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Fundamentals · chapter 7 · Vital Signs

How to Perform Vital Signs

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

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Key points

  1. Vital signs accuracy

    The consistent and accurate measurement of vital signs is a fundamental skill that healthcare providers in all facilities and settings should be able to deliver.

  2. Temperature route documentation

    It is important to document the route used to obtain a patient’s temperature because of normal variations in temperature in different locations of the body.

  3. Pediatric temperature route

    For children 5 years of age and under, the most accurate choice for taking a temperature is rectally; however, as most children do not like to have their temperature taken this way, it can also be done via tympanic or axillary routes.

  4. Oral temperature location

    Oral temperature is reliable when it is obtained close to the sublingual artery.

  5. Oral temperature accuracy factors

    Some factors can cause an inaccurate measurement using the oral route. For example, if the patient recently consumed a hot or cold food or beverage, chewed gum, or smoked prior to measurement, a falsely elevated or decreased reading may be obtained.

  6. Oral temperature timing

    Oral temperature should be taken fifteen to twenty-five minutes following consumption of a hot or cold beverage or food, or five minutes after chewing gum or smoking.

  7. Tympanic temperature accuracy

    It is an accurate measurement because the tympanic membrane shares the same vascular artery that perfuses the hypothalamus (the part of the brain that regulates the body’s temperature).

  8. Tympanic temperature contraindication

    The tympanic method should not be used if the patient has a suspected ear infection.

  9. Axillary temperature difference

    However, the axillary temperature can be as much as 1.8°F lower than the oral temperature.

  10. Rectal temperature accuracy

    However, when measuring infant temperature, it is considered a gold standard because of its accuracy.

  11. Rectal thermometer safety

    Thermometers that are specified for rectal use only should not be used to take any other type of temperature.

  12. Pulse assessment duration

    The pulse rate is measured in beats per minute, counted with the first beat detected. It is considered best practice to assess a patient’s pulse for a full sixty seconds, especially if there is an irregularity to the rhythm.

  13. Emergency pulse assessment

    In this situation, the nurse should check pulses that are more centrally located, such as the carotid or femoral pulses, and then check more peripheral pulses, such as radial or brachial pulses, only if necessary.

  14. Pulse palpation technique

    It is important to use your index and middle fingers to assess pulses; your own thumb has a pulse and may interfere with your assessment.

Terms to know

Pulse
Pulse refers to the pressure wave that expands and recoils arteries when the left ventricle of the heart contracts.
Doppler
Pulses were auscultated with a Doppler (a type of small ultrasound machine to help find pulses that cannot be palpated) upon arrival, and I assessed them as strong, meaning I could hear loud pulsing on the Doppler machine.
pulse point
This force manifests as a regular throb at a specific spot under the skin, called a pulse point, where the artery is close to the surface.
palpation
With palpation, pulse is assessed by feeling with fingers.

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

The graded version needs JavaScript. Every question is below anyway, with the answer and why.

Every question here, with the answer

  1. A nurse is about to obtain an oral temperature from an adult patient. The patient reports drinking hot tea a few minutes ago. Which action should the nurse take to obtain the most accurate temperature?

    1. Use a rectal thermometer because it is always required after a hot beverage.
    2. Wait fifteen to twenty-five minutes before taking the oral temperature.
    3. Ask the patient to chew gum first to stabilize the oral reading.
    4. Take the oral temperature immediately because hot beverages do not affect digital thermometers.

    Answer: Wait fifteen to twenty-five minutes before taking the oral temperature.

    A recent hot beverage can falsely elevate an oral temperature, so the nurse should delay the oral measurement for the recommended time. Chewing gum and smoking also affect oral readings, and rectal measurement is not automatically required in this situation.

  2. A nurse needs to measure the temperature of a 2-year-old child. Which routes are recommended for this age group? Select all that apply.

    1. Tympanic
    2. Axillary
    3. Oral
    4. Rectal
    5. Popliteal

    Answer: Tympanic, Axillary, Rectal

    For children from 3 months to 3 years, rectal, axillary, and tympanic routes are recommended. Oral temperature requires cooperation and is usually indicated for patients over 5 years of age; popliteal is a pulse site, not a temperature route.

  3. A nurse is preparing to obtain a tympanic temperature from a patient who reports ear pain and may have an ear infection. What is the best nursing action?

    1. Proceed with the tympanic temperature because it is the most accurate noninvasive route.
    2. Use the tympanic thermometer but insert it farther into the ear canal.
    3. Choose another appropriate temperature route.
    4. Pull the helix down because the patient is symptomatic.

    Answer: Choose another appropriate temperature route.

    The tympanic method should not be used when an ear infection is suspected, so the nurse should select another appropriate route. Forcing or inserting the probe farther is unsafe and can affect accuracy.

  4. A nurse is considering whether to obtain a rectal temperature. Which findings would cause the nurse to question or avoid this route? Select all that apply.

    1. The nurse can provide privacy before the procedure.
    2. The patient has leukemia.
    3. The patient is an infant and other methods are less accurate.
    4. The patient cannot be positioned for the procedure.
    5. The patient is taking blood thinners.

    Answer: The patient has leukemia., The patient cannot be positioned for the procedure., The patient is taking blood thinners.

    The section states that rectal temperatures may be contraindicated with certain disease states, blood thinners, or inability to position the patient. Infant temperature measurement is described as a situation where rectal temperature is considered a gold standard, and providing privacy is part of correct technique rather than a reason to avoid the route.

  5. A patient arrives after trauma and is unconscious. The nurse needs to assess a pulse quickly. Which pulse site should the nurse prioritize first?

    1. Carotid pulse
    2. Posterior tibial pulse
    3. Dorsalis pedis pulse
    4. Radial pulse

    Answer: Carotid pulse

    In an emergency, blood may be shunted away from the extremities toward the core, so a central pulse should be assessed first. Radial, dorsalis pedis, and posterior tibial pulses are more peripheral and may be less reliable in this situation.

  6. While assessing an adult patient’s pulse, the nurse notes that the rhythm is irregular. Which actions demonstrate correct pulse assessment technique? Select all that apply.

    1. Apply pressure somewhere between light and firm.
    2. Use the thumb to improve contact with the pulse point.
    3. Press hard enough to obliterate the pulse wave.
    4. Count the pulse for a full sixty seconds.
    5. Use the index and middle fingers to assess the pulse.

    Answer: Apply pressure somewhere between light and firm., Count the pulse for a full sixty seconds., Use the index and middle fingers to assess the pulse.

    The nurse should use the index and middle fingers, avoid the thumb because it has its own pulse, and count for a full sixty seconds when rhythm is irregular. Excessive pressure can obliterate the pulse wave, so pressure should be between light and firm.

Where every quote comes from

Section 7.2 How to Perform Vital Signs of Fundamentals of Nursing by Christy Bowen, Lindsay Draper, Heather Moore, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.