The nurse is caring for a client with pericarditis. What heart sounds does the nurse expect to hear during the physical assessment?

A. Up in chair at bedside: Early mobilization after CABG, such as sitting in a chair at the bedside, promotes circulation, prevents venous stasis, reduces the risk of pulmonary complications, and supports overall recovery. At 6 hours post-op and 4 hours post-extubation, this level of activity is safe and appropriate under close monitoring.

B. Remove epicardial pacing wires: Epicardial pacing wires are removed 24–48 hours after surgery, depending on physician orders and patient stability. Removing them only a few hours post-op is unsafe and could lead to arrhythmias or bleeding, this is not appropriate at this stage.

C. Use incentive spirometer: Incentive spirometry is critical to prevent atelectasis and improve lung expansion following cardiac surgery. Encouraging the client to use the device frequently helps restore pulmonary function, especially after recent extubation.

D. Dangle at the bedside: Dangling (sitting at the edge of the bed with feet on the floor) is an early step in mobilization that helps the client regain balance, promote circulation, and reduce orthostatic hypotension before ambulating. It is appropriate at this stage of recovery.

E. Maintain NPO status: At 4 hours post-extubation, clients are generally allowed clear liquids if there is no nausea, swallowing difficulty, or risk of aspiration. Continuing NPO status unnecessarily could delay recovery and nutrition.

F. Ambulate to bathroom: Ambulation to the bathroom is typically not safe so soon after extubation and major cardiac surgery due to risk of hypotension, dizziness, or sternal instability. Mobility should begin with bedside sitting and dangling before progressing to walking.

Aortic area: Aortic Stenosis.

Key findings:

• Orthopnea
• Peripheral cyanosis
• Narrow pulse pressure

These are classic findings of Aortic Stenosis.

• Obstruction of left ventricular outflow
• Decreased stroke volume
• Narrow pulse pressure (low systolic output)
• Pulmonary congestion - orthopnea
• Poor systemic perfusion - cyanosis

The best auscultation Site is the 2nd intercostal space, right sternal border
(Aortic valve area)

It is typically: Harsh, systolic and may radiate to the carotid arteries