The Nurse Is Admitting a Client Diagnosed with Congestive Heart

Multiple Choice

The nurse is admitting a client diagnosed with congestive heart failure.Although the client is sitting in a semi-Fowler position, the nurse is unable to auscultate distinct heart tones.Which action should the nurse perform first?

A) Document that the heart tones are muffled.
B) Count the radial pulse and document it as the heart rate.
C) Assist the client to lean forward and toward the left side.
D) Report the findings to the admitting physician.