Vital Signs Practice Test

Answer: D — The normal oral temperature for adults ranges from approximately 97.6°F to 99.6°F (36.4°C to 37.6°C), with 98.6°F (37°C) being the widely accepted average. Any reading above 100.4°F (38°C) is generally considered a fever and must be reported to the nurse immediately. CNAs should remember that temperature can vary slightly depending on time of day, activity level, and the individual resident.

Answer: A — The rectal route is considered the most accurate measurement of core body temperature because the rectum is an enclosed body cavity with excellent blood supply and is not affected by breathing, eating, or drinking. Rectal readings are approximately 1°F (0.6°C) higher than oral readings. However, rectal temperatures are the most invasive route and are contraindicated in residents with rectal surgery, diarrhea, hemorrhoids, or cardiac conditions where vagal stimulation could be dangerous.

Answer: D — Axillary temperatures read approximately 1°F (0.6°C) LOWER than oral temperatures because the armpit is not an enclosed body cavity and is exposed to environmental air. Therefore, to estimate the oral equivalent, you ADD 1°F to the axillary reading: 97.2°F + 1°F = 98.2°F. CNAs must know these conversion rules — rectal reads 1°F higher than oral, and axillary reads 1°F lower than oral — to accurately interpret and report temperature findings.

Answer: A — Oral temperatures should NOT be taken on residents who have consumed hot or cold food/drinks within the last 15-20 minutes (as it falsely alters the mouth temperature), residents who are confused or unconscious (risk of biting and breaking the thermometer), residents who are mouth-breathing or on oral oxygen delivery, those who have had recent oral surgery, or very young children. This resident has two disqualifying factors — confusion and recent hot coffee — making the oral route unreliable and potentially unsafe.

Answer: D — A tympanic reading of 96.1°F is abnormally low and most likely indicates a technique error rather than true hypothermia. The most common causes of falsely low tympanic readings are: the probe tip not being properly sealed in the ear canal, excessive earwax blocking the infrared sensor, or not pulling the ear pinna up and back (for adults) to straighten the ear canal. The CNA should retake the temperature in the opposite ear using correct technique before recording or reporting the value.

Answer: D — The normal adult resting pulse rate ranges from 60 to 100 beats per minute (bpm). A rate below 60 bpm is called bradycardia and a rate above 100 bpm is called tachycardia — both are abnormal findings that must be reported to the nurse immediately. When taking a pulse, the CNA assesses not only the rate but also the rhythm (regular vs. irregular) and strength/quality (strong and bounding vs. weak and thready).

Answer: D — The radial artery, located on the thumb side of the inner wrist, is the most common and convenient site for routine pulse measurement by CNAs. It is easily accessible, non-invasive, and comfortable for the resident. The carotid pulse (neck) is typically used only during emergencies like CPR. The brachial pulse (inner elbow) is used for blood pressure measurement and infant pulse checks. The apical pulse (over the heart) requires a stethoscope and is used when a radial pulse is difficult to feel or when the pulse is irregular.

Answer: B — The radial pulse must be taken using the pads of the index and middle fingers placed gently over the radial artery on the thumb side of the wrist. The thumb must NEVER be used because it has its own pulse (from the princeps pollicis artery), which can easily be confused with the resident's heartbeat, leading to an inaccurate count. Apply light to moderate pressure — pressing too hard compresses the artery and makes the pulse undetectable, while pressing too lightly may cause you to miss beats.

Answer: A — When an irregular pulse rhythm is detected, the CNA must count for a full 60 seconds (never use the 15-second shortcut, which is only acceptable for regular rhythms) to get the most accurate rate. The CNA should then immediately report both the rate AND the irregular rhythm to the nurse, as this could indicate a cardiac arrhythmia such as atrial fibrillation that requires medical evaluation. An irregular pulse is never 'normal' and should always be documented and reported.

Answer: A — A thready pulse is one that feels weak, faint, and barely perceptible under the fingertips — as if it could disappear with slight additional pressure. This is an important clinical finding because it often indicates low blood volume, dehydration, shock, heart failure, or poor cardiac output. The opposite is a 'bounding' pulse, which feels strong and forceful. CNAs must report a thready pulse to the nurse immediately as it may signal a serious and potentially life-threatening condition requiring urgent medical intervention.

Answer: C — The normal adult respiratory rate at rest is 12 to 20 breaths per minute, where one complete breath consists of one inhalation and one exhalation. A rate below 12 breaths/min is called bradypnea and a rate above 20 breaths/min is called tachypnea — both are abnormal findings that must be immediately reported to the nurse. Respiratory rates in the 30-40 range indicate severe respiratory distress and may be a medical emergency.

Answer: C — When people become aware that their breathing is being watched, they often unconsciously change their respiratory rate, depth, and pattern — breathing faster, slower, deeper, or more shallowly than normal. This produces an inaccurate measurement. The standard technique is to count respirations immediately after taking the pulse while continuing to hold the resident's wrist — the resident will assume you are still counting heartbeats and will breathe naturally without conscious alteration.

Answer: C — A complete respiratory assessment by the CNA includes three components: rate (number of breaths per minute), depth (shallow, normal, or deep), and rhythm (regular and even, or irregular with pauses). The CNA should also note any abnormal observations such as labored breathing, use of accessory muscles, wheezing or noisy breathing, nasal flaring, or changes in skin color (cyanosis). All abnormal findings must be documented and reported to the nurse immediately.

