A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.

Choice A rationale:

Sterile gloves are not necessary for routine oral care, even in the presence of oral Candida albicans.

Standard precautions, which include the use of gloves, are sufficient to protect the UAP from exposure to blood and body fluids.

Sterile gloves would only be indicated for invasive procedures, such as oral surgery or deep tissue sampling.

Choice B rationale:

Delegating oral care to the UAP is appropriate, as it is a routine task that does not require the specialized skills of a nurse.

The nurse should provide clear instructions to the UAP on how to perform oral care, but it is not necessary for the nurse to complete the task themselves.

Choice C rationale:

Using a soft-bristled toothbrush is important for patients with oral Candida albicans, as it can help to remove plaque and debris without further irritating the delicate tissues of the mouth.

A soft-bristled toothbrush is less likely to cause bleeding or pain than a harder-bristled toothbrush.

Choice D rationale:

Mouthwash is not typically recommended for patients with oral Candida albicans, as it can actually dry out the mouth and worsen symptoms.

In some cases, a healthcare provider may prescribe a special antifungal mouthwash, but this should only be used under their supervision.

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)