The nurse is completing a physical assessment on a clinic patient 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 S3

Question

Because of these findings, the nurse's priority will be to assess for which other finding? 1. Absence of bowel sounds
2. Lung sounds for crackles
3. Diminished pulses
4. Sluggish pupil response

Answer 1

2
Rationale 1: The absence of bowel sounds is not associated with the assessment described.
Rationale 2: S1 and S2 heart sounds are normal. An S3 indicates excess fluid, and the nurse would want to assess for crackles in the lungs. The nurse might also check for JVD, peripheral edema, ascites, and other signs of fluid overload.
Rationale 3: Diminished pulses would not be an expected finding in this scenario.
Rationale 4: Sluggish pupil response does not correlate with an S3 heart sound.