A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.)

a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the client's medications.


ANS: B
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

Nursing

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What will be an ideal response?

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