Vital Signs Measurement Flashcards

A resident's blood pressure was 118/76 mmHg this morning and is now 88/58 mmHg after standing up. This drop is called:

Answer: Orthostatic (postural) hypotension

Orthostatic hypotension is a significant drop in blood pressure (≥20 mmHg systolic or ≥10 mmHg diastolic) upon standing, which increases fall risk.

A CNA notices a resident's pulse oximeter reading is 88%. What action should the CNA take first?

Answer: Reposition the probe and reassess, then report to the nurse if still low

The CNA should first check for probe issues (nail polish, poor circulation, movement), then report the persistent low reading to the nurse; administering oxygen requires a nurse's order.

Which factor can cause a pulse oximeter reading to be falsely LOW?

Answer: Poor peripheral circulation or cold fingers

Poor peripheral circulation, cold extremities, or nail polish can interfere with the light sensor and produce falsely low SpO2 readings.

When documenting vital signs, the CNA should record which of the following in addition to the values?

Answer: The date, time, site used, and any resident complaints related to the measurement

Accurate documentation includes the date, time, measurement site, the values obtained, and any relevant observations or resident complaints.

A CNA obtains a blood pressure reading that seems much higher than the resident's baseline. What is the BEST next step?

Answer: Recheck the blood pressure in the same arm after a few minutes and report the finding to the nurse

Rechecking after a short rest confirms whether the elevated reading is accurate, and the finding must always be reported to the nurse for clinical decision-making.

Which resident situation requires the CNA to report vital signs to the nurse immediately rather than waiting until the end of the shift?

Answer: A respiratory rate of 8 breaths per minute and SpO2 of 90%

A respiratory rate of 8 breaths per minute (bradypnea) combined with SpO2 of 90% indicates potential respiratory compromise and requires immediate reporting.

The nurse asks the CNA to obtain orthostatic blood pressures. In which order should measurements be taken?

Answer: Lying down (supine), then sitting, then standing — with a brief wait between each position change

Orthostatic blood pressure is measured supine, then sitting, then standing (with 1–3 minutes between position changes) to detect positional pressure drops.