A nurse determines that a patient's jugular venous pressure is 3.5 inches. What additional data does the nurse expect to find?
A) Weight loss
B) Tented skin turgor
C) Peripheral edema
D) Capillary refill greater than 5 seconds

Question

Quizplus · Accepted Answer

The pressure should not rise more than 1 inch (2.5 cm) above the sternal angle. A pressure of 3.5 inches indicates fluid volume excess, which causes peripheral edema due to excessive fluid in blood vessels. Weight loss occurs with loss of fluid rather than fluid overload. Tented skin turgor occurs with fluid loss rather than fluid overload. Capillary refill greater than 5 seconds occurs with arterial insufficiency rather than fluid overload.

A Nurse Determines That a Patient's Jugular Venous Pressure Is