FORD CH35: Antianginal and Vasodilating Drugs

The nurse is caring for a client with angina who has been prescribed nitroglycerin. What health teaching about the client's lifestyle should the nurse provide? 1) "Make sure that you're able to get at least 6 hours of sleep each night, if possible." 2) "Avoid drinking grapefruit juice because it will interfere with how your body processes nitroglycerin." 3) "It's best to eliminate or reduce your intake of alcoholic beverages." 4) "It's important not to take nitroglycerin unless you're actually experiencing chest pain."

Correct response: "It's best to eliminate or reduce your intake of alcoholic beverages." Explanation: Clients should be taught to avoid or at least decrease use of coffee, cigarettes, and alcoholic beverages. Clients should ideally take nitroglycerin before the onset of chest pain. There is no particular need for adequate sleep, beyond the general benefits of this practice. Grapefruit juice does not interfere with the metabolism of nitroglycerin.

The nurse teaches the client how to use topical nitroglycerin and includes what points in the teaching plan? Select all that apply. 1) "Increase fluid intake to avoid low blood pressure." 2) "Make sure no one touches the side with the medication." 3) "Rotate application sites." 4) "Assess the skin for signs of breakdown." 5) "Do not shower with the patch in place."

Correct Response: "Rotate application sites." "Assess the skin for signs of breakdown." "Make sure no one touches the side with the medication." Explanation: Rotate the sites of topical forms of nitroglycerin to lower the risk of skin abrasion and breakdown; monitor for signs of skin breakdown to arrange for appropriate skin care as needed. Care should be taken not to touch the side of the patch with the medication by the client or anyone assisting in applying the patch. The client may shower with the patch in place. There is no need to increase fluid intake but clients should be encouraged to maintain adequate intake.

A client arrives at the urgent care center reporting chest pain. After diagnosis, the health care provider prescribes amlodipine for the client's condition. The nurse understands that this drug is indicated for which condition? 1) Atrioventricular (AV) block 2) Prinzmetal angina 3) Sick sinus syndrome 4) Cardiogenic shock

Correct response : Prinzmetal angina Explanation: The nurse should identify Prinzmetal angina as the condition for which amlodipine is indicated. Prinzmetal angina is a vasospastic angina for which calcium channel blockers are used for treatment. Cardiogenic shock, sick sinus syndrome, and AV block are the conditions for which amlodipine is contraindicated.

The nurse provides client teaching for a client diagnosed with angina about the prescribed nitroglycerin transdermal patch. Which client statement establishes the need for further teaching? 1) "I will apply the patch for 24 hours and then remove it, and place another transdermal patch." 2) "I will remove the patch and fold it on itself to prevent my dog or grandchildren from touching it." 3) "I will clean the previous site where I remove an old patch with soap and water and dry it thoroughly." 4) "I will rotate placement of the transdermal patch on my chest, abdomen, and thighs."

Correct response: "I will apply the patch for 24 hours and then remove it, and place another transdermal patch." Explanation: The nurse should provide further teaching about the nitroglycerin transdermal patch needs to be applied in the morning, and then removed after 10-12 hours, and left off until the next morning. The patch delivers a constant amount of the drug, which without removal of the drug leads to tolerance of the drug, making it ineffective. The client is correct in rotating sites of placement of the transdermal patch and to place it on chest, abdomen, and thighs. The client should avoid lower legs. It is important to fold the patch in half before disposing of it in the trash to prevent a person or pet from encountering the drug that remains in the delivery system. Cleaning the skin is important in removing any residual drug from the skin.

A 52-year-old client who experienced a myocardial infarction has an order for discharge. Part of the discharge teaching includes prior administration of nitroglycerin for chest pain. Which statement by the client indicates understanding of the teaching provided? 1) "I will take three tables every 5 minutes until the chest pain subsides." 2) "I will take three nitroglycerin tablets 5 minutes apart, and if I do not have any relief I will seek emergency care immediately." 3) "I will take two nitroglycerin tablets 15 minutes apart, and if I do not have any relief I will contact my health care provider." 4) "I will take one tablet and lay down for an hour."

Correct response: "I will take three nitroglycerin tablets 5 minutes apart, and if I do not have any relief I will seek emergency care immediately." Explanation: The client with stable or unstable angina will be prescribed sublingual nitroglycerin to relieve chest pain symptoms. The client may take up to three tablets of sublingual nitroglycerin 5 minutes apart. If the chest pain is unrelieved, the client needs to seek emergency medical care immediately.

