# A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620076&lang=en  
> language: en  
> subject: Lifestyle Choices  
> category: HPM

## Question

A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

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🎧Cardiac auscultation recording

Use headphones if available. You may replay the recording.

1

An irregularly irregular cardiac rhythm

✕

2

A regular paired S1 and S2 pattern at approximately 70/min

✕

3

An S3 gallop after each S2

✕

4

A scratchy pericardial friction rub

✕

## Explanation

The recording demonstrates a rapid irregularly irregular rhythm consistent with the acoustic pattern of atrial fibrillation. The nurse should document the observed rate and rhythm and correlate the finding with pulse, symptoms, and electrocardiography rather than diagnose from sound alone.

## In-depth explanation

Quick answer
The recording demonstrates a rapid irregularly irregular rhythm consistent with the acoustic pattern of atrial fibrillation. The nurse should document the observed rate and rhythm and correlate the finding with pulse, symptoms, and electrocardiography rather than diagnose from sound alone.
Key cues
Use the scenario findings and timing to identify the safest response.
Clinical reasoning
Connect the relevant cues to the nursing interpretation and action supported by the evidence.
Why the alternatives do not fit
Other responses are unsupported, mistimed, lower priority, or incomplete for this scenario.
Priority and safety
Address immediate threats first and reassess after intervention.
Takeaway
For atrial fibrillation auscultation, document observed findings and avoid unsupported diagnostic inference.
Audio attribution
James Heilman, MD - CC-BY-SA-3.0
**Sources**
- Open RN Nursing Skills: Cardiovascular Assessment

## Clinical scenario

A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

## Key concepts

- **Irregularly irregular rhythm** — A rhythm with no repeating pattern between beats.
- **Apical pulse** — The heart rate and rhythm assessed at the cardiac apex.
- **Electrocardiography** — Electrical rhythm testing used to confirm the cardiac rhythm.

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