RN Exam Practice
Management of CareQuestion 1659 of 2368

A client's head of bed is raised to 45 degrees and the nurse sees a bulging jugular vein on the right side of the neck. What should the nurse do?

  1. Document it as an expected finding
  2. Lower the head of bed and reassess later
  3. Encourage the client to drink more fluids
  4. Report it to the provider as an unexpected finding
Show answer

Correct answer: Report it to the provider as an unexpected finding

Jugular vein distension should not be present when the head of bed is at 30 to 45 degrees.

Source: Nursing Skills, 2nd edition (Open RN, Chippewa Valley Technical College, 2023), Cardiovascular Assessment: Objective Assessment. Licensed under CC BY 4.0.

Practice the topic "Management of Care"

Questions last reviewed: 18 October 2026