A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

Choice A rationale
Pancreatitis can lead to gastrointestinal bleeding. Inflammation of the pancreas can cause damage to the organ’s blood vessels, leading to bleeding. This can be a serious complication of pancreatitis.
Choice B rationale
Peptic ulcer disease is a common cause of gastrointestinal bleeding. Ulcers are sores that develop on the lining of the stomach, upper small intestine, or esophagus. When these ulcers erode into blood vessels, bleeding can occur.
Choice C rationale
Inflammatory bowel disease (IBD), which includes conditions like Crohn’s disease and ulcerative colitis, can cause ulcers in the digestive tract. These ulcers can bleed, leading to gastrointestinal bleeding.
Choice D rationale
Gastrointestinal malignancy, or cancer, can cause gastrointestinal bleeding. Tumors can erode into blood vessels or cause ulcers that bleed.
Choice E rationale
Diverticulosis involves the formation of small pouches in the wall of the digestive tract. These pouches can bleed, leading to gastrointestinal bleeding.
Choice F rationale
Gallbladder disease typically does not cause gastrointestinal bleeding. The gallbladder stores bile, a fluid produced by the liver to digest fats. While gallstones and inflammation of the gallbladder are common, they do not usually lead to gastrointestinal bleeding.
Choice G rationale
Hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone, is not typically associated with gastrointestinal bleeding. Symptoms of hypothyroidism can include fatigue, weight gain, and depression, but not gastrointestinal bleeding.

Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.