Counting Pulse and Respirations for CNAs: Step-by-Step Guide and Exam Tips

Pulse and respiration are two of the four core vital signs (the others are blood pressure and temperature) that CNAs measure and record regularly. The pulse tells you how fast the heart is beating and gives you information about the rhythm and strength of the heartbeat. Respirations tell you how fast and effectively a person is breathing. Together, they provide a snapshot of how well the cardiovascular and respiratory systems are functioning at any given moment.

On the NNAAP skills exam, pulse and respiration measurement are typically tested together as a single combined skill. You count the pulse first, then transition directly into counting respirations without interrupting the contact with the patient. There is a specific technique for making this transition that is central to the exam evaluation, so understanding why it works the way it does will help you execute it correctly under pressure.

Why This Skill Matters on the CNA Exam

The evaluator checks several specific points during this skill: that you use the correct fingers to find the pulse (not your thumb), that you count for a full minute or properly qualify a shorter count, that you do not announce you are counting respirations, and that you correctly note rate, rhythm, and character for both measurements. Failing to use the right fingers or telling the resident you are counting their breaths are both common deduction points.

In a real facility, pulse and respiration data help nurses detect early signs of deterioration. A pulse that has become irregular or a respiration rate that is climbing can signal a serious change hours before other symptoms appear. Your accuracy in measuring and documenting these values is a direct contribution to patient safety.

Normal resting pulse for an adult is 60 to 100 beats per minute. Normal resting respiration rate for an adult is 12 to 20 breaths per minute. Values outside these ranges should be reported to the supervising nurse promptly.

What You Need

• A watch with a second hand, or a phone or clock with a seconds display
• Pen
• Paper or documentation form

No stethoscope or equipment is required for radial pulse and visual respiration counting. This skill is done entirely with your fingertips and your eyes.

Step-by-Step: Counting the Pulse

1. Wash your hands. Hand hygiene is required before the skill begins. Identify the resident using two identifiers and explain that you are going to check their vital signs. You do not need to specify that you will be counting their pulse and breathing. Keep the explanation brief and natural.
2. Position the resident comfortably. The resident should be seated or lying down with their arm in a relaxed position. The wrist should be accessible without the resident needing to hold an awkward pose. If sitting, resting the arm across their lap works well. If lying down, the arm can rest at their side.
3. Turn the hand so the palm faces down. This naturally positions the wrist so the radial artery on the thumb side is accessible. Some CNAs prefer palm up, but the key is that your fingertips land in the groove on the inside of the wrist near the base of the thumb where the radial artery runs.
4. Place two or three fingertips on the radial artery. Press gently in the groove between the wrist bones and the tendon on the thumb side of the wrist. Apply moderate pressure. Too light and you will not feel the pulse. Too heavy and you will compress the artery and lose the beat. Adjust until you can feel a steady tapping under your fingertips.
5. Never use your thumb. Your thumb has its own pulse. If you press your thumb against a patient's wrist, you risk feeling your own heartbeat and confusing it with the patient's. This is one of the most commonly marked errors on this skill. Use your index and middle fingers, or index, middle, and ring fingers.
6. Count the beats for 60 seconds. Use your watch to time a full minute. Count each beat as one. If the pulse is clearly regular and steady after the first 15 to 30 seconds, you may count for 30 seconds and multiply by two, but if there is any irregularity at all, complete the full 60 seconds. In the exam setting, counting for the full minute is the safest choice.
7. Note the rate, rhythm, and strength. After counting, you should be able to report not only the number but also whether the rhythm was regular (evenly spaced beats) or irregular (uneven spacing), and whether the pulse felt strong and bounding, normal, or weak and difficult to feel. These additional observations are part of the complete vital sign assessment.

Step-by-Step: Counting Respirations

8. Keep your fingers on the wrist without telling the resident what you are doing next. This is the most important part of the respiration technique. After you finish counting the pulse, do not move your hand, do not look up at the resident's face, and do not say anything. Leave your fingers resting on the wrist as if you are still taking the pulse. The goal is for the resident to believe you are still measuring their pulse. If they realize you are watching their breathing, they will unconsciously breathe differently, and your count will not reflect their true resting rate.
9. Shift your gaze to the chest or abdomen. While keeping your hand still on the wrist, look toward the resident's chest. Watch for it to rise and fall. One complete breath is one rise (inhale) plus the following fall (exhale). Count only the rises to avoid double-counting.
10. Count for 60 seconds. Watch the clock and count each rise as one breath over a full minute. If breathing is regular, a 30-second count multiplied by two is acceptable, but complete the full minute if breathing seems irregular or shallow.
11. Note the rate, depth, and pattern. Record the breaths per minute, note whether the breaths appear shallow or deep, and note whether the pattern is regular or irregular. Labored breathing, noisy breathing (wheezing, gurgling), or breathing that involves visible effort should be noted specifically and reported to the nurse.
12. Wash your hands and document both measurements. Record the pulse rate, rhythm, and strength and the respiration rate, depth, and pattern together on the documentation form with the date and time. This keeps both measurements linked in the record, which helps nurses track trends.
13. Report abnormal values immediately. A pulse below 60 bpm (called bradycardia) or above 100 bpm (called tachycardia), or respirations below 12 or above 20 per minute, should be reported to the supervising nurse right away. Any irregular rhythm or labored breathing also warrants immediate reporting regardless of the rate.

