Chapter 43, Drugs Affecting Blood Pressure
A combination of drugs needs to be incorporated into the drug regimen for a hypertensive client. What type of diuretic would the nurse expect to administer? A) Thiazide B) Loop C) Potassium-sparing D) Osmotic
Ans: A Feedback: A somewhat controversial study, the Antihypertensive and LipidLowering Treatment to Prevent Heart Attack Trial (ALLHAT), reported in 2002 that clients taking the less expensive, less toxic diuretics did better and had better blood pressure control than clients using other antihypertensive agents. Replications of this study have supported its findings, and the use of a thiazide diuretic is currently considered the first drug used in the stepped-care management of hypertension.
The nurse is caring for a client newly prescribed iloprost. What is the nurse's priority teaching point about this medication? A) "Inhale this drug six to nine times a day during waking hours." B) "Men should not touch this pill." C) "It is safe for use in pregnancy." D) "This drug causes peripheral dilation of blood vessels."
Ans: A Feedback: Iloprost is an inhaled synthetic prostacyclin that directly dilates the pulmonary vascular bed, reducing pressure in the pulmonary vascular system, increasing gas exchange, and easing the signs and symptoms of pulmonary arterial hypertension. It is inhaled using a special delivery device six to nine times a day while awake. Clients report dizziness and syncope after using the drug and are therefore encouraged to change position slowly. Men and women should not ingest the drug or get it on their skin. It is a pregnancy category C drug and so is not considered safe in pregnancy.
A client was unable to achieve an acceptable blood pressure with just lifestyle changes. Thus, in stage 2 of the stepped-care plan to manage hypertension, monotherapy with an angiotensin-converting enzyme inhibitor was ordered. When an inadequate response was obtained from step 2, the nurse anticipates the provider will order what in step 3? A) Diuretic B) Beta-blocker C) Calcium channel blocker D) Vasodilator
Ans: A Feedback: In step 3, another drug will be added for combined effect. However, fixed-combination drugs should only be used when the client has been stabilized on each drug separately. A diuretic would be added before adding another class of medication unless the first drug was a diuretic. Vasodilators are generally used only in hypertensive emergencies.
A client has been prescribed losartan for hypertension. What client teaching points should the nurse include about this drug? A) "Report onset of a fever or persistent cough to your healthcare provider." B) "Limit your fluid intake to decrease urinary output, if this becomes problematic for you." C) "Monitor your blood pressure once a week and make sure to record the results." D) "Take the drug late in the day to prevent sleepiness."
Ans: A Feedback: Losartan is an angiotensin II-receptor blocker that is associated with a cough, back pain, fever, muscle weakness, and upper respiratory tract infections, so the client should be taught to report a fever or cough to the healthcare provider. Fluid intake should be normal. The drug is best taken in the morning. Blood pressure should be monitored daily, especially when first starting the drug, when adverse effects are not yet known.
The emergency department nurse is asked to prepare a nitroprusside infusion for a client being brought to the hospital in an ambulance. What is this client's most likely diagnosis? A) Hypertensive crisis B) Myocardial infarction accompanied by hypertension C) Hemorrhagic stroke D) Hypertension associated with diabetic ketoacidosis
Ans: A Feedback: Most of the vasodilators are reserved for use in severe hypertension or hypertensive emergencies. These include hydralazine, minoxidil, and nitroprusside. The presence of absence of a comorbidity such as stroke, diabetic ketoacidosis, or MI does not increase the likelihood of use.
The nurse is caring for a client who takes ramipril to treat hypertension. What would be an appropriate nursing diagnosis to include in this client's care plan? A) Ineffective tissue perfusion related to changes in cardiac output B) Acute pain related to skin effects and headache C) Altered gas exchange related to unrelenting cough D) Impaired body image
Ans: A Feedback: Nursing diagnoses related to drug therapy might include ineffective tissue perfusion (total body) related to changes in cardiac output because ramipril is associated with adverse effects such as reflex tachycardia, chest pain, angina, heart failure, and cardiac arrhythmias. Although dermatitis and rash may occur, headaches are not an associated adverse effect of this drug. Benazepril, enalapril, and fosinopril can cause an unrelenting cough but ramipril is not associated with this adverse effect. Impaired body image would not be associated with this drug.
