Question

The ICU RN is assessing the client who is 12 hours post myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

1. Notify the health-care provider immediately.
2. Elevate the head of the client's bed.
3. Document this as a normal and expected finding.
4. Administer morphine intravenously.

Answer 1

The nurse should notify the healthcare provider immediately when assessing an S3 heart sound in a patient who is 12 hours post myocardial infarction.

Step-by-step explanation:

In a patient who is 12 hours post myocardial infarction, the presence of an S3 heart sound is concerning and should not be considered a normal finding. An S3 heart sound is associated with decreased ventricular compliance and can be an indication of congestive heart failure, especially if heard later in life. Therefore, the nurse should notify the healthcare provider immediately, as further tests and interventions may be necessary to address the patient's condition.