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. Document this finding in the patient's record.
b. Obtain vital signs, including oxygen satu-ration.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: D
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.
You might also like to view...
A parent is concerned that her 16-year-old is spending most of his time away from the family in his room and does not want to be involved in family activities he used to enjoy. What action by the nurse is best?
a. Reassure the parent the teen is exerting independence. b. Ask the parent about the teen's friends and activities. c. Assess the teen for depression and possible suicide risk. d. Refer the family to the community depression support group.
A nurse on an inpatient unit helps a client understand the significance of treatments, and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the "Tidal Model of Recovery?"
1. Know that Change Is Constant 2. Reveal Personal Wisdom 3. Be Transparent 4. Give the Gift of Time
A 54-year-old diabetic patient has come to the urology clinic complaining of erectile dysfunction. His history includes obesity, coronary artery disease that required CABG 3 years ago, hypertension, and gout
The nurse practitioner is reviewing his record in order to prescribe medication. The practitioner is considering prescribing sildenafil (Viagra). Which of the following home medications is contraindicated if taken concurrently with sildenafil? A) Diltiazem (Cardizem), a calcium channel blocker B) Cordarone (amiodarone), an antiarrhythmic C) Imdur (isosorbide mononitrate), a vasodilator D) Lasix (furosemide), a diuretic
The leadership team for a multisystem healthcare organization learns that Medicare reimbursement will be 10% lower for the next quarter. Which data should the team analyze to determine the reason for this decline in reimbursement? Select all that apply.
A) Fall rates B) Staff turnover C) Surgical errors D) CAHPS surveys E) Readmission rates