Evolve HESI Practice Exam

What should a nurse do if abnormal heart sounds are detected in a patient?

1. Continue with routine assessments only

2. Immediately notify the physician for further evaluation

3. Ignore it if the patient appears stable

4. Document it and monitor closely

The correct answer is: Immediately notify the physician for further evaluation

When abnormal heart sounds are detected in a patient, the appropriate action is to immediately notify the physician for further evaluation. Abnormal heart sounds can indicate underlying cardiovascular issues, such as murmurs, gallops, or rubs, which may signify conditions that require urgent attention. Early intervention can be critical in preventing complications, and notifying the physician allows for prompt assessment and potential intervention. While documentation and monitoring are important components of nursing practice, the immediate step should be to escalate the concern to the physician. This ensures that the patient receives a comprehensive evaluation to determine the underlying cause of the abnormal sounds and to initiate any necessary treatment. Relying solely on routine assessments or ignoring the findings could lead to missed opportunities for timely intervention, especially if the patient’s condition deteriorates. Therefore, advocating for the patient by involving the physician is the best course of action in this situation.