Following the administration of a scheduled dose of 50-mg atenolol PO, the nurse should prioritize what assessment? 1) Oxygen saturation levels 2) Blood pressure 3) Level of consciousness (LOC) 4) Oral temperature

Correct response: Blood pressure Explanation: Atenolol and other beta-blockers have an antihypertensive effect, making the monitoring of blood pressure a priority. They are unlikely to affect temperature, LOC, or oxygen saturation levels.

A client is diagnosed with erectile dysfunction. He asks what effect sildenafil (Viagra) has because he is taking nitroglycerin for chest pain. What is the best explanation for why nitrates are contraindicated with sildenafil? 1) "Taking the drugs together can lead to prostate cancer." 2) "Nitroglycerine decreases the effect of sildenafil for erectile dysfunction." 3) "Nitroglycerine and sildenafil will diminish the effectiveness of chest pain relief." 4) "The combination can cause a severe decrease in blood pressure."

Correct response: "The combination can cause a severe decrease in blood pressure." Explanation: Nitrates and phosphodiesterase enzyme type 5 inhibitors decrease blood pressure, and the combined effect can produce profound, life-threatening hypotension. The other options do not accurately describe the risk posed by concurrent use of the two medications.

The nurse is caring for a male client with a history of hypertension and Prinzmetal angina who is currently taking amlodipine 10 mg orally every day, and minoxidil 25 mg orally twice a day. The client stated that he is concerned about a recent enlargement of his breasts. What is the best therapeutic response to the client's concern? 1) "The increase in breast size is an adverse effect of minoxidil, and I will notify your primary care provider so other options may be explored." 2) "You have a history of severe hypertension, and unfortunately, you have to stay on the medications prescribed, so you may try wearing lose clothing." 3) "Don't worry, this is an expected side effect of minoxidil, and it is hardly noticeable, and your blood pressure is stable with the meds." 4) "If you lose some weight, it will help your blood pressure and decrease the breast size, and you will feel much better about how you look."

Correct response: "The increase in breast size is an adverse effect of minoxidil, and I will notify your primary care provider so other options may be explored." Explanation: The best therapeutic response is factual and involves action to help the client. Telling a client to not worry and that the breasts are hardly noticeable is nontherapeutic and patronizing. It is incorrect to tell the client he must stay on the prescribed meds because there are other drugs in the same categories available that do not lead to gynecomastia. Telling the client that he needs to lose weight to help his blood pressure and decrease the breast size is blaming the client for the situation.

A client's angina pectoris is being successfully treated on an outclient basis with sublingual nitroglycerin. What teaching point should the nurse convey to the client when reporting concern about the headache that follows the use of the medication? 1) "I'll contact your health care provider. This may mean that nitroglycerin is not the right drug for you." 2) "The headache is actually a result of your angina, not the nitroglycerin." 3) "If you can take your nitroglycerin on a full stomach, it might reduce the frequency and severity of your headaches." 4) "This is a common adverse effect of nitroglycerin; try taking acetaminophen to treat your headache."

Correct response: "This is a common adverse effect of nitroglycerin; try taking acetaminophen to treat your headache." Explanation: The most common adverse effect of nitroglycerin is a severe headache, which is typically treated with acetaminophen. Taking the drug on a full stomach is ineffective, and headaches do not contraindicate the use of the drug.

The client tells the nurse he does not like taking his prescription isosorbide because it makes him feel weak, dizzy, flushed, and he gets a severe headache. What is the nurse's best response? 1) "You are experiencing severe reactions and the medication needs to be stopped immediately." 2) "Your physician may need to change your medications." 3) "It is important to take your medications no matter how badly they make you feel." 4) "With time, these adverse reactions often subside."

Correct response: "With time, these adverse reactions often subside." Explanation: Adverse reactions such as headache, flushing, and postural hypotension that are seen with the administration of the antianginal drugs often become less severe, or even disappear, after a period of time. The client should continue to take the medication.

A 62-year-old man is admitted to the hospital with a diagnosis of chest pain. He has an order for 0.3 mg of sublingual nitroglycerin prn for chest pain. Which action should the nurse do first when he reports chest pain? 1) Ask the client to lie back and try to relax. 2) Call the health care provider. 3) Administer a tablet under the tongue and repeat the action in 5 and 10 minutes if the pain has not subsided. 4) Have the client swallow a tablet every 5 minutes for 15 minutes.

