A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which piece of documentation is correct?

• A. Pulse 52/min
• B. Respiratory rate 24
• C. SaO2 97% right index finger, room air
• D. Blood pressure 132/86 mm Hg

Answer: (C)

Understanding how vital signs are documented is key: some measurements require not just the number but also how and under what conditions it was obtained. Oxygen saturation is one of those. The reading is meaningful only if you specify the measurement method and the patient’s oxygen status, because oxygen therapy or the sensor site can change the value.

The correct documentation includes the oxygen saturation value along with the site and the fact that the patient is on room air. SaO2 97% right index finger, room air communicates exactly where the sensor was placed and that there’s no supplemental oxygen affecting the reading, so this entry is complete and unambiguous.

The other entries lack that crucial context. A pulse rate of 52 per minute could be normal for an athlete or could indicate bradycardia, but as documentation it’s missing notes about the measurement site (radial, carotid, apical) and resting state. A respiratory rate of 24 lacks any context about effort, pain, or measurement technique. A blood pressure reading of 132/86 mm Hg is informative on its own, but without noting the measurement site, patient position, or cuff size, it’s less complete.