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Registered Nurse (RN)
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NCLEX®
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NCLEX-RN® Test Plan: Client Needs
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Changes/Abnormalities in Vital Signs

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NCLEX-RN® Test Plan: Client Needs | Registered Nurse (RN) School Study Aid

Changes/Abnormalities in Vital Signs
5 Picmonics to Learn | 12 mins
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (94%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
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2 mins
Airway, Breathing, Circulation (ABC's)
Airway Assessment
Changed Sound of Voice
"See-saw" Respirations
Stridor
Breathing Assessment
Normal Respiratory Rate: 12–20 Breaths/Min
Use of Accessory Muscles in Respiration
Cyanosis
Circulation Assessment
Color of Hands and Digits
Normal Capillary Refill Time (CRT): 2 Seconds
Decreased LOC
Considerations
Initial ‘Look, Listen and Feel” Assessment
Emergency Treatment
Prioritization in Exam Questions
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5 mins
Glasgow Coma Scale
LOC Assessment
Score of 3 to 15
8 or Less = Coma
Eye Opening
Verbal Response
Motor Response
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1 min
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
Conscious
Confused
Delirious
Somnolent
Obtunded
Stuporous
Comatose
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3 mins
Neurovascular Assessment 6 P's
Pain
Paresthesia
Pulse
Pallor
Pressure
Paralysis
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1 min

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