Question

The intensive care department nurse is assessing the client who is 12 hrs post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

a. Notify the health care provider immediately.
b. Elevate the HOB.
c. Document this is a normal and expected finding.
d. Administer IV morphine.

Answer 1

An S3 heart sound post-myocardial infarction is a sign of potential heart failure and is not normal. The nurse should notify the health care provider immediately for further evaluation and manage the patient's condition accordingly.

Step-by-step explanation:

When a nurse assesses an S3 heart sound in a client who is 12 hours post-myocardial infarction, it could be indicative of changes in the ventricular filling and potential heart failure. This is not a normal finding after a myocardial infarction. The presence of an S3 sound can imply a worsened prognosis for the patient's cardiac function, and it requires immediate evaluation by a healthcare provider. Therefore, the most appropriate intervention would be to notify the health care provider immediately for further assessment and possible modification of the patient's treatment plan. It is part of the nurse's responsibility to document all findings and communicate significant changes to ensure appropriate management.