Question

A nurse is assessing a patient who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

A) Weight loss
B) Hypotension
C) Jugular vein distention
D) Decreased respiratory rate

Answer 1

In a patient with late-stage heart failure and fluid volume overload, the nurse should expect to find jugular vein distention (C).

Step-by-step explanation:

The nurse should expect to find juggular vein distention (C) in a patient with late-stage heart failure and fluid volume overload. Juggular vein distention occurs when there is an increase in central venous pressure, which occurs in fluid volume overload. The increased pressure in the veins causes jugular vein distention, which can be observed as a bulging of the veins in the neck.