The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?

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11ecbb05_c949_a535_b433_51b2f70b1114_MD0009_00 Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distension and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload. pulsation (Options B and C) JVD may still be present at 60- and 90-degree angles if marked fluid overload is present. Placement this high might miss mild to moderate JVD. (Option D) JVD may be present while the client is flat. This is not considered abnormal, and the client with possible fluid overload or respiratory issues may not be able to lie flat. Educational objective: The nurse should position the client with the head of the bed at a 30- to 45-degree angle to assess for the presence of JVD.

The Nurse Is Assessing for the Presence of Jugular Venous