Apical pulse should be done for one full minute with an irregular rhythm, in cardiac patients, children < 2 years, and before the administration of digoxin and beta blockers.

In anemia, tachycardia, and a bounding pulse will be present when the hemoglobin is < 7.0 g/dL. The bounding pulse is reflective of the increased cardiac output which is needed to compensate for the decrease in oxygen carrying capacity in anemia.

In shock, tachycardia, and a weak pulse will be present as cardiac output falls. In compensated shock, tachycardia and a normal BP will be present. In decompensated shock, tachycardia and hypotension will be present.

Normal respiration and pulse rates have a ratio of 1:4. With a fever, dehydration, or hypotension, the pulse will be higher. The way to remember the normal rates for adult, child, and infant is to use 20-30-40 for the respiratory rate and then times it by 4 for the expected pulse rate.

For an accurate blood pressure reading, nicotine or caffeine should be avoided 30 minutes before the reading and an accurate cuff size should be used. When a cuff is too large, the reading will be low. When the cuff is too small, the reading will be falsely elevated. For the initial reading, two or more readings should be taken separated by 2 minutes and the results should be averaged.

Pulse pressure is the difference between systolic and diastolic pressures. It narrows in decreased cardiac output and widens in increased in increased intracranial pressure. In compensated shock, pulse pressure will decrease and the blood pressure will be maintained.

• Tympanic > 6 months and rectal has contraindications.
• Normal fluid intake 2,000-2,500. Urine output half.
• Fever reduction after ABCs and increase fluids by 500-1,000 mL. Urine output less.
• Respirations to pulse 1:4 and 20-30-40 for adult, child, and infant.
• Too Large of a BP cuff causes a Low reading.

In preparing for the NCLEX exam there are multiple considerations with vital signs. Proper monitoring of the temperature is based on age and clinical conditions. Fever reduction needs to be a priority and additional fluid will be needed due to the hypermetabolic state. In select conditions, apical pulse monitoring is recommended. Tachycardia is frequently seen. In anemia the pulse will be bounding but in shock it will be weak. Accuracy in blood pressure monitoring is dependent on several factors including the size of the cuff. Use of 20-30-40 is beneficial in answering NCLEX style questions. This may also be used in the clinical environment for a quick reference prior to use of a Braslow tape for more accurate ranges.