The nurse, assessing a patient for cardiac failure, has elected to test for abdominojugular reflux. Which action is indicated?
1. Ask the patient to bear down as if moving the bowels.
2. Compress the right upper abdomen for 30 seconds.
3. Use a reflex hammer to tap on the xiphoid process.
4. Roll the patient to the right side and percuss over the left abdomen.
2
Rationale 1: Bearing down is not associated with the abdominojugular reflux.
Rationale 2: Compression of the right upper abdomen will cause the blood volume in the abdomen to be displaced back to the right atrium. This influx of blood will be reflected in the jugular veins if the heart if failing.
Rationale 3: Eliciting the abdominojugular reflux does not require the use of a reflex hammer.
Rationale 4: This action does not test for the abdominojugular reflux.
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