Correct response: Administer a tablet under the tongue and repeat the action in 5 and 10 minutes if the pain has not subsided. Explanation: The initial action by the nurse should be sublingual administration of the drug by placing one tablet under the client's tongue and repeating the action in 5 and 10 minutes if necessary. Asking the client to relax is important and should be done, but administering the tablets would need to be done first. The nurse would not call the health care provider if the pain has subsided by the third tablet. If the pain has not subsided, the client is considered to be having an acute MI, and it would be urgent to call the provider. Nitroglycerin does not come in oral form; therefore, it would not be swallowed.

The nurse is providing education to a client who has been prescribed nitroglycerin transdermal spray. What instruction should the nurse provide the client concerning how to administer the spray? 1) Administer the spray after consulting with the health care provider or a nurse. 2) Administer the spray if the angina pain is unrelieved by 30 minutes of rest. 3) Administer the spray as soon as chest pain develops. 4) Do not administer more than one dose.

Correct response: Administer the spray as soon as chest pain develops. Explanation: Administration transdermal spray is essential as soon as chest pain develops. It is unnecessary and inappropriate to delay administration. The client can administer as many as three doses.

A client is prescribed a transdermal nitroglycerin system. The nurse educates the client on which action? 1) When adding a patch, do not remove the old one until the medication is absorbed. 2) Apply the new transdermal system at the same time daily. 3 If the transdermal system comes off, tape it back onto the skin firmly. 4) Spread the contents of the patch across the chest area for maximum effect.

Correct response: Apply the new transdermal system at the same time daily. Explanation: It is important that the transdermal system be applied at approximately the same time every day. The system should be firmly pressed onto the skin to ensure contact. If the system comes off, a new transdermal system should be applied.

The client is experiencing an acute onset of angina. The nurse would most likely administer which medication? 1) Nitro-Dur 2) Procardia 3) Norvasc 4) Nitrostat

Correct response: Nitrostat Explanation: Nitrostat is administered for acute relief of angina. Nitro-Dur is used to prevent angina. Procardia and Norvasc are indicated for chronic angina.

A client is admitted to the emergency department with severe chest pain. The emergency department health care provider orders intravenous nitroglycerin 5 mcg/min, titrate dose by 5 mcg/min every 3 to 5 minutes per infusion pump as needed. Before administering the nitroglycerin, the nurse should prioritize which assessment? 1) Urinary output 2) Heart rate 3) Blood pressure 4) Blood urea nitrogen (BUN)

Correct response: Blood pressure Explanation: Before administering IV nitroglycerin, the nurse should first assess blood pressure to make sure that the client does not have hypotension and to establish a baseline blood pressure. It is also important to assess the heart rate and urinary function (urinary output and BUN). However, in the case of administering intravenous nitroglycerin, the nurse would first assess the blood pressure.

Prior to the administration of nitroglycerin, the nurse would assess which of the following? 1) Pulse 2) EKG 3) Blood pressure 4) Breath sounds

Correct response: Blood pressure Explanation: It is important to assess the client's blood pressure prior to administering nitroglycerin because it can cause hypotension. Pulse, breath sounds, and EKG are not a priority before administration.

The client is taking a calcium channel blocker. Which assessment findings would the nurse expect? 1) Restlessness 2) Palpitations 3) Vomiting 4) Bradycardia

Correct response: Bradycardia Explanation: Calcium channel blockers slow the conduction velocity of the cardiac impulse and the client may experience bradycardia. Palpitations, vomiting, and restlessness are associated with peripheral vasodilators.

A client with angina is prescribed atenolol. Following absorption of the drug, the nurse should monitor the client for what desired effect? 1) Increased oxygen saturation levels 2) Relief of fatigue 3) Mild to moderate drowsiness 4) Decreased heart rate

Correct response: Decreased heart rate Explanation: Beta-blockers cause a slowing of the heart rate referred to as negative chronotropy. They do not normally cause drowsiness, short-term relief from fatigue, or a notable increase in SaO2 since the action of this medication is to inhibit beta2 receptors in the bronchial and vascular musculature.

The nurse is providing education to a client who has been prescribed bisoprolol. During teaching, the nurse explains that the drug achieves a therapeutic effect in what way? 1) Increasing the force of myocardial contractions 2) Prolonging the QT interval 3) Decreasing heart rate 4) Shortening the time required for repolarization

Correct response: Decreasing heart rate Explanation: Bisoprolol reduces the workload of the heart and decreases myocardial oxygen demand by decreasing heart rate and the force of myocardial contractions. It does not prolong the QT interval or shorten the time required for repolarization.

