Page 1703 - Saunders Comprehensive Review For NCLEX-RN

100 mm Hg or 25 mm Hg lower than the previous
reading, lower the head of the bed and notify the
PHCP.
13. Administer beta blockers as prescribed to slow the
heart rate and increase myocardial perfusion while
reducing the force of myocardial contraction.
14. Provide reassurance to the client and family.

H. Interventions following the acute episode

1. Maintain bed rest as prescribed.
2. Allow the client to stand to void or use a bedside
commode if prescribed.
3. Provide range-of-motion exercises to prevent
thrombus formation and maintain muscle strength.
4. Progress to dangling legs at the side of the bed or out
of bed to the chair for 30 minutes 3 times a day as
prescribed.
5. Progress to ambulation in the client’s room and to the
bathroom and then in the hallway 3 times a day.
6. Monitor for complications.
7. Administer angiotensin-converting enzyme (ACE)
inhibitors, angiotensin-II receptor blockers (ARBs),
calcium channel blockers, aspirin, thienopyridines
(clopidogrel), and lipid-lowering agents as prescribed.
8. Encourage the client to verbalize feelings regarding
the MI.
I. Cardiac rehabilitation: Process of actively assisting the client with
cardiac disease to achieve and maintain a vital and productive life
within the limitations of the heart disease; also refer to section VII,
D (Coronary Artery Disease, Interventions).
X. Heart Failure

A. Description

1. Heart failure is the inability of the heart to maintain
adequate cardiac output to meet the metabolic needs
of the body because of impaired pumping ability.
2. Diminished cardiac output results in inadequate
peripheral tissue perfusion.
3. Congestion of the lungs and periphery may occur; the
client can develop acute pulmonary edema.
B. Classification
1. Acute heart failure occurs suddenly.
2. Chronic heart failure develops over time; however, a
client with chronic heart failure can develop an acute
episode.
C. Types of heart failure
1. Right ventricular failure, left ventricular failure

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