The pediatric nurse examines an 11-year-old client with mildly elevated blood pressure who is 15% above the upper age-based weight limits. What is the nurse's priority teaching point? A) Strategize with the client and family about ways to increase the child's activity level. B) Explain how to administer diuretics to maximize benefits and reduce adverse effects. C) Establish firm limits around the client's food intake. D) Explain the most common adverse effects of calcium channel blockers.
Ans: A Feedback: Treatment of childhood hypertension should be done very cautiously because the long-term effects of the antihypertensive agents are not known. Lifestyle changes should be instituted before drug therapy is started if at all possible. This should be done using a collaborative approach that includes the family. Weight loss and increased activity may bring an elevated blood pressure back to normal in many children. As a result, the priority teaching point is to help parents understand how to adapt the child's diet to reduce weight and introduce family activities to increase exercise. A prescriptive approach to diet is likely to be perceived as punitive, possibly reducing adherence and self-esteem. Drug teaching would only be required if lifestyle changes is inadequate to lower blood pressure.
The nurse is caring for a client who has been nonadherent with treatment for hypertension. The nurse explains that untreated hypertension increases the risk of what? Select all that apply. A) Renal disease B) Cerebral infarction C) Heart failure D) Cholecystitis E) Migraine headache
Ans: A, B, C Feedback: Hypertension is a common chronic disorder. It is estimated that at least 20% of the people in the United States have hypertension. Hypertension increases risks of myocardial infarction, heart failure, cerebral infarction and hemorrhage, and renal disease. It does not increase the risk of cholecystitis or migraine headache.
The nurse works in a clinic that has many African American clients. What would the nurse need to consider when caring for clients with hypertension? Select all that apply. A) African American men are at highest risk for hypertension. B) African Americans respond best to single-drug therapy. C) African Americans are most responsive to angiotensin-converting enzyme inhibitors. D) Increased adverse effects occur when using thiazide and thiazide-like diuretics. E) First-line use of a calcium channel blocker with changes to lifestyle is best in African Americans.
Ans: A, B, D Feedback: In the United States, African Americans are at highest risk for developing hypertension, with men more likely than women to develop the disease. African Americans are most responsive to single-drug therapy (as opposed to combination drug regimens). African Americans are less responsive to angiotensinconverting enzyme inhibitors and beta-blockers. Increased adverse effects (e.g., depression, fatigue, drowsiness) often occur when using thiazide and thiazide-like diuretics. Because African Americans are more responsive to diuretics, the treatment approach should include the first-line use of a diuretic in combination with diet and other lifestyle changes.
The nurse cares for a client with diabetes and uncontrolled hypertension who has been prescribed losartan. The healthcare provider changes this client's prescription to losartan with hydrochlorothiazide. What benefits should the nurse anticipate this client will receive from this change in drug therapy? Select all that apply. A) Slowed progression of diabetic nephropathy in type 2 diabetes B) Increased excretion of fluid and sodium resulting in lower blood volume C) Alteration of electrolyte and acid-base balance D) Improved control of blood pressure due to combination therapy E) Fewer adverse effects resulting from the combination
Ans: A, B, D Feedback: Many clients require more than one type of antihypertensive to achieve good control of their blood pressure. There are now many fixed combination drugs available for treating hypertension. This allows for fewer tablets or capsules each day, making it easier for the client to comply with drug therapy. Losartan slows the progression of diabetic nephropathy in clients with hypertension and type 2 diabetes. Hydrochlorothiazide is a diuretic that will increase excretion of fluid and sodium resulting in a lower circulating blood volume that will help to reduce blood pressure, preload, and afterload. The two drugs will work together to better control the client's blood pressure. Alteration in electrolytes and acid-base is a reasonable expectation, but it is an adverse effect and not a benefit. There are likely to be more adverse effects when taking drugs that are not fixed combinations.
While studying the antihypertensive drugs, the nursing students learn that the pressure in the cardiovascular system is regulated by various elements. What are they? Select all that apply. A) Heart rate B) Stroke volume C) Preload D) Total peripheral resistance E) Pulse pressure
Ans: A, B, D Feedback: The pressure in the cardiovascular system is determined by three elements: heart rate, stroke volume, or the amount of blood that is pumped out of the ventricle with each heartbeat (primarily determined by the volume of blood in the system), and total peripheral resistance, or the resistance of the muscular arteries to the blood being pumped through. The preload and the pulse pressure are not factors that regulate pressure in the cardiovascular system.
