Basic Nursing Skills and Vital Signs
Vital signs are the aide's early-warning system. Know the adult normal ranges cold: oral temperature 97.6 to 99.6 F, pulse 60 to 100 beats per minute, respirations 12 to 20 per minute, blood pressure under 120/80, and pain rated 0 to 10 as the fifth vital sign. Rectal temperatures run about one degree higher than oral; axillary about one degree lower.
Measure consistently. For an oral temperature, wait 15 minutes after the resident drinks hot or cold fluids or smokes. Never take an oral temperature on a resident who is confused, unconscious, has a seizure disorder, or is on oxygen by mask. Take the radial pulse with two or three fingertips - never the thumb, which has its own pulse - and note rate, rhythm, and volume. Count respirations while the resident still believes you are counting the pulse; announcing it makes people change how they breathe. Count 30 seconds and multiply by two if the rhythm is regular, a full minute if irregular.
Blood pressure: resident seated or lying, arm supported at heart level, correct cuff size, no talking. Note dizziness on standing, which suggests an orthostatic drop.
Document what you actually measured, in the correct units, and report anything outside the normal range or any change from that resident's usual baseline. A pulse of 48 or a respiratory rate of 28 matters more than a single number looks.
Trap: answer choices that skip the rest period or that use the thumb for a pulse.
Rule of thumb: compare to the resident's own baseline, not just to the textbook range.