Practice Question
In assessing a client's heart sounds, the nurse hears an S₁ and S2 after placing the diaphragm of the stethoscope at the second intercostal space just to the right of the sternum while the client is supine in bed. Which action should the nurse take next?
Answer Choices:
Correct Answer:
Inch the stethoscope down the right side of the sternum.
Rationale:
🟦 Hearing S₁ and S₂ at the second intercostal space, right sternal border indicates the nurse is listening at the aortic area, which is correct according to the standard cardiac auscultation sequence.
🟦 The next appropriate step in a thorough cardiac assessment is to inch the stethoscope downward along the right sternal border, moving to the second, third, and fourth ICS, followed by the fifth ICS on the left side.
🟦 This systematic approach ensures full assessment of all major heart valves—aortic, pulmonic, Erb’s point, tricuspid, and mitral.
🟦 The nurse should continue auscultation at each landmark to compare heart sounds and identify abnormalities such as murmurs, extra sounds, or splitting.
🟦 Therefore, progressing downward along the sternum allows completion of a complete and accurate cardiac auscultation.
❌ Incorrect Options
Document normal heart sounds
— Incorrect at this stage because the nurse has not completed the full cardiac exam yet.
— Only the aortic area has been assessed.
Turn the client to left side-lying
— This position is useful for hearing S₃, S₄, or mitral murmurs, but not appropriate until basic auscultation landmarks are completed.
Move the diaphragm to the left of the sternum
— This prematurely skips auscultation steps. The next area to assess after the right 2nd ICS is still along the right sternal border, not the left.
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This question is from Fall 2025-BSN -246 RN Health Assessment which contains 59 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: Health Assessment
- Answer Choices: 4