The nurse is assessing the hepatojugular reflux in a patient with congestive heart failure. To perform this assessment technique correctly, the nurse should

elevate the head of bed to 45 degrees

Explanation

• The hepatojugular reflux test is used to measure jugular vein distention seen in tricuspid regurgitation, heart failure, and other conditions.

• The nurse places the patient's head at 45 degrees.

• The nurse observes the jugular pulsations during quiet respirations, then firmly presses the right upper quadrant or center of the abdomen for 30-60 seconds.

• The nurse then again observes the jugular pulsations during respirations. If there is a sustained rise in the jugular vein (>3 cm), the result is positive.

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