A patient is admitted with acute pericarditis. When auscultating heart sounds, the nurse should ask the patient to perform which action?
1. sit and lean forward while the nurse auscultates at the left lower sternal border
2. lie supine and breathe quietly while the nurse auscultates for expiratory wheezes
3. sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds
4. sit and lean forward while the nurse auscultates at the second right intercostal space, near the sternal border
Correct Answer: 1
Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heard on expiration and may be constant or intermittent. Auscultating lung sounds for expiratory wheezes and vesicular breath sounds is done but does not focus on the pericardial friction rub. Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub.
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