While Assessing a Patient Who Was Admitted with Heart Failure,the

question 8

Multiple Choice

While assessing a patient who was admitted with heart failure,the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed.Which action should the nurse take next?

• A) Document this finding in the patient's record.
• B) Obtain vital signs, including oxygen saturation.
• C) Have the patient perform the Valsalva maneuver.
• D) Observe for JVD with the patient upright at 45 degrees.

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