The nurse's comprehensive assessment of a patient who has HF includes evaluation of the patient's hepatojugular reflux. What action should the nurse perform during this assessment?
A) Elevate the patient's head to 90 degrees.
B) Press the right upper abdomen.
C) Press above the patient's symphysis pubis.
D) Lay the patient flat in bed.
Ans: B
Feedback:
Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
You might also like to view...
While helping a client with the evening meal, the nurse observes the client close his eyes, bow his head, and murmur words of thanks and praise. What does this behavior indicate to the nurse?
A) The client did not want the nurse to leave. B) The client was asking that the meal be better than the last. C) The client is confused. D) The client was praying before eating.
Which of the following factors is not regulated by circadian rhythms?
A) Aging process B) Bedtime schedule C) Body temperature D) Mood
When considering the issue of the politics behind health care in the United States, the nurse identifies one of the third-party payer stakeholders as:
a. health care provider. c. special interest group. b. government. d. the National Institutes of Health.
The nurse is doing preconception counseling with a 28-year-old woman with no prior pregnancies. Which statement made by the patient indicates to the nurse that the patient has understood the teaching?
1. "I can continue to drink alcohol until I am diagnosed as pregnant." 2. "I need to stop drinking alcohol completely when I start trying to get pregnant." 3. "A beer once a week will not damage the fetus." 4. "I can drink alcohol while breastfeeding, since it doesn't pass into breast milk."