The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which of the following findings would the nurse anticipate?
1. poor skin turgor
2. presence of rales and rhonchi
3. jugular vein distention
4. weak, thready pulse
3
Rationale: Normal right arterial pressure is 2 to 6 mm Hg. A right arterial pressure of 12 mm Hg indicates high right ventricular preload, causing fluid to back up into the venous system. Jugular venous distention, hepatomegaly, and peripheral edema are all signs of increased right heart preload. With good volume, the patient's skin turgor should be normal. Rales and rhonchi are signs of left-sided heart failure. The pulse is usually full and bounding.
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