pharm prepu 28: Drug Therapy for Coronary Heart Disease

A client with chronic angina is prescribed ranolazine, a piperazine acetamide agent. Which information would the nurse include when teaching the client about this medication?

"Avoid grapefruit juice when taking this medication." Explanation: Ranolazine is a drug to treat chronic angina. It may inhibit late sodium influx but does prolong the QT interval without decreasing the heart rate or blood pressure. This medication will react to the chemicals in grapefruit juice. Because of this, the client should be instructed to avoid grapefruit juice while taking this medication. Dizziness and nausea are common adverse effects and do not need to be reported to the health care provider. Diarrhea is not an adverse effect of the medication; however, the client should be instructed to take the medication as prescribed and not to skip any doses.

A nurse is giving discharge instructions to a client receiving nitroglycerin for angina. The nurse recognizes the client needs additional information when the client makes what statement?

"I will take a pill every 15 minutes until the pain subsides." Explanation: When experiencing angina, the client may take one pill every five minutes times three doses. Nitroglycerin needs to be stored in its original dark container and may cause a headache. It is important the client lie down prior to taking nitroglycerin because it may cause hypotension.

A client is diagnosed with angina pectoris. What would the nurse include when explaining this condition to the client?

"The heart muscle isn't getting enough oxygen." Explanation: The body's response to a lack of oxygen in the heart muscle is pain, which is called angina. The narrowing of arteries due to fatty deposits is called atherosclerosis. Although left ventricular enlargement may occur with coronary artery disease, it is not the underlying mechanism involved with angina. Damage to the heart muscle in response to ischemia is called a myocardial infarction.

The nurse is caring for a client prescribed ranolazine. The client asks how this drug is different from the beta-blocker that the client was previously taking. What is the nurse's best response?

"This drug does not slow your heart rate." Explanation: The newest drug approved for the treatment of angina is a piperazine acetamide agent called ranolazine. The mechanism of action of this drug is not understood. It prolongs QT intervals, does not slow heart rate or blood pressure, but decreases myocardial oxygen demand.

A client taking amlodipine (Norvasc) is having chest pain and is ordered sublingual nitroglycerin. The nurse evaluates the client for:

Hypotension Explanation: When combined, nitrates and calcium channel blockers can cause symptomatic orthostatic hypotension.

The nurse is caring for a client who has been prescribed nitroglycerin sublingually. When providing client education, the nurse should tell the client to expect relief of chest pain within what period of time?

1 to 3 minutes Explanation: Sublingual nitroglycerin acts within 1 to 3 minutes. The medication does not take 5 or more minutes to act. The primary health care provider should be notified if the medication does not work in the expected time.

A nurse is teaching a client who is diagnosed with angina how to properly administer transdermal nitroglycerin. The nurse instructs the client to apply the patch for how long?

10-12 hours Explanation: The transdermal nitroglycerin patch should be applied every day for 10 to -12 hours. If the patch is applied for a shorter time, the therapeutic dosage may not be delivered. Applying the patch for a longer time will result in the development of tolerance to the antianginal effects. Applying the patch in the morning and leaving it on for 10 to -12 hours, followed by a patch-free period of 10 to -12 hours, delays the development of tolerance.

A 75-year-old client is being treated for type 2 diabetes, hypertension, gout, angina, coronary artery disease, and peptic ulcer disease. The nurse is concerned because the client is taking a traditional antianginal drug in combination with seven other medications. The nurse understands that what could be the consequence?

A greater incidence of adverse drug effects Explanation: Traditional antianginal drugs that act via hemodynamic mechanisms (e.g., beta-blockers, calcium antagonists, nitrates) can pose a problem in older adults because of the associated higher risk of drug interactions and greater incidence of adverse drug effects.

The nurse knows that nitroglycerin can be administered in what ways? (Select all that apply.) IV Transmucosal Transdermal

IV Transmucosal Transdermal Explanation: Nitroglycerin is administered in transdermal, and IV preparations. Nitroglycerin is not administered intrathecally.

