The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding?

Question

The nurse is performing a cardiac assessment on a client.  The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border.  How should the nurse document this finding?

Quizplus · Accepted Answer

11ecbb05_c949_3004_b433_83e7e71f758a_MD0009_00 Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border. (Option A) An arterial bruit is a turbulent blood flow sound heard in a peripheral artery. (Option C) A pericardial friction rub is a high-pitched, scratchy sound during S₁ or S₂ at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. It occurs when inflamed surfaces of the heart rub against each other. (Option D) An S₃ gallop is an extra heart sound that occurs closely after S₂. It is a low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop. The mitral area is located at the fifth intercostal space, medial to the mid-clavicular line. Educational objective: Murmurs indicate turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas.

The Nurse Is Performing a Cardiac Assessment on a Client