While assessing a patient who was admitted with heart failure, ...

[newyorker26]

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
 
  a. Document this finding in the patient's record.
  b. Obtain vital signs, including oxygen satu-ration.
  c. Have the patient perform the Valsalva maneuver.
  d. Observe for JVD with the patient upright at 45 degrees.

Question 2

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
 
  a. it will be important to lie completely still during the procedure.
  b. a flushed feeling may be noted when the contrast dye is injected.
  c. monitored anesthesia care will be provided during the procedure.
  d. arterial pressure monitoring will be re-quired for 24 hours after the test.

[lauravaras]

Answer to Question 1

ANS: D
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.

Answer to Question 2

ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety-producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.

[newyorker26]

TYSM

[dantucker]

Gracias!