A client does not want to take medication to treat existing hypertension if it can be avoided. The client asks the nurse whether any other options are available? What lifestyle changes should the nurse recommend? Select all that apply. A) "Increase the amount of exercise that you do." B) "Eliminate all salt from your diet." C) "Reduce your overall intake of fluids." D) "Lose some weight, if possible." E) "Try meditation, if it's something you're interested in."
Ans: A, D, E Feedback: Exercising, losing weight, and meditation to reduce stress are all effective lifestyle changes the client can make. It is not necessary, or even possible, to eliminate all sodium from the diet, but cutting back will reduce water retention. Reducing intake of fluids is not a healthy option and would not be suggested unless comorbidities, such as possibility of heart failure, were present.
A client who works in construction has been diagnosed with hypertension. After attempting to decrease the client's blood pressure with lifestyle changes and a mild diuretic, it is determined that the client needs to begin taking an angiotensinconverting enzyme (ACE) inhibitor. In an effort to prevent adverse effects, the nurse should address what client-related variable? A) Frequent constipation B) Excessive sweating on the job C) Consumption of three large meals a day D) Drinking one alcoholic beverage every night after work
Ans: B Feedback: A client taking an ACE inhibitor should be sure to maintain fluid intake, so excessive sweating on the job places the client at risk for a drop in fluid volume. Excessive sweating, vomiting, diarrhea, or dehydration need to be monitored and treated if they occur while taking an ACE inhibitor. Six smaller meals rather than three larger ones would be better and should be encouraged. However, this could be a problem with the client's job. The best treatment for constipation would be to increase fluid and fiber and one alcoholic beverage a night would be within reason when considering alcohol intake.
A client's hypertension has not responded significantly to first-line therapies, so the healthcare provider has prescribed aliskiren and spironolactone. In addition to blood pressure monitoring, what assessment should the nurse prioritize? A) AST, ALT and bilirubin levels B) Serum potassium level C) Quantity and character of urine output D) Heart rhythm
Ans: B Feedback: Aliskiren can cause an increase in potassium levels because it prevents the stimulation of aldosterone. Spironolactone is a potassium-sparing diuretic, so it also creates a risk for hyperkalemia. Liver enzyme levels are unlikely to be affected, since there is no significant risk for hepatotoxicity. Urine output and heart rhythm are not normally affected.
The nurse is providing drug teaching for a client who is prescribed enalapril. What drug-specific adverse effect will the nurse include in the drug teaching? A) Sedation B) Persistent cough C) Hypersensitivity reaction D) Hepatic dysfunction
Ans: B Feedback: Benazepril, enalapril, and fosinopril are generally well tolerated but cause an unrelenting cough, possibly related to adverse effects in the lungs, where the angiotensin-converting enzyme is inhibited, which may lead clients to discontinue the drug. This persistent cough develops in approximately 10% to 20% of clients.
The nurse provides drug teaching to the client prescribed captopril. What statement made by the client does the nurse interpret to mean teaching has been effective? A) "I will monitor the effectiveness by watching for any symptoms of hypertension." B) "I will call my doctor if I bruise easily or become extremely tired." C) "I'll take the drug in the morning so that I don't have to go to the bathroom often at night." D) "I will increase my intake of foods high in potassium, such as bananas."
Ans: B Feedback: Captopril has been associated with a sometimes-fatal pancytopenia, cough, and unpleasant gastrointestinal (GI) distress so the client should be alert to symptoms related to anemia, reduction in platelets, or infection. There is no need to increase potassium intake because a slight rise in potassium level is associated with this drug. Orthostatic hypotension is not a listed adverse effect. Effectiveness can only be gauged by blood pressure monitoring; most clients experience no symptoms of hypertension unless it is extreme.
The nurse is caring for a client with hypertension who is preparing to be discharged from the hospital after suffering a myocardial infarction. What drug would both treat the client's hypertension and reduce myocardial oxygen consumption? A) Captopril B) Losartan C) Diltiazem D) Nitroprusside
Ans: C Feedback: Diltiazem inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells, depressing the impulse and leading to slowed conduction, decreased myocardial contractility, and dilation of arterioles, which lowers blood pressure and decreases myocardial oxygen consumption. Captopril, losartan, and nitroprusside do not have actions to reduce myocardial oxygen consumption.
