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91Ó°ÊÓ

The charge nurse is observing a newly hired nurse measure jugular venous pressure. Which action on the part of the new nurse requires correction by the charge nurse? The newly hired nurse A. positions the client supine. B. raises the head of the bed \(30-45\) degrees. C. shines a light tangentally across the client's neck. D. measures the vertical distance from the manubrium to the meniscus of the internal jugular vein.

Short Answer

Expert verified
The incorrect action that requires correction is D. The vertical distance for jugular venous pressure should be measured from the sternal angle to the meniscus of the internal jugular vein, not from the manubrium.

Step by step solution

01

Understand the Correct Procedure for Measuring Jugular Venous Pressure

To properly measure jugular venous pressure (JVP), the client should be positioned at a 30-45 degree angle. The light should be positioned to shine tangentially across the neck to visualize the internal jugular vein's meniscus (top). JVP is measured as the vertical distance above the sternal angle (not the manubrium) to this meniscus.
02

Identify Incorrect Action

The correct actions include positioning the client correctly (supine and with the head of the bed elevated 30-45 degrees) and using a light to visualize the meniscus. Comparing all options provided, option D is incorrect because it measures the distance from the manubrium rather than from the sternal angle.
03

Recommend Correction

The charge nurse should instruct the newly hired nurse to measure the vertical distance from the sternal angle, not from the manubrium, to the meniscus of the internal jugular vein.

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Key Concepts

These are the key concepts you need to understand to accurately answer the question.

NCLEX-RN Examination
The National Council Licensure Examination for Registered Nurses (NCLEX-RN) is a standardized test that each nurse in the United States must pass to demonstrate competency and obtain a nursing license. It covers a wide range of topics essential for safe and effective nursing practice, including anatomy, physiology, pathophysiology, and various nursing procedures.

Among these procedures, measuring jugular venous pressure (JVP) is an important clinical assessment skill that may be tested. The NCLEX-RN examination evaluates a candidate's ability to perform such tasks correctly and to identify and correct errors in clinical practice. It's crucial for the nurse to demonstrate a clear understanding of these procedures to not only pass the examination but also to ensure quality patient care.
Nursing Procedures
Nursing procedures are standardized actions that nurses are trained to perform to care for patients. Procedures often include administrative tasks such as recording medical history and vital signs, as well as more hands-on interventions like administering medications or measuring JVP.

Properly conducting these procedures is essential for accurate diagnosis and effective treatment. When measuring JVP, for instance, the nurse must position the patient appropriately, use correct anatomical landmarks for measurements, and employ optimal lighting to visualize the internal jugular vein's meniscus. These steps ensure the readings obtained reflect the patient's true hemodynamic status. Instructions on performing such procedures are routinely updated based on the latest clinical evidence and should be strictly adhered to for the safety of the patient.
Clinical Assessment Skills
Clinical assessment skills involve the systematic collection and interpretation of patient information to guide medical decision-making. These skills are crucial for accurate diagnosis and ongoing management of patients. Skills include physical examination, history taking, and the use of diagnostic tools like the measurement of JVP to assess cardiac function and fluid status.

When measuring JVP, meticulous attention to detail is required, including the correct positioning of the patient, the angle of bed elevation, and the use of correct anatomical landmarks such as the sternal angle. This precision demonstrates the nurse's competency in clinical assessment and ensures that any potential issues like heart failure or volume overload are appropriately identified and managed. The ability to correct errors, such as measuring from the manubrium instead of the sternal angle, reflects a nurse's commitment to delivering high-quality patient care and is an integral part of clinical assessment skills.

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