The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen,
just below the rib cage?
a.
The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working.
b.
The jugular veins will remain elevated as long as pressure on the abdomen is maintained.
c.
An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line.
d.
The jugular veins will not be detected during this maneuver.
ANS: B
When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.
You might also like to view...
The nurse is preparing to administer a blood transfusion to a child with a severe anemia. Which type of transfusion reaction may be within the nurse's realm of prevention?
1. Allergic 2. Hemolytic 3. Febrile 4. Septic
A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patient's diet
As the staff delivers the plan of care the primary nurse evaluates whether the plan is working. Which attribute is the primary nurse displaying? a. Responsibility b. Interprofessional collaboration c. Delegation d. Staff involvement
To lead in the midst of change and chaos, it is necessary to have a clear vision and support from one's followers. Which of the following illustrates that the staff support the nurse manager's vi-sion on a nursing unit?
A. Staff members refuse to attend orientation to electronic documentation on their own time even though lunch or dinner is pro-vided at a nearby restaurant. B. The division's suggestion box reveals eight complaint messages about the nurse manager from nurses on her unit. C. No one attends a mandatory orientation class on electronic documentation even though staffing would allow for half of the unit to participate. D. Staff members are attending the manag-er's summer party to kick-off a new initi-ative for the unit's electronic documenta-tion change.
The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?
a. Eschar b. Slough c. Granulation d. Purulent drainage