While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
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