Final answer:
The nurse should document any abnormal heart sounds such as a heart murmur, S4, pericardial friction rub, or ventricular gallop in a patient's medical record if detected during an assessment.
Step-by-step explanation:
A nurse assessing heart sounds in a patient reporting substernal, recordable pain should document any abnormal heart sounds in the patient's medical record. These sounds could include a heart murmur, which indicates a turbulent flow of blood typically graded on a scale from 1 to 6, where 6 is the most severe.
Another abnormal sound could be an S4, which is associated with the contraction of the atria pushing blood into a stiff or hypertrophic ventricle, suggesting left ventricular failure. An additional sound is known as pericardial friction rub, which indicates inflammation of the pericardium, the fibrous sac surrounding the heart. Lastly, a ventricular gallop may be heard in the presence of congestive heart failure.