While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Jugular vein atherosclerosis

Increased fluid volume

Decreased fluid volume

Incompetent jugular vein valves

Answer and Explanation

The Correct Answer is B

Jugular venous distention (JVD) is a clinical sign that indicates increased fluid volume or fluid overload in the cardiovascular system. When the head of the client's bed is elevated at 45 degrees, the jugular veins should normally be flat or slightly distended. However, if the jugular veins appear engorged and bulging, it suggests that there is an increased amount of blood returning to the right side of the heart and is unable to be efficiently pumped forward, leading to jugular venous distention.

JVD is commonly seen in conditions such as heart failure, where the heart's ability to pump blood efficiently is compromised, leading to fluid accumulation in the veins and eventually causing jugular venous distention.

Option A, jugular vein atherosclerosis, is not a common cause of JVD. Atherosclerosis refers to the build-up of plaque within arteries, not veins.

Option C, decreased fluid volume, would lead to dehydration and decreased venous filling, which would not cause jugular venous distention. It would lead to flat or sunken jugular veins.

Option D, incompetent jugular vein valves, would not cause jugular venous distention with the head of the bed elevated. Incompetent valves may lead to venous reflux or backward flow of blood, but it would not lead to the distention of the jugular veins in this position.

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Correct Answer is D

Explanation

When a patient with dilated cardiomyopathy develops new onset atrial fibrillation (AF) that has been unresponsive to drug therapy, the nurse should prioritize patient education about anticoagulant therapy. Atrial fibrillation increases the risk of blood clots forming in the heart's atria due to the irregular and ineffective pumping of blood. These blood clots can potentially travel to other parts of the body, leading to serious complications such as stroke.

Anticoagulant therapy, also known as blood-thinning medication, is commonly prescribed for patients with atrial fibrillation to prevent the formation of blood clots. The most common anticoagulant prescribed for AF is warfarin or direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, dabigatran, or edoxaban. The nurse should educate the patient about the importance of taking the anticoagulant as prescribed and the need for regular monitoring of clotting times (INR for warfarin) to ensure the medication is effective and the dose is appropriate.

While other options listed in the choices may be relevant in specific situations, the priority in this case is to address the potential risk of stroke associated with atrial fibrillation and the importance of anticoagulant therapy to manage that risk effectively.

A. pH 7.25, HCO3- 19mEq / L PaCO2 30 mm Hg B. pH 7.30, HCO3-26 26mEq / L PaCO2 50 mm Hg C. pH 7.50 0. HCO * 3 - 20mE /L, PaCO2 32 mm Hg D. pH 7.55, HCO3- 30mEq / L PaCO2 31 mm Hg

Correct Answer is A

Explanation

In a client with chronic kidney disease (CKD), metabolic acidosis is a common acid-base disorder due to impaired excretion of acid and decreased bicarbonate reabsorption in the kidneys. The arterial blood gas values associated with metabolic acidosis in CKD are a low pH (acidemia), low bicarbonate (HCO3-), and normal or low partial pressure of carbon dioxide (PaCO2). Option A fits this pattern, with a pH of 7.25 (acidic), HCO3- of 19 mEq/L (low), and a PaCO2 of 30 mm Hg (within the normal to low range).

Option B shows a pH of 7.30 (acidic) but with a higher bicarbonate level of 26 mEq/L, which is not consistent with metabolic acidosis. The elevated bicarbonate level suggests metabolic alkalosis, which is not expected in a client with CKD.

Option C has a pH of 7.50 (alkaline) with an elevated bicarbonate level of 20 mEq/L and a low PaCO2 of 32 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.

Option D has a pH of 7.55 (alkaline) with an elevated bicarbonate level of 30 mEq/L and a low PaCO2 of 31 mm Hg. This set of values is indicative of metabolic alkalosis, which is not expected in a client with CKD.

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While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. What topic should the nurse plan to include in patient teaching?

Correct Answer is D

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Correct Answer is A

Explanation

While assessing an older adult client, the nurse notes jugular venous distention (JVD) with the head of the client's bed elevated 45 degrees. What does this finding indicate?

Which topic will the nurse plan to include in discharge teaching for a client who has heart failure with reduced ejection fraction?

The nurse is caring for a patient with manifestations of acute decompensated heart failure (ADHF). What is the priority nursing assessment?

Which patient is most likely to develop chronic kidney disease (CKD) and should be taught preventive measures by the nurse?

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