A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan?

Rationale:

• Antibiotic: Administering an antibiotic addresses the underlying infection, which is likely causing the fever, low blood pressure, and altered mental status. Prompt antibiotic treatment reduces the risk of progression to septic shock. Early intervention improves patient outcomes in suspected sepsis.

• Antipyretic: An antipyretic helps reduce fever but does not treat the underlying infection. Lowering the temperature alone would not address the systemic inflammatory response seen in sepsis. This option does not prevent clinical deterioration.

• Anti-anxiety medication: An anti-anxiety medication may temporarily calm the patient but can worsen confusion and mask signs of deterioration. It does not treat the infection or improve hemodynamic status. This is inappropriate in suspected sepsis.

• Suspected surgical site infection and sepsis: The inflamed, draining surgical wound, fever, hypotension, and high WBC strongly indicate a developing infection. Mental status changes are also typical in sepsis. This makes infection the most urgent concern requiring antibiotic therapy.

• Elevated temperature and heart rate: While these signs are concerning, they are common with many conditions and not specific to sepsis. They are part of the clinical picture but not the driving reason for immediate antibiotic treatment.

• History of Parkinson’s disease and confusion: The confusion may partly relate to Parkinson’s or sensory impairment, but acute mental status changes with fever and hypotension suggest sepsis. Parkinson’s is chronic and not the immediate priority.

Rationale:

 • An endoscopy is necessary to visualize the upper gastrointestinal tract for potential ulcers or bleeding sites, especially given the client’s positive fecal occult blood and anemia. This procedure will help identify active bleeding and confirm a diagnosis of peptic ulcer disease.

 • An antifungal prescription is inappropriate because there is no evidence of fungal infection such as thrush or candidiasis. The client’s symptoms and diagnostic findings are more consistent with a gastrointestinal disorder, particularly peptic ulcer disease.

 • Oxygen via nonrebreather mask is not indicated because the client's oxygen saturation is normal at 98% on room air. There are no respiratory symptoms or signs of hypoxia that would necessitate supplemental oxygen at this level of intensity.

 • Low hemoglobin and hematocrit indicate a state of anemia, which is likely due to chronic gastrointestinal bleeding. The client’s history of dark, tarry stools (melena) further supports ongoing blood loss from the upper GI tract, necessitating diagnostic evaluation.

 • History of gnawing epigastric pain is suggestive of peptic ulcer disease but does not on its own justify urgent endoscopy. This history becomes more significant when paired with other alarming signs like bleeding or anemia, but alone it is not a definitive indicator.

 • Stool test results showing a positive hemoccult test confirm the presence of gastrointestinal bleeding. Combined with anemia and pain, this is a key indicator for immediate endoscopic evaluation to locate and treat the bleeding source.

 • H. pylori results support a peptic ulcer etiology, but the infection alone does not require urgent visualization unless there are complications like bleeding, anemia, or severe symptoms, which would necessitate further diagnostic action.

 • Presence of epigastric tenderness is a non-specific physical finding that could result from many conditions and is not sufficient to determine the need for endoscopy without other supportive clinical evidence pointing toward bleeding or ulceration.

 • Smoking and alcohol intake history increase the risk for peptic ulcer disease but are not acute indicators for endoscopy. They contribute to the etiology and chronic risk but do not demonstrate the immediate need for invasive diagnostics.