Question

A nurse is performing a cardiac assessment for a client who had an MI 2 days ago. Which of the following actions should the nurse take after hearing this sound?

Answer 1

After hearing abnormal heart sounds during a cardiac assessment of a client who had an MI, the nurse should report these findings to the healthcare team. Abnormal sounds may indicate complications or issues requiring further investigation through an echocardiogram, ECG, and blood tests.

Step-by-step explanation:

In the context of a cardiac assessment after a myocardial infarction (MI), auscultation is a critical diagnostic technique. Upon hearing abnormal heart sounds, such as a murmur or other deviations from the typical 'lub-dub' sound, the nurse should understand that these may be indicative of valve disorders, heart failure, or continued cardiac distress. Abnormal sounds following an MI could involve a new or worsening valve issue, or suggest complications such as a ventricular septal defect or papillary muscle dysfunction. The finding of abnormal heart sounds during the assessment of a client dictates that the nurse should report these sounds promptly to the healthcare team for further evaluation, which may include diagnostic tests such as an echocardiogram (echo), electrocardiogram (ECG), and relevant blood tests. The follow-up steps are critical in determining the severity of the condition, the precise pathology, and in planning subsequent care.