The nurse is caring for a child who is obese and has hypertension and a slightly elevated serum glucose level. What would the nurse anticipate will be ordered if lifestyle changes do not return blood pressure to an acceptable limit? A) Angiotensin-converting-enzyme (ACE) inhibitor B) Diuretic C) Calcium channel blocker. D) Beta-adrenergic blocker
Ans: B Feedback: Lifestyle changes should be instituted before drug therapy if at all possible. If drug therapy is used, a mild diuretic may be tried first, with monitoring of blood glucose and electrolyte levels on a regular basis. Calcium channel blockers have been used to treat hypertension in children and may be among the first considerations if drug therapy other than mild diuretics is needed. Beta-blockers have been used with success in some children; adverse effects may limit their usefulness in others. The safety and efficacy of the angiotensin-converting-enzyme (ACE) inhibitors and the angiotensin-receptor blockers (ARBs) have not been established in children.
A client has been diagnosed with hypertension and prescribed ramipril. When planning this client's care, what outcome should the nurse identify? A) A blood pressure of ≤ 110/70 mm Hg B) Close adherence to the prescribed regimen C) Absence of any adverse effects of treatment D) Resolution of peripheral edema
Ans: B Feedback: Regardless of what medication the client is prescribed, adherence to the regimen is a priority outcome. A blood pressure of ≤ 110/70 mm Hg may not be realistic, or even desirable, for many clients. Most antihypertensives, including ACE inhibitors, do not address fluid volume excess and peripheral edema. Adverse effects should be anticipated and managed; it is unrealistic to expect a complete absence of adverse effects.
An older adult client is taking a sustained-release antihypertensive drug. What is the nurse's priority teaching point about this medication? A) "Take your blood pressure only at night so that it's most accurate." B) "Swallow the drug whole and do not to cut, crush, or chew it." C) "Take the drug before bedtime to reduce your risk of falling." D) "Use over-the-counter (OTC) cold medications cautiously."
Ans: B Feedback: Sustained-release drugs cannot be cut, crushed, or chewed; it destroys the matrix system and allows absorption of the complete dose all at once. Older clients should be especially cautioned about sustained-release antihypertensives that cannot be cut, crushed, or chewed to avoid the potential for excessive dosing if these drugs are inappropriately cut. Many OTC drugs contain ingredients that increase blood pressure and so are not recommended for clients with hypertension. The client can take his or her blood pressure any time in the day, but it is usually recommended for the morning.
What drug is a safe and effective calcium channel blocker only if the nurse administers it as a sustained-release or extended-release preparation to treat hypertension? A) Aliskiren B) Diltiazem C) Atenolol D) Metoprolol
Ans: B Feedback: The calcium channel blockers available in immediate-release and sustained-release forms that are used in treating hypertension include amlodipine, felodipine, isradipine, and nicardipine. Other calcium channel blockers are safe and effective for this use only if they are given as sustained-release or extended-release preparations. These include diltiazem, nifedipine, nisoldipine, and verapamil. Aliskiren is a renin inhibitor. Atenolol and metoprolol are beta-blockers, not calcium channel blockers.
A client with hypertension has been started on losartan. After 6 weeks of therapy, the healthcare provider decides that the losartan alone is not controlling the client's hypertension. What does the nurse anticipate will be added to the losartan regimen for better control of this client's hypertension? A) Candesartan B) Hydrochlorothiazide C) Captopril D) Antidiuretic hormone (ADH)
Ans: B Feedback: When losartan therapy is started, maximal effects on blood pressure usually occur within 3 to 6 weeks. If losartan alone does not control blood pressure, a low dose of a diuretic may be added. A combination product of losartan and hydrochlorothiazide is available. Adding a second ARB such as candesartan or captopril would risk causing toxic adverse effects. ADH causes retention of water in the nephrons, which would further increase blood pressure.
