A nurse is collecting data from a client prior to administering a calcium channel blocker (CCB) for treatment of hypertension. For which of the following findings should the nurse contact the provider?

A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.

B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.

C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.

D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself

A. Dry skin:

Dry skin is not typically associated with respiratory alkalosis. Instead, it may occur in conditions such as dehydration or impaired skin integrity.

B. Diarrhea:

Diarrhea is not typically associated with respiratory alkalosis. Respiratory alkalosis primarily involves changes in the respiratory system, leading to alterations in blood pH and carbon dioxide levels.

C. Hyperventilation:

Hyperventilation is a characteristic finding in respiratory alkalosis. It is a compensatory mechanism where the client breathes rapidly and deeply to blow off excess carbon dioxide, attempting to restore acid-base balance.

D. Abdominal pain:

Abdominal pain is not typically associated with respiratory alkalosis. While some individuals with respiratory alkalosis may experience symptoms such as dizziness, lightheadedness, or tingling sensations, abdominal pain is not a common manifestation of this acid-base imbalance.