Florida Nursing Assistant Competency Pracrice Exam

For which of the following situations should a nurse aid inform the nurse immediately?

1. The client has elevated blood pressure

2. The client vomits coffee grounds

3. The client is feeling fatigued

4. The client requests extra fluids

The correct answer is: The client vomits coffee grounds

The scenario of the client vomiting coffee grounds is particularly concerning and requires immediate notification to the nurse. This symptom typically indicates the presence of digested blood in the vomit, which can suggest a serious underlying condition such as gastrointestinal bleeding. Prompt intervention is critical in such situations, as it can significantly impact the client’s health and requires further assessment and potential treatment by the nursing staff. In contrast, while elevated blood pressure, fatigue, and a request for extra fluids may indicate that a client needs attention, they do not represent the same level of urgency as vomiting coffee grounds. Elevated blood pressure could be managed over time or assessed within the routine checks, fatigue can be monitored, and a request for extra fluids can be handled without immediate intervention unless accompanied by other concerning symptoms. Therefore, it is crucial to recognize the priority of signs indicating potential critical health issues and respond accordingly.