The nurse is preparing to assess the client's cardiovascular system. Which of the following positions will the nurse need to place the client in during the assessment? Standard Text: Select all that apply

Question

1. Dorsal recumbent
2. Leaning forward
3. Right lateral position
4. Left lateral position
5. Sitting upright

Answer 1

1,2,4,5
Rationale 1: Dorsal recumbent. 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.
Rationale 2: Leaning forward. 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.
Rationale 3: Right lateral position. This is not a common position to place the client in during this type of examination.
Rationale 4: Left lateral position. 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.
Rationale 5: Sitting upright. The nurse will most likely begin this examination while the client is in this position. This is the position the nurse should ask the client to assume when beginning chest auscultation.