Answer: C — Bradypnea is an abnormally slow respiratory rate below 12 breaths per minute in an adult. A rate of 8 breaths/min with shallow depth is a serious finding that significantly reduces oxygen delivery to the body and must be reported to the nurse as an emergency. Tachypnea is an abnormally fast rate (above 20/min), dyspnea is difficulty or labored breathing at any rate, and apnea is the complete absence of breathing. Bradypnea can be caused by opioid medications, brain injury, or severe metabolic conditions.

Answer: B — Cheyne-Stokes respiration is a distinctive abnormal breathing pattern that cycles between gradually increasing depth and rate of breathing, followed by a period of gradually decreasing breathing, and then a period of apnea (no breathing at all) — this cycle then repeats. It is commonly seen in residents who are approaching end of life, those with severe heart failure, brain injuries, or stroke. This is a critical finding that must be reported to the nurse immediately as it often indicates a serious deterioration in the resident's condition.

Answer: C — A normal adult blood pressure is approximately 120/80 mmHg, where 120 is the systolic pressure (the force of blood against artery walls when the heart contracts/beats) and 80 is the diastolic pressure (the force when the heart is resting between beats). Readings consistently above 130/80 are classified as hypertension (high blood pressure) and readings below 90/60 are classified as hypotension (low blood pressure). Both abnormal readings must be reported to the nurse promptly.

Answer: D — The top number is the systolic pressure, which measures the force of blood pushing against the artery walls during a heartbeat (when the heart muscle contracts and pumps blood out). The bottom number is the diastolic pressure, which measures the pressure in the arteries when the heart is resting and refilling between beats. The systolic reading is always the higher number. Understanding what each number represents helps CNAs recognize why both values matter and when to report abnormal findings.

Answer: A — A blood pressure cuff that is too SMALL for the resident's arm will give a falsely elevated (high) reading because the narrow cuff must be inflated to a higher pressure to compress the artery through the extra tissue. Conversely, a cuff that is too LARGE will give a falsely low reading. Other causes of falsely high readings include crossing legs, a full bladder, recent caffeine or smoking, pain, anxiety, talking during the measurement, and positioning the arm below heart level.

Answer: A — A blood pressure reading of 88/56 mmHg is below the threshold of 90/60 mmHg and is classified as hypotension (low blood pressure). This is a significant finding that must be reported to the nurse immediately because hypotension can cause dizziness, fainting, falls, confusion, and in severe cases, shock and organ damage from inadequate blood flow. The CNA should also assess the resident for symptoms such as lightheadedness, weakness, blurred vision, and nausea, and ensure the resident's safety by keeping them in bed or seated.

Answer: B — Orthostatic (postural) hypotension is diagnosed by measuring blood pressure in three sequential positions: first lying down (supine), then sitting, then standing, with 1-3 minutes of rest between each position change. A drop of 20 mmHg or more in systolic pressure or 10 mmHg or more in diastolic pressure upon standing confirms orthostatic hypotension. This is critical information because it tells the care team the resident is at high risk for falls and may need slower position changes, increased hydration, or medication adjustments.

Answer: B — Normal oxygen saturation (SpO₂) for a healthy adult is 95-100%, meaning that 95-100% of the hemoglobin molecules in the blood are carrying oxygen. A reading below 95% is considered abnormal and should be reported to the nurse. A reading below 90% is a medical emergency called hypoxemia, indicating that the body's organs and tissues are not receiving adequate oxygen. Some residents with chronic lung diseases like COPD may have a lower baseline SpO₂ that is acceptable — this will be noted in their care plan.

Answer: B — A pulse oximeter is a small, non-invasive device that clips onto a fingertip (most common site), toe, or earlobe. It works by shining two wavelengths of light (red and infrared) through the tissue and measuring how much light is absorbed by oxygenated versus deoxygenated hemoglobin. The fingertip is preferred because it has excellent blood flow and is easily accessible. The earlobe is used as an alternative when fingers are unavailable or when peripheral circulation is poor.

Answer: C — Dark nail polish (especially black, blue, green, or brown) can interfere with the light transmission of the pulse oximeter and produce inaccurate readings — either falsely low or unreliable values. Other factors that cause inaccurate readings include: cold fingers or poor peripheral circulation, excessive movement or shivering, bright overhead lighting, skin pigmentation, carbon monoxide poisoning (gives falsely high readings), and anemia. The CNA should remove nail polish or use an alternative site like the earlobe when polish cannot be removed.

Answer: B — An SpO₂ reading of 88% is significantly below the normal range of 95-100% and indicates hypoxemia — the resident's blood is not carrying enough oxygen to adequately supply the body's tissues and organs. This is an urgent finding that must be reported to the nurse IMMEDIATELY. While the CNA waits for the nurse, they should ensure the resident is positioned upright (Fowler's position) to maximize lung expansion, remain calm, and observe for other signs of respiratory distress such as cyanosis, confusion, restlessness, or labored breathing.

Answer: C — Some residents with chronic lung diseases like COPD (Chronic Obstructive Pulmonary Disease) have a documented lower baseline SpO₂ that is considered acceptable for them — in this case 90%. A reading of 91% is actually slightly above their established baseline and within their expected range, so no emergency intervention is needed. The CNA should document the reading and continue monitoring. However, applying high-flow oxygen to a COPD resident without an order can be dangerous because it may suppress their respiratory drive — oxygen should NEVER be adjusted by a CNA without a specific physician's order.