4.2 Vital Signs & Measurement
Key Takeaways
Normal adult ranges: oral temperature 97.6-99.6°F, pulse 60-100 bpm, respirations 12-20/min, blood pressure under 120/80 mmHg
On the New Jersey skill test, count the radial pulse and respirations for a FULL 60 seconds; the recorded pulse must be within ±4 beats and respirations within ±2 breaths of the correct rate, weight within ±2 lb, and urine output within ±25 ml/cc
In routine care, count respirations without telling the resident, immediately after the pulse, while keeping a hand on the wrist — awareness changes the rate. The New Jersey respirations task opens with explaining the procedure to the resident, so follow that step on the test
Take blood pressure with the bare arm at heart level, the correct cuff size, the resident rested 5 minutes, and NEVER on an arm with an IV, dialysis access, cast, or the affected side
Report a pulse under 60 or over 100, respirations under 12 or over 20, oral temperature over 101°F, or BP over 140/90 (or under 90/60) — after comparing to the resident's baseline
The four vital signs
Vital signs are measurements used in resident care. For the New Jersey exam, use the current 22-task list and task-specific instructions: five tasks begin with hand washing and four random selections. Do not infer a mandatory measurement task or an electronic blood-pressure assignment from another program's checklist.
The four primary vital signs are temperature (T), pulse (P), respirations (R), and blood pressure (BP), often written as T-P-R and BP.
Normal Adult Ranges
| Vital Sign | What It Measures | Normal Adult Range | Report If |
|---|---|---|---|
| Temperature | Body heat | Oral 97.6-99.6°F (36.4-37.6°C) | Over 101°F or under 97°F |
| Pulse | Heartbeats per minute | 60-100 beats/min | Under 60 or over 100 |
| Respirations | Breaths per minute | 12-20 breaths/min | Under 12 or over 20 |
| Blood Pressure | Force on artery walls | Under 120/80 mmHg | Over 140/90 or under 90/60 |
A single reading outside the range is not automatically an emergency — always compare it to the resident's baseline (their usual values, recorded in the chart) and report the change to the nurse. A 'normal' number that is far from a resident's baseline can also matter.
Temperature Sites
Different sites read differently, so always record which site you used.
| Site | Reads vs. Oral | Notes |
|---|---|---|
| Oral | Baseline | Common; not for confused residents or just after hot/cold fluids |
| Rectal | ~0.5-1°F higher | Most accurate; used when oral is unsafe |
| Axillary (armpit) | ~0.5-1°F lower | Least accurate; safest |
| Tympanic (ear) | About equal to oral | Fast; quick screening |
Use the site ordered in the care plan, and never take an oral temperature on a confused resident, an unconscious resident, or one who just ate, drank, or smoked.
Measuring Pulse and Respirations
The radial pulse, felt with the fingertips on the thumb side of the wrist, is the routine site. The apical pulse, heard with a stethoscope over the heart's apex, is used for irregular rhythms or before certain heart medications. For routine charting, count a regular pulse for 30 seconds and multiply by 2; count an irregular pulse for a full 60 seconds. On the New Jersey radial-pulse task you count for a full 60 seconds, write the number on the recording sheet, and it must be within ±4 beats of the correct rate. Note the rate, rhythm (regular/irregular), and force.
Immediately after the pulse, keep your hand on the wrist as if still counting it and count respirations. One respiration = one full inhale + exhale. Count for 30 seconds and multiply by 2 if regular, or a full minute if irregular; the New Jersey respirations task is a full 60 seconds, written on the sheet, within ±2 breaths of the correct rate. In routine care, do not tell the resident you are counting breaths — awareness changes the rate. The New Jersey task itself opens with explaining the procedure to the resident, so follow that step on the test. Observe depth and whether breathing is labored, shallow, or noisy.
Measuring Blood Pressure
Blood pressure has two numbers: systolic (heart contracting, the top number) over diastolic (heart at rest, the bottom number), reported in mmHg. Accurate technique:
- Resident seated and rested at least 5 minutes, legs uncrossed, feet flat on the floor, back supported.
- Bare upper arm supported at heart level, palm up.
- Correct cuff size — a cuff too small or too loose gives a falsely high reading; too large gives a falsely low one.
- Never use an arm with an IV line, dialysis shunt/fistula, cast, or the affected (paralyzed or post-mastectomy) side.
Common Error Sources
| Error | Effect on Reading |
|---|---|
| Cuff too small or loose | Falsely high |
| Arm below heart level | Falsely high |
| Deflating the cuff too fast | Inaccurate (often low) |
| Resident talking or not rested | Falsely high |
| Recent caffeine, smoking, or exercise | Falsely high |
| Legs crossed | Falsely high |
Height, Weight, and Pain
Weigh the resident at the same time of day, on the same scale, in similar clothing, after voiding so the reading is comparable. A sudden weight gain can signal fluid retention (often from heart or kidney problems) and must be reported. Weight is on the New Jersey skills list: zero the scale, center the resident with arms at the sides and holding nothing, and record a weight within ±2 lb of the correct weight. Measure height with the resident standing straight or, if bedbound, with a tape measure from the top of the head to the heel along the body.
Pain is widely called the fifth vital sign. The resident's own report — often on a 0-10 numeric scale, or a faces scale for residents who cannot use numbers — is the most reliable measure. The CNA records exactly what the resident says, notes nonverbal clues (grimacing, guarding, restlessness, moaning), and reports it to the nurse. The CNA never decides whether the pain is 'real' or treats it; pain relief (medication) is a nurse responsibility.
Recording and Reporting
Record every value immediately after taking it — do not rely on memory or estimate a number. Document the actual reading, the site or arm used, and the time. Objective data (a measured 98.6°F, a pulse of 88) is fact; subjective data is what the resident states ("my chest hurts"). Report any abnormal value or change from baseline to the nurse right away, because vital-sign changes are often the first warning of infection, bleeding, or cardiac problems. Documentation is a permanent legal record, so it must be accurate, timely, and never altered.
On the New Jersey skill test, a candidate is asked to count a resident's radial pulse. How should the candidate count, and how close must the recorded value be to the correct rate?
Count for 15 seconds and multiply by 4; within ±10 beats
Count for 30 seconds and double it; exact match required
Estimate from the heart rate monitor; within ±20 beats
Count for a full 60 seconds; within ±4 beats of the correct rate
A New Jersey CNA finishes counting a resident's radial pulse and, while still holding the wrist, begins counting the resident's breathing. The resident asks, 'Are you checking my breathing now?' What should the CNA do?
Say yes and ask the resident to breathe normally
Continue counting without confirming, because telling the resident can change the breathing rate
Stop and recount the pulse instead
Tell the resident to take ten slow deep breaths so it is easier to count
A CNA is about to take a blood pressure on a New Jersey resident who had a right-side mastectomy and has an IV in the left forearm. Both arms are otherwise available. What is the BEST action?
Use the right arm because the IV is in the left arm
Use the left arm because the right side had surgery
Do not take the BP on either arm; report the situation to the nurse
Take it on the right ankle without telling the nurse
A resident's oral temperature reads 101.4°F, the pulse is 96, respirations are 18, and BP is 118/76. Which finding should the CNA report to the nurse?
The temperature of 101.4°F
The pulse of 96
The respirations of 18
The blood pressure of 118/76
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