Measuring Oral Temperature

Temperature is not part of the NNAAP 23-skill list, but it is tested in some states as part of a combined vital signs task and is a routine CNA responsibility in clinical practice. The most common method CNAs use is oral temperature measurement with a digital thermometer.

1. Wash your hands and put on gloves. Explain to the resident that you are going to take their temperature.
2. Place a disposable probe cover on the thermometer. Never insert a thermometer without a clean cover. This prevents cross-contamination between residents.
3. Ask the resident to open their mouth. Place the probe under the tongue, toward the back and slightly to one side. The sublingual pocket (the area under the tongue near the base) gives the most accurate oral reading because blood vessels run close to the surface there.
4. Ask the resident to close their lips around the thermometer. They should breathe through their nose, not their mouth. Air passing over the probe will cool it and give a falsely low reading.
5. Wait for the thermometer to beep. Digital thermometers signal when the reading is stable. Do not remove it early.
6. Read and record the temperature. Normal oral temperature is approximately 97.6 to 99.6 degrees Fahrenheit (36.4 to 37.6 degrees Celsius). Record the reading with the date, time, and method (oral).
7. Dispose of the probe cover without touching it. Press the release button to eject the cover into the trash. Clean the thermometer per facility policy.
8. Remove gloves and wash hands. Report any temperature outside the normal range to the supervising nurse immediately.

When NOT to take an oral temperature: Do not use the oral method if the resident has had hot or cold food or drink in the last 15 minutes, if they are breathing through their mouth, if they are confused or uncooperative, or if they have mouth sores or recent oral surgery. In these cases, notify the nurse, who may direct you to use an alternative method.

What the Examiner Looks For

• Hand hygiene performed before starting
• Resident identified and procedure explained (without mentioning respirations)
• Fingertips (not the thumb) used to locate and count the pulse
• Pulse counted for at least 30 seconds (full 60 seconds if irregular)
• Pulse rate, rhythm, and strength noted
• Transition to respiration counting happens without telling the resident
• Fingers remain on wrist during respiration count
• Respirations counted for at least 30 seconds (full 60 seconds if irregular)
• Respiration rate, depth, and pattern noted
• Hand hygiene performed after skill
• Both values documented with date and time
• Abnormal values identified and reported (or verbally stated as reportable)

Common Mistakes to Avoid

• Using your thumb to find the pulse. This is one of the top-marked errors in this skill. Retrain yourself now to always use your index and middle fingers, even during casual practice. The habit needs to be automatic before exam day.
• Telling the resident you are counting their respirations. Any verbal cue that draws attention to the resident's breathing will cause them to take conscious control of it. Keep your hand on the wrist and say nothing during the respiration count.
• Not counting for the full minute when the rhythm is irregular. If the pulse has any irregularity, a 30-second count multiplied by two will not capture the true average rate. Always complete the full 60 seconds for an irregular pulse or irregular breathing pattern.
• Pressing too hard on the radial artery. Compressing the artery too firmly cuts off the pulse signal and makes it difficult or impossible to feel beats accurately. Press firmly enough to detect the pulse but gently enough that the artery remains open.
• Forgetting to note rhythm and strength of the pulse. Students who practice only counting the rate sometimes forget that rhythm and strength are also part of the expected documentation. Make noting all three characteristics a habit from the start of your practice.
• Losing count during the 60-second window. If you lose count, start again rather than guessing. A restarted count is better than a fabricated number. In a testing environment, remaining calm and restarting is perfectly acceptable.

Printable Practice Checklist

Use this checklist when practicing with a partner. Check off each step as you complete it.

1. Washed hands
2. Identified resident and explained vital signs check (did not mention respirations)
3. Positioned resident's arm comfortably
4. Located radial pulse using fingertips (not thumb)
5. Counted pulse for 60 seconds (or 30 seconds if clearly regular)
6. Noted pulse rate
7. Noted pulse rhythm (regular or irregular)
8. Noted pulse strength (strong, normal, or weak)
9. Kept fingers on wrist without telling resident about respiration count
10. Shifted gaze to chest or abdomen
11. Counted breaths for 60 seconds (or 30 seconds if clearly regular)
12. Noted respiration rate
13. Noted respiration depth (shallow or deep)
14. Noted respiration pattern (regular or irregular)
15. Washed hands
16. Documented both measurements with date and time
17. Identified any abnormal values and stated intention to report

Counting pulse and respirations accurately takes repetition with a real person. Find CNA programs in your area where you can practice under instructor supervision.

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