The nurse is assessing a client who was admitted with heart failure and notes that the client has jugular venous distension (JVD) when lying flat in bed. Which of the following actions should the nurse take next?

Question

Quizplus · Accepted Answer

When the client is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the client is sitting at a 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the client is ata
45-degree angle or more. JVD is an expected finding when a client performs the Valsalva manoeuvre because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.

The Nurse Is Assessing a Client Who Was Admitted with Heart