While Assessing a Patient Who Was Admitted with Heart Failure,the

While assessing a patient who was admitted with heart failure,the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed.Which action should the nurse take next?

A) Document this finding in the patient's record.
B) Obtain vital signs, including oxygen saturation.
C) Have the patient perform the Valsalva maneuver.
D) Observe for JVD with the patient upright at 45 degrees.

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