A nurse is completing a physical assessment on a clinic client who has been complaining of fatigue and intermittent chest pain over the last several weeks. Upon auscultation of the chest, the nurse hears an S1, S2, and an S3
Because of these findings, the nurse will also be certain to check for: 1. Lung sounds for crackles.
2. Absence of bowel sounds.
3. Diminished pulses.
4. Sluggish pupil response.
Lung sounds for crackles.
Rationale: An S3 indicates excess fluid, and the nurse would want to evaluate the client for crackles in the lungs. S1 and S2 heart sounds are normal. The nurse might also check for JVD, peripheral edema, ascites, and other signs of fluid overload. The absence of bowel sounds and sluggish pupil response does not correlate with an S3 heart sound. Diminished pulses could be a result of excess fluid, but could also be related to other cardiac problems.
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