The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy.
He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.

Choice A rationale:

Pneumonia is the most likely diagnosis given the rapid development of pulmonary infiltrates within a 24-hour period. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. It typically presents with symptoms such as fever, cough, shortness of breath, and chest pain. The presence of pulmonary infiltrates on imaging studies, such as a chest X-ray, is a key diagnostic feature of pneumonia.

The distribution of the infiltrates, involving the lower lobes with a predominance on the right side, is also consistent with pneumonia. This is because the lower lobes are more susceptible to pneumonia due to their anatomy and gravity.

The absence of active processes on Day 1 makes other diagnoses less likely. For example, tuberculosis typically develops more slowly over weeks or months, and bronchitis usually does not cause pulmonary infiltrates.

Pulmonary embolism can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Choice B rationale:

Tuberculosis is a chronic infection that typically develops slowly over weeks or months. It is less likely to cause rapid development of pulmonary infiltrates as seen in this case.

Tuberculosis often involves the upper lobes of the lungs, and it may be associated with other symptoms such as fever, night sweats, and weight loss.

Choice C rationale:

Bronchitis is an inflammation of the bronchi, the large airways that carry air to the lungs. It typically causes a cough, but it does not usually cause pulmonary infiltrates.

Bronchitis is often caused by a virus, and it usually resolves on its own within a few weeks.

Choice D rationale:

Pulmonary embolism is a blockage of a pulmonary artery, one of the blood vessels that carries blood to the lungs. It can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Pulmonary embolism is often caused by a blood clot that travels from a vein in the leg to the lungs.

The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.

Choice A rationale:

Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.

Choice B rationale:

Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.

Choice C rationale:

Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.

Choice D rationale:

Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.

Choice E rationale:

Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.

Choice F rationale:

Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.

Choice G rationale:

Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.