The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD)when lying flat in bed. Which follow-up action should the nurse take next?

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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.

The Nurse Notes That a Patient Who Was Admitted with Heart