A Patient Who Reports an Intestinal Fistula Also Reports Feeling

question 31

Multiple Choice

A patient who reports an intestinal fistula also reports feeling "weak and dizzy" when she stands.While taking her blood pressure she becomes temporarily unresponsive but quickly regains consciousness when put into a supine position.What nursing interventions will the nurse implement before calling the physician?

• A) Sit her up again, with proper support, so you can have an accurate upright blood pressure and heart rate to report.
• B) Give her a drink of water or juice, talk with her to calm her down, and ask if she slept well last night.
• C) Give her water or juice and some salty crackers and ask if she has had any diarrhea or vomiting.
• D) Assess small vein filling time, look for ankle edema, and ask if she had any fluid to drink yet today.

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