A male patient has been admitted with congestive heart failure. Although the patient is sitting in a semi-Fowler position, the nurse cannot auscultate distinct heart tones. The nurse will correctly first
A) Document that the heart tones are muffled.
B) Count the apical rate as best as possible and then document it.
C) Have the patient lean forward and toward his left side.
D) Report the findings to the charge nurse.

Question

Quizplus · Accepted Answer

Having the patient lean forward and toward his left side can help to bring the heart closer to the chest wall, making the heart tones easier to auscultate. The other options may be necessary, but the nurse should first try to improve the ability to auscultate the heart tones before documenting or reporting the findings.

A Male Patient Has Been Admitted with Congestive Heart Failure