The nurse administers ambrisentan to the client with pulmonary arterial hypertension. What assessment should the nurse prioritize in order to monitor the effectiveness of this medication? A) Assess the client's oxygen saturation. B) Assess the client's lying, sitting, and standing blood pressures. C) Assess the client's exercise tolerance. D) Auscultate the client's lungs.
Ans: C Feedback: Although it is certainly important to assess all aspects of oxygenation and ventilation, the single best indicator of drug effectiveness in clients with pulmonary arterial hypertension is improved exercise tolerance. This drug is not given to treat systemic hypertension or orthostatic hypotension, so postural blood pressures are not necessary.
The clinic nurse assesses a client taking benazepril to control hypertension. What change in the client's health status may require a change in drug therapy? A) The client is diagnosed with depression and begins taking a selective serotonin reuptake inhibitor (SSRI). B) The client is treated for hepatitis A. C) The client's creatinine clearance is steadily declining. D) The client is diagnosed with gastroesophageal reflux disease.
Ans: C Feedback: Benazepril is an angiotensin-converting enzyme inhibitor; drugs in this class are contraindicated in the presence of impaired renal function. Mental illness, hepatic disease, or GERD are not contraindications with this drug.
A client taking diltiazem for hypertension has come to the clinic for a followup appointment. What adverse effects should the nurse assess the client for? A) Chest pain and pale skin B) Shortness of breath and wheezing C) Peripheral edema and bradycardia D) Tachycardia and anxiety
Ans: C Feedback: Cardiovascular adverse effects of diltiazem include bradycardia, peripheral edema, and hypotension. Skin flushing and rash may occur. There should be no effect on the lungs, and anxiety is not expected.
The nurse provides dietary teaching to a client with hypertension. The nurse determines that the client has understood the information when the client selects what meal? A) Hot dogs, baked beans, and coleslaw B) French fries, grilled hamburger, and diet cola C) Grilled chicken, green salad with dressing, and baked apple D) Bologna sandwich with mayonnaise and potato salad
Ans: C Feedback: Chicken, salad, and fruit are all low in sodium. The other meal options all contain foods high in sodium (i.e., hot dogs, French fries, processed meats like bologna, and potato salad).
What is the nurse's priority assessment question before giving a female client her prescription for an angiotensin II-receptor blocker (ARB)? A) "Do you eat something when you take your medications?" B) "How much physical exercise do you get?" C) "When was your last menstrual period (LMP)?" D) "Have you always weighed 130 lbs as an adult?"
Ans: C Feedback: It would be important to know when the client's LMP occurred and that the client was not pregnant. These drugs can cause fetal abnormalities and fetal death. The other questions are appropriate and would help the nurse plan care for the client; however, it would not be as important as assessing for the possibility of pregnancy before beginning of therapy. The nurse should teach the client the need to avoid pregnancy using a barrier contraceptive.
A client taking a calcium channel blocker is seen in the clinic and receives a diagnosis of drug toxicity. When collecting the nursing history, consumption of what product would indicate the likely cause of this drug toxicity? A) One to two alcoholic drinks daily B) Dairy products in the morning C) Grapefruit juice D) Aged cheese
Ans: C Feedback: The calcium channel blockers are a class of drugs that interact with grapefruit juice. When grapefruit juice is present in the body, the concentrations of calcium channel blockers increase, sometimes to toxic levels. Advise clients to avoid drinking grapefruit juice taking a calcium channel blocker. If a client on a calcium channel blocker reports toxic effects, ask whether he or she is drinking grapefruit juice. Use of alcohol could be important if the client was ingesting large amounts but that would not be the most likely cause of drug toxicity. Dairy and cheese should not cause any food-drug interaction.
A pregnant client has been diagnosed with hypertension, and the care team has determined that the benefits of drug therapy outweigh the risks. What category of antihypertensive is most appropriate? A) Angiotensin-converting enzyme (ACE) inhibitor B) Angiotensin-receptor blocker (ARB) C) Renin inhibitor D) Calcium channel blocker
Ans: D Feedback: ACE inhibitors, ARBs, and renin inhibitors should not be used during pregnancy, and women of childbearing age should be advised to use barrier contraceptives to prevent pregnancy while taking these drugs. Calcium channel blockers and vasodilators can be used in pregnancy with caution if the benefit to the mother clearly outweighs the potential risk to the fetus.
