When performing - he-d-to-toe -ssessment, the nurse h-s difficulty he-ring the
client's he-rt sounds. Wh-t should the nurse do to better -uscult-te the S1 -nd
S2 he-rt sounds?
Ask the client to le-n forw-rd in -
sitting position [33%]
1.
2. H-ve the client inh-le deeply -nd hold
the bre-th [21%]
3. Instruct the client to r-ise the left -rm
over the he-d [8%]
Use the bell of the stethoscope inste-d
of the di-phr-gm [36%]
4.
Incorrect
Correct -nswer
1
Expl&n&tion:
, To -uscult-te the he-rt, the nurse should listen -t e-ch of the v-lve -re-s (-ortic,
pulmonic, tricuspid, mitr-l) -nd Erb's point in - Z p-ttern. The S1-nd S2 he&rt
sounds, -s well -s -ny -dventitious sounds (eg, S3, S4, murmurs), should be
identified. The r-te -nd rhythm should -lso be -ssessed, listening for - full
minute -t the -pex (-pic-l pulse).
If he-rt sounds -re difficult to &uscult&te, the nurse c-n -sk the client to
either sit up -nd le&n forw&rd (best for -ortic -nd pulmonic -re-s) or lie
down on the left side (best for the mitr-l -re-). These positions move the
he-rt closer to the chest w&ll.
(Option 2) Exh-ling -nd holding the bre-th -id in -uscult-ting he-rt sounds th-t
-re difficult to he-r. Inh-ling introduces more -ir into the lung, which m-y muffle
he-rt sounds.
(Option 3) R-ising the -rm over the he-d helps to fl-tten the bre-st tissue,
m-king -ny lumps more pronounced. It does not help with -uscult-tion.
(Option 4) The di-phr-gm of the stethoscope is best for -uscult-ting higher-
client's he-rt sounds. Wh-t should the nurse do to better -uscult-te the S1 -nd
S2 he-rt sounds?
Ask the client to le-n forw-rd in -
sitting position [33%]
1.
2. H-ve the client inh-le deeply -nd hold
the bre-th [21%]
3. Instruct the client to r-ise the left -rm
over the he-d [8%]
Use the bell of the stethoscope inste-d
of the di-phr-gm [36%]
4.
Incorrect
Correct -nswer
1
Expl&n&tion:
, To -uscult-te the he-rt, the nurse should listen -t e-ch of the v-lve -re-s (-ortic,
pulmonic, tricuspid, mitr-l) -nd Erb's point in - Z p-ttern. The S1-nd S2 he&rt
sounds, -s well -s -ny -dventitious sounds (eg, S3, S4, murmurs), should be
identified. The r-te -nd rhythm should -lso be -ssessed, listening for - full
minute -t the -pex (-pic-l pulse).
If he-rt sounds -re difficult to &uscult&te, the nurse c-n -sk the client to
either sit up -nd le&n forw&rd (best for -ortic -nd pulmonic -re-s) or lie
down on the left side (best for the mitr-l -re-). These positions move the
he-rt closer to the chest w&ll.
(Option 2) Exh-ling -nd holding the bre-th -id in -uscult-ting he-rt sounds th-t
-re difficult to he-r. Inh-ling introduces more -ir into the lung, which m-y muffle
he-rt sounds.
(Option 3) R-ising the -rm over the he-d helps to fl-tten the bre-st tissue,
m-king -ny lumps more pronounced. It does not help with -uscult-tion.
(Option 4) The di-phr-gm of the stethoscope is best for -uscult-ting higher-
