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The nurse completes a cardiac focused assessment and documents jugular vein distension when lying flat. How...

The nurse completes a cardiac focused assessment and documents jugular vein distension when lying flat. How should the nurse proceed?

A. Assess for pink nail beds with a 90 degree angle at the base

B. Assess for carotid artery thrill and bruit to avoid an impending transient ischemic attack

C. Immediately assess the blood pressure to avoid potential cerebral artery complication

D. Assist the client to a 45 degree angel to complete the assessment

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