The nurse is caring for a 39-year-old African American client who is 25 lbs overweight and who has received a new diagnosis of hypertension. What initial drug therapy should the nurse anticipate? A) Angiotensin-converting enzyme (ACE) inhibitor B) Beta blocker C) Calcium channel blocker D) Diuretic
Ans: D Feedback: African Americans are at highest risk for developing hypertension, with men more likely than women to develop the disease. African Americans have documented differences in response to antihypertensive therapy. They are most responsive to single-drug therapy and diuretics. The first line use of a diuretic is in combination with diet and other lifestyle changes. The use of a calcium channel blocker and/or alpha-adrenergic blocker should follow. African Americans are less responsive to ACE inhibitors and beta-blockers.
A client is admitted to the intensive care unit in shock with hypotension. What is an appropriate nursing diagnosis for this client? A) Impaired gas exchange B) Deficient fluid volume C) Risk for falls D) Ineffective peripheral tissue perfusion
Ans: D Feedback: An appropriate nursing diagnosis would be ineffective peripheral tissue perfusion. If blood pressure becomes too low, the vital centers in the brain, as well as the rest of the tissues of the body, may not receive enough oxygenated blood to continue functioning. The client's risk for falls would be low because he or she is acutely ill and confined to bed. There is no direct indication of altered gas exchange or deficient fluid volume.
The nurse evaluates the client's lifestyle for factors that are contributing to hypertension and then addresses the need to change what factor? A) Working outdoors in the sun B) Weight lifting at the gym C) High-protein diet D) Exposure to high-frequency noise
Ans: D Feedback: Factors that are known to increase blood pressure in some people include high levels of psychological stress, exposure to high-frequency noise, a high-salt diet, lack of rest, and genetic predisposition. Working outdoors in the sun may increase risk for skin cancer but does not contribute to hypertension. Weight lifting is good exercise, especially if he uses low weight and frequent repetition. High protein intake is not a contributing factor for hypertension.
A stepped-care management approach to treating hypertension includes weight loss, smoking cessation, decreased use of alcohol, reducing sodium in the diet, and increased physical exercise. During a stepped-care management approach, when should the nurse teach about these changes in lifestyle? A) Step 1 only B) Steps 1 and 2 C) Steps 1, 2, and 3 D) Steps 1, 2, 3, and 4
Ans: D Feedback: Lifestyle changes are encouraged in all four steps and should be advocated for the maintenance of good health. These changes are stressed in steps 1 and 2 in the hope that drug therapy will not be necessary. However, these changes should occur in steps 3 and 4 as well.
Which client is most likely to be diagnosed with secondary hypertension? A) A client whose most recent blood pressure readings were 143/92, 147/94, and 144/94 mm Hg B) A client with type 1 diabetes who has developed nephropathy C) A client whose body mass index is 31 (obese) D) A client who is being treated for pheochromocytoma
Ans: D Feedback: The majority of clients with hypertension have the primary (essential) form, in which there is no obvious cause. A client with a pheochromocytoma would have secondary hypertension, because the cause is identifiable. Obesity and diabetes are associated with hypertension but are not the direct causes of it. A client with blood pressures of 143/92, 147/94, and 144/94 mm Hg would be likely diagnosed with hypertension, but not likely the secondary type.
A nurse is reviewing the function of the renin-angiotensin-aldosterone system before assessing a client with hypertension. Place these events in the function of the renin-angiotensin-aldosterone system in the order that they occur. A) Renin is released by juxtaglomerular cells. B) Blood pressure increases due to vasoconstriction. C) Angiotensinogen is converted to angiotensin I.D) Low blood pressure is detected. E) Angiotensin II reacts with blood vessel receptors.
Ans: D, A, C, E, B Feedback: Low blood pressure or poor oxygenation of a nephron causes the release of renin from the juxtaglomerular cells, a group of cells that monitor blood pressure and flow into the glomerulus. Renin is released into the bloodstream and arrives in the liver to convert the compound angiotensinogen (produced in the liver) to angiotensin I. Angiotensin I travels in the bloodstream to the lungs, where the metabolic cells of the alveoli use angiotensin-converting enzyme (ACE) to convert angiotensin I to angiotensin II. Angiotensin II reacts with specific angiotensin II receptor sites on blood vessels to cause intense vasoconstriction.
