HESI Registered Nurse EXIT Practice Exam

While auscultating heart sounds, which term should the nurse use to document a murmur?

1. Regular rhythm

2. Click

3. Gallop

4. Murmur

The correct answer is: Murmur

When documenting heart sounds, the term "murmur" is the most appropriate choice to describe an extra sound that occurs during the cardiac cycle, which is typically indicative of turbulent blood flow. Murmurs can vary in intensity, duration, and timing within the heart cycle, and they may be classified as systolic or diastolic, depending on when in the heart beat they occur. Documenting a murmur is essential for evaluation and management, as it can provide insights into underlying cardiac conditions such as valve abnormalities or heart defects. The other terms—regular rhythm, click, and gallop—describe different characteristics of heart sounds. Regular rhythm indicates a normal pattern of heartbeats, while a click is a sharp, distinct sound often related to valve function. A gallop refers to a specific abnormal rhythm characterized by an additional heart sound, resembling the rhythm of a galloping horse, typically associated with heart failure or volume overload. These terms are distinct from murmur and do not encompass the same meaning or implications as "murmur" does in the documentation of heart sounds. Therefore, "murmur" is the most accurate term to use for this specific type of abnormal sound heard during auscultation.