The nurse is assessing the client's cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which directions should the nurse provide for the client? Select all that apply

Question

1. "I am going to put you into a position where your feet are actually above your head."
2. "I need you to turn to your left side."
3. "Can you please turn onto your stomach?"
4. "I need you to sit up straight."
5. "I am going to elevate your head to a 30-degree angle while you lie on your back."

Answer 1

Correct Answer: 4, 5
The nurse should inspect the client's chest for heaves or lifts while the client is sitting upright. The nurse should inspect the client's chest for heaves or lifts while the client is in a semi-fowler position with the head of bed at 30 degrees. The client should not be placed into Trendelenburg position to assess for heaves or lifts. The client does not need to turn to the left side to evaluate the presence of heaves or lifts. The nurse should not evaluate the client's chest for the presence of heaves or lifts while the client is in a prone position.