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Everything You Need to Know About NCLEX Vital Signs

Victoria Derlin, BS, RN, BSN Nursing and Student Advice, Nursing Content

Vital signs are one of the first things you learn in nursing school. They are an important part of the patient assessment. Vital signs are objective, meaning they are not influenced by personal opinion. In some cases they could be the only indication that something is seriously wrong with a patient. Depending on your job, you may be expected to assess and monitor vitals signs several times during your work day.  That is why it is essential to know them like the back of your hand before taking the NCLEX and becoming a working nurse. Use this guide as a vital sign review before taking the NCLEX. 

Know What the 5 Vital Signs Are

  • Temperature
  • Heart Rate
  • Respiration Rate
  • Oxygen Saturation
  • Blood Pressure

Know What Normal Vital Signs Throughout the Lifespan

Remember that vital signs vary depending on age. A heart rate of 170 beats per minute is not reason for concern in a newborn but would be extremely concerning for an adult patient at rest. You will likely come across questions on the NCLEX that will test to see if you know what is normal and abnormal depending on the patient's age.

AGE RELATED VARIATIONS IN NORMAL VITAL SIGNS

Age

Temp (C/F)

Pulse (beats per min)

Respirations (breaths per min)

Blood Pressure (mm HG)

Newborn

35.9 - 36.9 C

96.7 - 98.5 F

70-190

30-55

73/55

Infant

37.1 - 38.1C

98.7 - 100.5 F

80-150

20-40

85/37

Toddler

37.1 - 38.1C

98.7-100.5F

70-120

20-30

89/46

Child

36.8-37.8C

98.2-100F

70-115

20-25

95-57

Preteen

35.8-37.5C

96.4-99.5F

65-110

18-26

102/61

Teen

35.8-37.5C

96.4-99.5F

55-105

12-22

112/64

Adult

35.8-37.5C

96.4-99.5F

60-100

12-20

120/80

Aged Adult (65+)

35.8-36.8C

96.4-98.3F

40-100

16-24

120/80

Know When to Assess Vital Signs

  • On admission and discharge
  • Based on your workplace’s policy and procedures
  • When there is a change in the patient’s condition (examples: loss of consciousness, a fall, or the patient reports not feeling well)
  • Before and after a surgical or invasive diagnostic procedure (examples: dialysis and any surgery)
  • Before administering medications that affect cardiovascular and respiratory function

Know How to Assess Vital Signs

You should have learned this in your health assessment class and clinicals but if you need a review go back to your health assessment textbook or notes and make sure you practice on your friends and family.

Know How to Convert Temperatures From Celsius to Fahrenheit and Vice Verus 

Conversion from Celsius to Fahrenheit

(9/5 * C) + 32 = degrees in Fahrenheit

Conversion from Celsius to Fahrenheit

(9/5 * C) + 32 = degrees in Fahrenheit

 

Know The General Factors That Affect Vital Signs

  • Circadian Rhythms
  • Age
  • Gender
  • Exercise
  • State of Health and Medical Conditions
  • Stress and Emotions
  • Medications, Alcohol and Illegal Drugs
  • Weight
  • Body Positioning
  • Alterations in Fluid Balance
  • Trauma
  • Infection
  • Pain
  • Caffeine
  • Having a Full Bladder

It is beneficial to know these factors so that you are able to make an accurate assessment of the patient.

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Know the Difference between a Peripheral and Apical Pulse

A peripheral pulse can be palpated over a peripheral artery such as the radial or carotid artery. An apical pulse is auscultated over the apex of the heart.

Know What Pulse Amplitude Is

Pulse amplitude describes the quality of the pulse in terms of its fullness and strength. Pulse amplitude is when you palpate a pulse and it is given a grade. A grade of 0 would mean that the pulse is absent and you cannot palpate it. A grade of +1 means the pulse is diminished and weaker than expected. A grade of +2 is a normal pulse. A grade of +3 would be a bounding pulse.

Know the Types of Respiration Patterns

 

Description

Associated

Normal

12-20 breaths/min

Regular

normal pattern

Tachypnea

>24 breaths/min

Shallow

fever, anxiety, exercise, respiratory disorders

Bradypnea

<10 breaths/min

Regular

depression of respiratory center caused by med, brain damage

Hyperventilation

increased rate and depth

exercise, fear, diabetic ketoacidosis

Hypoventilation

decreased rate and depth, irregular

overdose

Cheyne-Stokes Respirations

alternating periods of deep, rapid, breathing followed by periods of apnea; regular

drug overdose, heart failure, renal failure

Biot’s Respirations

varying depth and rate of breathing followed by periods of apnea; irregular

meningitis, severe brain damage

Know When Not Assess Blood Pressure and Temperature the Standard Way

 There are times when you should not assess blood pressure in a specific limb. If someone has had a mastectomy, lymph node removal, recent surgery, a broken bone,  has an HD line, or a central line you should not take a blood pressure reading in that limb.

When taking a temperature you should select the site depending on age, state of consciousness, pain, and other current medical treatments. For example, if a patient has recently drank their streaming hot cup of morning coffee then you should avoid taking an oral temperature. Know that a rectal temperature should not be taken on newborns. 

Know The Vocabulary That Goes Along With Vital Signs

 There are a lot of vocabulary terms that you should know that are related to vital signs. If you need practice memorizing these, make flashcards and study them a couple of times a day.

Vocabulary Related to Temperature

  • Afebrile: person with normal body temperature
  • Febrile: person with fever
  • Hypothermia: low body temp
  • Hyperthermia: high body temp
  • Hyperpyrexia: when fever is equal to or greater than 106 F
  • Neurogenic fever: a fever that is the result of damage to hypothalamus from causes such as intracranial trauma, intracranial bleeding, increased intracranial pressure

Vocabulary Related to Blood Pressure

  • Systole: blood pressure reading when the heart ventricles contract
  • Diastole: blood pressure when the heart ventricles relax
  • Korotkoff sounds: series of sounds that nurses listens to in order to determine BP, first sound is the systolic pressure, the diastolic pressure is when the sounds disappear
  • Hypertension: above normal blood pressure
  • Hypotension: below normal blood pressure
  • Orthostatic hypotension: decrease in systolic blood pressure of 20 mm Hg or decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with BP from sitting or lying down
  • Pulse Pressure: difference between systolic and diastolic pressure

Know The Vocabulary That Goes Along With Vital Signs

  • Bradycardia: a heart rate lower than 60 beats per minute
  • Tachycardia: a heart rate greater than 100 beats per minute
  • Dysrhythmia: irregular pattern of heartbeats

Vocabulary Related to Respirations

  • Ventilation: breathing, respiration
  • Inspiration: inhalation
  • Expiration: exhalation
  • Perfusion: exchange of oxygen and carbon dioxide between blood and tissue
  • Eupnea: normal, unlabored respiration
  • Tachypnea: increased respiration rate
  • Hyperventilation: more than the normal amount of air entering and leaving the lungs
  • Hypoventilation: decreased rate and depth of breaths
  • Bradypnea: decrease in respiratory rate
  • Apnea: periods which there is no breathing
  • Dyspnea: difficult or labored breathing
  • Orthopnea: type of dyspnea where breathing is easier when sitting up or standing
  • Cheyne-Stokes Respirations: alternating periods of deep, rapid, breathing followed by periods of apnea
  • Biot’s Respirations: varying depth and rate of breathing followed by periods of apnea
Use this as a guide to assist you with your studies. It is guaranteed that vital signs will be a part of your NCLEX exam. They are an essential component of a good physical assessment. Prepare yourself for the NCLEX by reviewing this material often. Happy Studying!