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.

Question

Quizplus · Accepted Answer

Her substantial systolic postural blood pressure decreases with tachycardia and syncope when upright are indicators of ECV deficit and she needs salt and water.Your questions will provide information for her physician regarding the origin of the ECV deficit.She fainted the first time when she sat upright and is likely to faint again,given her upright systolic pressure of 77 mm Hg.She needs salt and water to increase her ECV and sleep quality is not directly related to ECV deficit.Ankle edema is a sign of ECV excess.

A Patient Who Reports an Intestinal Fistula Also Reports Feeling