An 82-year-old female patient arrives at the emergency department after a fall off of ladder while putting up her Christmas lights on the outside of her house. She states "I just misstepped on the ladder rung I won't dizzy or anything like that. She currently reports being very dizzy and reports some abdominal pain Vital signs include Heart rate: 115 bpm Blood pressure: 88/54 mm Respiratory rate: 22 breaths per minute Oxygen saturation 56% on room air Skin Cool and clammy What should the nurse watch for in this patient, and what is the first action? (Select all that apply