Vital signs normal ranges for the CCMA exam

Patient Intake and Vitals is 14 of the 150 scored items on the NHA CCMA exam, about 9 percent. The exam does not want you to recite a table. It wants you to recognize a value that is out of range, know what pushed it there, and know the medical assistant's job: recheck if appropriate, document, and notify the provider. This post covers the ranges and the technique points from the intake and vital signs unit of the free NHA CCMA course. It is a study aid, not clinical guidance; the provider, facility policy, state law and your training decide practice.

If you want to test a number before reading on, the vital signs normal ranges checker tells you which band an adult value falls in.

A note on sources before the numbers

Reference ranges differ by textbook. The course uses OpenStax Clinical Nursing Skills and MedlinePlus, and the table says where they disagree. Learn the shape of each range first and the edges second, as in how to memorize a list, a table or a formula sheet.

Adult ranges at a glance

Temperature by route

The route changes the number, and the exam likes to ask which route reads highest or lowest.

• Rectal reads highest, about 0.5 to 1 F (0.3 to 0.6 C) above oral. It is the most accurate and most invasive route and the gold standard for infants under 1 year. Avoid it after anorectal surgery or in patients with low blood counts. Rectal probes are color-coded red.
• Tympanic reads slightly higher than oral, because the eardrum shares blood supply with the hypothalamus. Avoid it with a known or suspected ear infection or ear or facial trauma.
• Oral is the baseline route, with the probe under the tongue. The patient must be able to follow directions. Wait about 25 minutes after hot or cold drinks and 5 minutes after smoking or chewing gum, and remember that mouth breathers can read low.
• Temporal artery scanners read the forehead by infrared and can be used on a sleeping child.
• Axillary reads lowest, about 1 F (0.6 C) below oral. It is minimally invasive and used for young children and people who cannot follow directions. A probe that is not deep in the armpit reads falsely low.

MedlinePlus fever thresholds in children are rectal 100.4 F (38 C), oral 99.5 F (37.5 C) and axillary 99 F (37.2 C). An infant 3 months or younger with a rectal temperature of 100.4 F or higher should be seen right away. If any temperature is abnormal, repeat it.

The conversions are fair game too. F = (C x 1.8) + 32, so 38 C becomes 100.4 F. C = (F - 32) / 1.8, so 101.3 F becomes 38.5 C. The classic wrong answer adds 32 before multiplying.

Pulse

The radial pulse on the thumb side of the wrist is the routine adult site. The apical pulse is heard with a stethoscope at the fifth intercostal space on the left midclavicular line and is counted for a full minute. Take an apical pulse when the rhythm is irregular, when the peripheral pulse is too weak or fast to count, when the radial site is not accessible, and for patients on digoxin. An irregular pulse is counted for a full minute, and an irregular rhythm is reported, because it can point to a problem such as atrial fibrillation.

Record rate, rhythm and strength. Strong is normal, bounding is very strong, and weak or thready can come from blood volume loss, peripheral vascular disease or heart failure. Athletes and adolescents may rest at 40 to 50 beats per minute. Other sites to know: carotid (one side at a time, used in emergencies), brachial (the emergency site in infants), femoral, dorsalis pedis, temporal, popliteal and posterior tibial.

If a question gives you an EKG strip instead of a wrist, the same 60 to 100 range applies and how to calculate heart rate on an EKG strip shows the three counting methods.

Respirations

Count respirations right after the pulse, with your fingers still on the pulse site, so the patient does not know you are watching their breathing. Awareness changes the rate. Note rate, rhythm and depth.

Vocabulary that appears in stems:

• Dyspnea is difficulty breathing. It is subjective, so only the patient can say it is present.
• Orthopnea is the inability to breathe comfortably lying flat, linked to left-sided heart failure.
• Hyperventilation is rapid or deep breathing that blows off carbon dioxide, seen with anxiety and as compensation for acidosis.
• Kussmaul respirations are rapid and deep, classically in diabetic ketoacidosis.
• Cheyne-Stokes respirations cycle with periods of apnea.

Blood pressure

Systolic is the top number and diastolic the bottom, recorded in mm Hg. Normal is below 120 and below 80 under the ACC/AHA guideline, and the full four-category scheme, the cuff-size errors and orthostatic readings are in blood pressure categories explained. The points that recur in vitals questions:

• Patient preparation: empty bladder; no caffeine, tobacco, food or exercise for at least 30 minutes; at least 5 minutes of quiet rest.
• Position: back supported, feet flat, legs uncrossed, arm supported at heart level, bare upper arm.
• No talking by patient or MA during the reading.
• A cuff that is too small reads falsely high; a cuff that is too large reads falsely low.
• Take 2 or 3 readings 1 minute apart. The first office reading is often the highest.
• Avoid an arm with an IV, lymphedema or a dialysis fistula.

Pulse pressure is systolic minus diastolic, normally about 40 mm Hg. If a question goes one step further and asks for perfusion pressure, the mean arterial pressure formula and normal range covers it.

Pulse oximetry

A pulse oximeter estimates oxygen saturation by passing light through the skin, and it also displays the pulse rate. A reliable reading shows a rhythmic waveform that matches the palpated pulse. Factors that reduce accuracy per the FDA include poor circulation, skin pigmentation, skin thickness, skin temperature, current tobacco use and fingernail polish; MedlinePlus adds artificial nails and cold skin. Patients with COPD may normally run 88 to 93 percent.

Pediatric ranges

Children run faster than adults, and both heart rate and respiratory rate fall with age. These are the OpenStax Clinical Nursing Skills bands the course uses.

Sources differ on the newborn band, so expect items to test the direction (faster in children) rather than an exact infant number. Take a child's BP in the right arm, because the normative data come from the right arm.

Factors that move vital signs

The test plan names age and medications as examples, and the course adds the rest:

• Heart rate rises with exercise, fear, anxiety, fever, hyperthyroidism, low oxygen, low blood volume and heart failure, and falls with sleep and relaxation. Digoxin affects rate, which is why an apical pulse is taken before it is given.
• Temperature rises with exercise, thyroid hormone, strong emotion, infection and inflammation. It is lowest in the early morning. It drops just before ovulation and rises after.
• Respiratory rate rises with exertion, emotion, low oxygen and respiratory distress.
• Blood pressure rises with caffeine, tobacco, meals, exercise and stress in the previous 30 minutes, and the white-coat effect is common in older adults.

The same "trend versus baseline" habit runs through prehospital care, which is why EMT patient assessment, step by step reads like a cousin of this post.

What the exam actually asks

Most vitals items fit one of three shapes: a value and its term (a pulse of 52 is bradycardia), a technique error and its effect (a small cuff reads high), or an abnormal finding and the MA's action, which is recheck as appropriate, document, and report to the provider, never diagnose or treat. The CCMA practice questions post has worked examples in that style, and NHA CCMA exam: what's on it shows where the 14 intake items sit against the other domains. For height, weight and the body mass index that rounds out an intake, see BMI formula and categories.