The nurse is teaching a client with angina who is prescribed sublingual tablets. The nurse would instruct the client to use a tablet at which frequency when experiencing an acute attack? 1) Every 15 minutes 2) Every 10 minutes 3) Every 5 minutes 4) Every 2 minutes

Correct response: Every 5 minutes Explanation: Sublingual nitroglycerin should be taken every 5 minutes up to a maximum number of 3 tablets in 15 minutes. The client should seek medical care if pain is not relieved after the 3 doses.

The nurse is providing education to a client who has been prescribed sublingual nitroglycerin tablets. What action should the nurse instruct the client to take if the medication is not effective in relieving chest pain? 1) Call the health care provider 2) Lie down after taking an aspirin 3) Go to the emergency department 4) Take more tablets until pain subsides, to a maximum of six tablets

Correct response: Go to the emergency department Explanation: A sublingual dose may be repeated in 5 minutes if relief is not felt, for a total of three doses. If pain persists, the client should go to the emergency department. The client should not delay treatment by calling the health care provider or lying down. It would be unsafe to take more than three tablets.

The client is taking a calcium-channel blocker. What adverse effects might the client experience? 1) Headache and dizziness 2) Palpitations and tingling of extremities 3) Hypertension and tachycardia 4) Fever and bronchospasm

Correct response: Headache and dizziness Explanation: Adverse effects of calcium channel blockers include hypotension, headache, dizziness, lightheadedness, weakness, edema, nausea, and constipation.

The nurse is caring for a client with angina who is taking a calcium-channel blocker. What adverse effects would the nurse caution this client about? 1) Hypertension and tachycardia 2) Itching and rash 3) Headache and dizziness 4) Nausea and diarrhea

Correct response: Headache and dizziness Explanation: The adverse effects associated with these drugs are related to their effects on cardiac output and on smooth muscle. Central nervous system (CNS) effects include dizziness, light-headedness, headache, and fatigue. Gastrointestinal (GI) effects can include nausea and hepatic injury related to direct toxic effects on hepatic cells. Cardiovascular effects include hypotension, bradycardia, peripheral edema, and heart block. Skin effects include flushing and rash. The adverse effects do not, however, include diarrhea, hypertension, tachycardia, or itching.

A 49-year-old client is admitted with uncontrolled chest pain. The client is currently taking nitroglycerin. The health care provider adds nifedipine to the client's regimen. The nurse should observe the client for what adverse effects? 1) Hypotension 2) Hypoglycemia 3) Hypokalemia 4) Renal insufficiency

Correct response: Hypotension Explanation: Both nitroglycerin and nifedipine have hypotension as a potential adverse effect, so frequent assessment of blood pressure is important. Other cardiovascular effects include bradycardia, peripheral edema, and heart block. Skin effects include flushing and rash. Adverse effects do not include renal insufficiency, hypokalemia, or hypoglycemia.

A client with a history of angina has sustained a mild head injury in a motor vehicle accident. When the client reports chest pain, what explanation should the nurse provide to support the decision not to treat the angina-related pain with nitroglycerin tablets? 1) Nitroglycerin will increase intracranial pressure. 2) Nitroglycerin will cause decreased cerebral edema. 3) Nitroglycerin will raise the client's blood pressure. 4) Nitroglycerin will decrease blood glucose.

Correct response: Nitroglycerin will increase intracranial pressure. Explanation: Nitroglycerin should be used cautiously in the presence of a head injury or cerebral hemorrhage because it may increase intracranial pressure. Nitroglycerin will lower blood pressure. Nitroglycerin can increase cerebral edema. Nitroglycerin does not have a direct effect on blood glucose.

A client has been diagnosed with angina and prescribed nitroglycerin. What aspect of the client's health history should prompt the nurse to monitor the client particularly closely after administration of the drug? 1) Orthostatic hypotension 2) Reynaud syndrome 3) Depression and use of a selective serotonin reuptake inhibitor 4) Gastroesophageal reflux disease (GERD)

Correct response: Orthostatic hypotension Explanation: Underlying hypotension can be exacerbated by nitroglycerin, creating a risk for syncope or falls. GERD, depression, and Reynaud syndrome do not complicate the use of nitrates for angina.

Clients who are taking nifedipine should be monitored for which of the following adverse effects? 1) Asthma 2) Peripheral edema 3) Tetany 4) Hyperkalemia

Correct response: Peripheral edema Explanation: Nifedipine is a calcium channel blocker. Of the four choices offered, only peripheral edema is an adverse effect of this drug class.

