Day 1: 0800: Temperature 37 C (98.6 F). Respiratory rate 18/min. Heart rate 65/min. Blood pressure 149/87 mm Hg. Weight 90.3 kg (199 lb). Height 180.3 cm (71 in). BMI 27.75 kg/m. Day 3: 0800: Temperature 38.3 C (100.9 F). Respiratory rate 18/min. Heart rate 82/min. Blood pressure 105/68 mm Hg. Weight 90.3 kg (199 lb). Height 180.3 cm (71 in). BMI 27.75 kg/m. Based on these findings, which actions should the nurse take, what is the potential condition, and which parameters should the nurse monitor?

Choice A rationale The patient is exhibiting signs of an acute infection as evidenced by the rise in temperature from 37 C to 38.3 C and a drop in blood pressure. C. difficile is a common healthcare-associated infection characterized by diarrhea and systemic inflammatory responses. Contact precautions are essential to prevent the spread of spores, which are resistant to non-bleach cleansers. Monitoring serum potassium is vital because profuse diarrhea leads to significant electrolyte loss. Choice B rationale Barium swallow studies are typically used to visualize the upper gastrointestinal tract for structural issues like strictures or hiatal hernias. Celiac disease is an autoimmune reaction to gluten, usually diagnosed via biopsy or serology, not barium studies. While steatorrhea occurs in malabsorption, the clinical presentation of sudden fever and hypotension more strongly suggests an infectious process like colitis rather than a chronic gluten intolerance flare-up which lacks this acute hemodynamic shift. Choice C rationale Crohn's disease is an inflammatory bowel disease that can cause fever and hypotension during severe flares or perforation. However, a gluten-free diet is the specific treatment for celiac disease, not Crohn's disease, which requires immunosuppressants or biologics. Monitoring hemoglobin and hematocrit is important in Crohn's due to potential occult bleeding or malabsorption of B12, but this choice incorrectly links the education to the diagnosis and fails to address the emergency. Choice D rationale Appendicitis presents with right lower quadrant pain, fever, and leukocytosis. While the fever and blood pressure changes could indicate peritonitis, emergent surgery is only indicated after definitive imaging like CT or ultrasound confirms the diagnosis. C. difficile colitis is highly likely in hospitalized patients with these symptoms. Monitoring a surgical incision is a postoperative action and does not help in the current diagnostic or stabilization phase for a patient showing acute systemic distress. Choice E rationale The drop in blood pressure from 149/87 mm Hg to 105/68 mm Hg indicates significant fluid volume deficit or systemic vasodilation from sepsis. Intravenous fluid resuscitation is the priority to maintain organ perfusion in a patient with suspected infectious colitis and hypotension. Monitoring blood pressure allows the nurse to evaluate the effectiveness of fluid boluses and track the patient’s hemodynamic stability as the infectious process is managed with antibiotics and supportive care.