During an assessment for jugular vein distension of a client with right sided heart failure (HF), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

Document the findings as observed.

Repeat without using the lighting.

Flex the client's neck with a pillow and repeat assessment.

Position the client supine and repeat the assessment.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Document the findings as observed: Jugular vein distention (JVD) observed bilaterally in a client with right-sided heart failure while in a semi-Fowler’s position and using proper lighting is an abnormal but expected finding. Since the technique was performed correctly, the nurse should document the findings accurately in the client's medical record for appropriate clinical follow-up.

B. Repeat without using the lighting: Tangential lighting is specifically used to better visualize venous distention and pulsations. Eliminating the lighting would make it harder to see the veins and does not improve the accuracy of the assessment, making repetition without lighting unnecessary.

C. Flex the client's neck with a pillow and repeat assessment: Flexing the neck may obscure venous return and hinder visualization of the jugular veins. The head should remain in a neutral position with slight elevation for optimal assessment, not flexed.

D. Position the client supine and repeat the assessment: Having the client completely supine can cause the veins to become overly distended even in healthy individuals, which would distort the findings. Semi-Fowler’s position is the correct posture for assessing JVD accurately.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. "Why don't I come back in a few minutes after you are more composed.": Leaving the client alone during an emotional moment can convey disinterest or lack of support. It misses an opportunity to build trust and demonstrate empathy, which are critical in sensitive discussions like past pregnancy experiences.

B. Allow the client to compose herself then change the subject: Although allowing time for composure is respectful, abruptly changing the subject can minimize the client's emotions and signals avoidance rather than offering the necessary emotional support during a vulnerable moment.

C. Offer a tissue and sit quietly until the crying subsides: Offering a tissue and remaining present without rushing the client shows empathy, respect, and emotional support. Sitting quietly allows the client to express feelings at her own pace and fosters a trusting therapeutic relationship, essential in prenatal care.

D. "I'm so sorry that I made you cry. I didn't mean to upset you.": Apologizing focuses attention on the nurse's feelings rather than the client’s experience. It shifts the emotional burden to the client to reassure the nurse, which is not therapeutic or client-centered during emotional disclosures.

A. Assess the elasticity of the client's skin. B. Auscultate the client's breath sounds. C. Ask about any environmental allergies D. Measure the client's core temperature.

Correct Answer is B

Explanation

Rationale:
A. Assess the elasticity of the client's skin: Skin elasticity, or turgor, is useful for evaluating hydration status, especially in older adults. However, it does not address the client’s immediate complaints of nocturnal dyspnea, sweating, and tachycardia, which are potentially life-threatening signs of worsening heart failure.

B. Auscultate the client's breath sounds: Awakening with dyspnea, sweating, and a racing heartbeat are classic symptoms of paroxysmal nocturnal dyspnea, often seen in decompensated heart failure. Auscultating the lungs can quickly detect crackles or pulmonary congestion, providing critical information needed to prioritize urgent interventions.

C. Ask about any environmental allergies: Environmental allergies can cause nighttime breathing issues like nasal congestion, but the combination of cold sweats and tachycardia points more toward a cardiovascular cause rather than an allergic reaction, making this a less urgent assessment initially.

D. Measure the client's core temperature: While fever can indicate infection, it is less likely to explain the sudden onset of dyspnea and palpitations in a client with known heart failure. Addressing possible pulmonary congestion through breath sound assessment takes precedence to prevent further cardiac compromise.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During an assessment for jugular vein distension of a client with right sided heart failure (HF), the nurse observes distension bilaterally using tangential lighting with the client in a semi-Fowler's position. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

An older adult client with a history of heart failure (HF) comes to the clinic troubled by awakening during the night in a cold sweat, accompanied by difficulty breathing, and a racing heart beat. Which assessment should the nurse complete first?

Correct Answer is B

Explanation

While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

The nurse is performing a cranial nerve exam on an older adult client. The nurse notes that the client has a reduced upward gaze, a decreased corneal reflex, a high frequency hearing loss, and a reduced gag reflex. Which action should the nurse take next?

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider (HCP)?

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this older adult client?

The nurse is assessing a healthy adult male during an annual physical examination. The nurse auscultates the client's abdomen and hears a gurgling sound every ten seconds. Which action should the nurse take in response to this finding?