The nurse is performing a physical assessment on a patient suspected of being in heart failure. What sign that the heart is beginning to fail does the nurse auscultate the chest for?
A) An S3 heart sound
B) Crackles
C) Wheezing
D) An S4 heart sound
Ans: A
Feedback: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Crackles and wheezing may be heard in a patient with heart failure but do not indicate that the heart is beginning to fail. An S4 heart sound in an adult is pathologic and usually indicates a stiff left ventricle and denotes the beginning of left ventricular failure.
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