The nurse is preparing to perform a cardiac assessment on a ...

[Chloeellawright]

The nurse is preparing to perform a cardiac assessment on a client. Rank the assessment steps in the order in which they will occur. Select the correct choice from the list.
 
  Response 1. Auscultation of the client's heart, apical pulse, and carotid arteries.
  Response 2. Inspection of the client's head and neck, chest, abdomen, and extremities.
  Response 3. Percussion of the client's chest.
  Response 4. Palpation of the precordium and pulses.

Question 2

The nurse is preparing to assess the client's cardiovascular system. Which client positions will the nurse use when conducting this assessment? Select all that apply.
 
  1. Dorsal recumbent.
  2. Leaning forward.
  3. Right lateral position.
  4. Left lateral position.
  5. Sitting upright.

[mcomstock09]

Answer to Question 1

Correct Answer: 2, 4, 3, 1
Physical assessment of the cardiovascular system follows an organized pattern. It begins with inspection of the client's head and neck. The upper extremities, chest, abdomen, and lower extremities are also inspected. Palpation includes the precordium and carotid pulses. Percussion of the chest is conducted to determine the cardiac borders. Auscultation includes the heart in five areas with the diaphragm and the bell of the stethoscope. The carotid arteries and the apical pulse are auscultated.

Answer to Question 2

Correct Answer: 1, 2, 4, 5
The nurse will most likely begin this examination with the client sitting upright. This is the position the nurse should ask the client to assume when beginning chest auscultation. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the client's heart while the client is leaning forward. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best heard at the apical area with the client in the left lateral position. Right lateral position is not a common position to place the client in during this type of examination.