A 22-year-old client is admitted with a head injury after passing out at a friend's party. The nurse should ask the client about the use of which? 1) Alcohol consumption 2) Herbal remedies 3) Amphetamines 4) Rush poppers

Correct response: Rush poppers Explanation: "Rush poppers" (amyl nitrite, butyl nitrite, and isobutyl nitrite) are popular among young people. The head rush, euphoria, uncontrollable laughter or giggling, and other sensations that result from the blood pressure drop are often felt to increase sexual arousal and desire. The nurse should inquire about "popper" use when injury and low blood pressure are presenting symptoms in the urgent care or emergency department.

A client with chronic alcoholism has been admitted to the health care center for acute angina management and is started on nitrates. The nurse emphasizes the need for the client to avoid alcohol use to prevent which reaction? 1) Decreased effectiveness of nitrates 2) Increased risk of hypoglycemia 3) Severe hypotension 4) Increased hypersensitivity reactions

Correct response: Severe hypotension Explanation: The nurse should inform the client that severe hypotension and cardiovascular collapse may occur due to the drug interaction between alcohol and nitrates. Nitrates given for treating angina interact with alcohol and cause severe hypotension. Increased risk of hypoglycemia, increased hypersensitivity reactions, and decreased effectiveness of nitrates do not result from the interaction of nitrates and alcohol.

The nurse cautions a client receiving nitrate therapy about avoiding the use of alcohol to prevent which reaction? 1) Severe hypotension 2) Myocardial infarction 3) Acute anginal attack 4) Hypertensive emergency

Correct response: Severe hypotension Explanation: The use of alcohol with nitrates can result in severe hypotension and cardiovascular collapse may occur. Acute angina attack and myocardial infarction are seen with heart disease and emboli.

The nurse is teaching a 63-year-old client about sustained-release oral nitrates which has been prescribed for treatment of angina. Which instructions would the nurse offer to the client when teaching how to properly self-administer the medication? 1) Crush the medication and mix it with food. 2) Take the medication immediately following a meal. 3) Take the medication on an empty stomach. 4) Crush the medication and dissolve it in water.

Correct response: Take the medication on an empty stomach Explanation: Oral nitrates should be taken on an empty stomach with a glass of water. Clients should not crush or chew sustained-release tablets.

A recent episode of chest pain while doing yard work prompted a 70-year-old man to seek care and he has been subsequently diagnosed with chronic stable angina. The nurse should recognize what guiding principle in the treatment of this client's angina? 1) The client's angina may necessitate the use of a calcium channel blocker. 2) The client indicates a need for daily low-molecular weight heparin therapy 3) The client would benefit from a weekly intravenous dose of a beta blocker. 4) The client will likely have a trial of antiplatelet drugs before being prescribed nitrates.

Correct response: The client's angina may necessitate the use of a calcium channel blocker. Explanation: Calcium channel blockers are used in chronic stable angina when the client cannot tolerate beta blockers, or if the symptoms are not adequately controlled while on this therapy. Regularly scheduled beta blockers are not administered intravenously. Low molecular weight heparin is not typically used in the treatment of stable angina, and antiplatelet medications do not need to precede the use of nitrates.

The nurse is preparing to administer sublingual nitroglycerin to a client for the first time. What effect might the client experience right after administration? 1) Throbbing headache or dizziness 2) Drowsiness or blurred vision 3) Tinnitus or diplopia. 4) Nervousness or paresthesia

Correct response: Throbbing headache or dizziness Explanation: Headache and dizziness commonly occur at the start of nitroglycerin therapy. When administering nitroglycerin, the nurse must use caution to avoid self-contamination, especially with the topical paste formulation because the nurse can experience the same symptoms. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not occur as a result of nitroglycerin therapy.

The chest pain and pressure a client experiences during an anginal attack is caused by which of the following? 1) decreased oxygen supply to the heart. 2) vasodilation of the arteries around the heart. 3) increased oxygen supply to the heart. 4) decreased workload on the heart.

Correct response: decreased oxygen supply to the heart. Explanation: Chest pain and pressure during an anginal attack are the result of decreased oxygen supply to the heart. Vasodilation would allow more oxygen to the heart and a decreased workload would be oxygen promoting to the heart.

The client has been started on nitroglycerin ointment for angina. The nurse identifies that the nitroglycerin ointment has been effective if the client reports: 1) that he gets a headache each time the ointment is applied. 2) minimal episodes of angina. 3) dizziness after each application. 4) no episodes of angina since ointment was initiated.

Correct response: no episodes of angina since ointment was initiated. Explanation: Topical nitroglycerin is used to manage angina. The treatment is effective if the client reports no episodes of angina. Headache and dizziness are adverse effects of the medication.