While Assessing a Patient Who Was Admitted with Heart Failure

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) Use a ruler to measure the level of the JVD.
• B) Document this finding in the patient's record.
• C) Observe for JVD with the head at 30 degrees.
• D) Have the patient perform the Valsalva maneuver.

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Definitions:

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