A nurse is implementing a bladder-training program for a patient.
Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?

Choice A rationale:

Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.

Choice B rationale:

Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.

Choice C rationale:

Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing

(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.

Choice D rationale:

Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.

Choice A rationale:

A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.

Choice B rationale:

Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.

Choice C rationale:

A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.

Choice D rationale:

Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.