain (fifth vital) | Client's own 0–10 report | New, sudden, or worsening pain; chest pain always now |
Hypotension means the blood pressure is too low for that person. Hypertension means it is too high. Training manuals often use adult classroom flags such as a systolic below 90 mm Hg or a reading at or above 140/90 mm Hg. On the unit, the licensed nurse and the care plan tell you which numbers to call. A textbook-normal blood pressure that is 40 points below yesterday's reading is still a verbal report.
Do not invent a Colorado Board numeric cut for when a CNA may ignore a vital sign. There is no such published ignore-list. If the number is outside the range you were taught, outside the range the nurse flagged, or different from this client's baseline, tell the nurse.
Temperature sites
The site changes the number. Always chart the site with the reading.
- Oral: Probe under the tongue, lips closed. Wait after a hot or cold drink per training (often 15–20 minutes). Do not use oral if the client cannot hold the probe, is unconscious, is a young child, or is receiving oxygen by a mask that you cannot safely interrupt — follow the care plan.
- Axillary: In the dry armpit, arm held down. Typically reads lower than oral. Used when oral is not appropriate.
- Tympanic: In the ear canal, following the device instructions and positioning the pinna as trained. Earwax, a hearing aid just removed, or the wrong ear direction will fake a number.
- Temporal: Across the forehead and temporal artery with the device the facility stocks. Sweat, hats, and an incomplete sweep alter it.
- Rectal: Only if you are trained and it is ordered. Follow facility policy. Do not take a rectal temperature on a cardiac client without nurse direction. Rectal stimulation can affect heart rhythm. Never force a rectal probe. Lubricate, insert only the trained depth, hold the thermometer, and protect privacy first.
If the care plan says oral and the client just drank hot coffee, you wait or you ask the nurse whether another site is ordered. You do not invent a rectal temperature because you are in a hurry.
What changes a reading
A wrong vital sign is sometimes a wrong setup.
- Hot or cold drink, smoking, chewing gum — wait before an oral temperature.
- Exercise, transferring, or a long walk — pulse, respirations, and blood pressure rise. Rest first when the assignment allows, then measure.
- Pain, anxiety, and crying — raise pulse, respirations, and blood pressure. Still measure, still report, and include that the person is in pain.
- Medications — some lower pulse or blood pressure; some raise them. You do not hold a medication. You report the number.
- Caffeine — can raise pulse and blood pressure.
- Wrong cuff size, arm below or above heart level, talking during the reading — fake blood-pressure numbers.
- Thumb on the pulse, or counting 15 seconds and multiplying — fake pulse numbers on the skills test and on the unit.
Report first, then document
Chapter 4 taught the same sequence. Vital signs do not get a special exception.
- Obtain the number correctly.
- Compare it to the care-plan limits and this client's baseline.
- If it is abnormal, sudden, or a large change — verbal report to the licensed nurse now.
- Then document the number, the site, the time, and that the nurse was notified.
Stay with a client who has chest pain, shortness of breath, or a fainting feeling. Do not leave a hypotensive person sitting on the toilet so you can find a computer.
Never ignore a machine error
Electronic thermometers, pulse oximeters, and blood-pressure machines fail. They also tell the truth when the client is crashing. Never throw away an abnormal machine reading because you decided the machine is broken.
- Recheck the setup: probe in the right place, cuff on a safe arm and the correct size, client still, batteries working.
- Repeat the measurement correctly.
- If the number is still abnormal, report it. Tell the nurse it was a machine reading, that you rechecked, and what you obtained.
- You may also obtain a manual pulse or a manual blood pressure if you are assigned and trained — that is still a report, not a reason to hide the first number.
Writing machine error and walking away is a data-collection failure. The exam will offer that option. It is wrong.
Pain is the fifth vital sign
Pain is what the client says it is. You do not decide the person is not really hurting.
Report:
- Location — left hip, across the chest, low back
- Intensity on a 0–10 scale (0 = no pain, 10 = worst pain)
- What makes it worse or better — movement, lying flat, a transfer, swallowing
- Onset — new, sudden, or changed from this morning
- Effect on function — cannot bear weight, cannot take a deep breath
Chest pain or pressure is an immediate verbal report, not a wait-and-see number. You do not diagnose angina. You report location, the 0–10 rating, and what you see (color, breathing, clutching the chest).
Colorado scenario
You are assigned morning vitals on a Greeley long-term-care unit. Mr. Alvarez's care-plan card says report a systolic blood pressure below 100 or above 160, and his usual reading is 128/74. The electronic machine first flashes an error, then displays 78/42. He says his pain is 7 out of 10 in the left chest when he sits forward. A coworker tells you those cuffs error all morning — just write machine error and move on.
You do not write machine error and leave. You recheck the cuff size, keep the arm at heart level, and repeat. If the number is still far below his baseline — or if he still has chest pain — you stay with him and give an immediate verbal report to the licensed nurse: blood pressure 78/42 after a recheck, usual 128/74, chest pain 7/10, worse sitting forward. Then you document the numbers, the site, the pain location and rating, and that the nurse was notified. You do not diagnose a heart attack. You do not wait until the end of the 0700 vital-sign round.
Exam traps
- Treating textbook ranges as a Credentia written cut score.
- Ignoring a large change from this client's baseline because the number is still in the book range.
- Taking a rectal temperature on a cardiac client without nurse direction.
- Charting first and reporting later — or never — when the number is abnormal.
- Writing machine error and skipping the recheck and the nurse.
- Deciding pain is not real because the person is talking or watching television.
- Diagnosing hypotension, hypertension, or a heart attack instead of reporting the facts.
A Colorado CNA obtains an oral temperature of 102.8°F. The client looks flushed. What should the CNA do first?
Which statement about adult temperature sites is correct for a Colorado CNA?
An electronic blood-pressure machine flashes an error and then displays 78/40. The client's usual reading is 128/76. A coworker says the machine has been wrong all morning. What should the CNA do?