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?

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?

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.

Which of the following if administered with nitrates can cause severe hypotension and possible cardiovascular collapse? Select all that apply: Alcohol Phosphodiesterase inhibitors

Alcohol Phosphodiesterase inhibitors Explanation: Alcohol and phosphodiesterase inhibitors when administer with nitrates can cause severe hypotension and possible cardiovascular collapse.

Prior to the administration of nitroglycerin, the nurse would assess which of the following?

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.

A client diagnosed with angina has been prescribed nifedipine 15 mg PO three times a day. The client has received the first two doses of the medication and reports dizziness. What is the nurse's best action?

Assess the client's blood pressure. Explanation: If a client reports dizziness after beginning treatment with a calcium channel blocker, hypotension is a likely cause. The nurse should obtain objective data by assessing the client's blood pressure before taking further action. The nurse should not independently withhold the drug. The nurse should assess the client before providing reassurance. There may be no need to report this to the provider if it is transient.

The client has been started on nitroglycerin ointment for angina. The nurse identifies that the nitroglycerin ointment has been effective if the client reports:

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.

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?

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 client is at risk for silent ischemia after experiencing a transmural MI. What would the nurse expect the health care provider to order?

Beta-blockers Explanation: Beta-blockers are more effective than nitrates or calcium channel blockers in decreasing the likelihood of silent ischemia and improving the mortality rate after transmural MI.

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?

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.

When caring for a client with angina, the nurse instructs the client to place the nitroglycerin tablet between the cheek and the gums. Which form of nitroglycerin is the nurse administering?

Buccal Explanation: The nurse is administering the buccal route of administration. When administering buccal nitroglycerin, the nurse should instruct the client to place the tablet between the cheek and gums or the lips and gums above the incisors. The nurse should instruct the client to allow the tablet to dissolve and not to chew the tablet. Nitrates can also be given by the sublingual, transdermal, and translingual routes. When administering nitroglycerin sublingually, it should be placed under the tongue. In the transdermal route, the patch is applied directly onto the skin. In the translingual route, a spray is directed under or onto the tongue.

A current client, an overweight 61-year-old with a history of diabetes mellitus, is status post-MI 1 month and has returned for a cardiology follow-up. Along with dietary changes, the nurse will discuss which nonpharmacologic lifestyle modification to reduce microvascular changes?

Glucose control Explanation: Glucose and blood pressure control can reduce the microvascular changes associated with diabetes mellitus. Increased cholesterol consumption, nicotine use, and maintaining overweight status will contribute to continued coronary artery disease.

A client is prescribed verapamil as treatment for angina. Which information should the nurse point out in the teaching plan for this client? Select all that apply. Capsules may be opened and sprinkled on food. Tablet coverings can be expelled in the stool. Drug should be administered with a meal.

Capsules may be opened and sprinkled on food. Tablet coverings can be expelled in the stool. Drug should be administered with a meal. Verapamil frequently causes GI upset and should be administered with a meal. Capsules may be opened and sprinkled on food or mixed in liquids for clients who have difficulty swallowing. Sometimes the capsule coverings are expelled in the stool. Extended-release tablets should be swallowed whole.

Ms. Quinn is admitted to the surgical intensive care unit after open heart surgery. The health care provider prescribes IV nitroglycerin, according to a hospital protocol for titration of the drug. Which factor would be most important when determining increases or decreases in the dose?

Current blood pressure Explanation: For a client receiving IV nitroglycerin, the nurse must monitor the blood pressure and presence of continued chest pain while the IV therapy continues. If chest pain continues, the IV dose can be increased; however, due to the vasodilation effects of the drug, if the blood pressure drops below a certain point, the dose cannot be further increased. It is important to assess for alcohol intoxication if giving high doses for a prolonged period. A client's susceptibility to renal insufficiency and intracranial pressure is not likely to be affected by the IV therapy and therefore need not be monitored closely. The GI tract is also not likely to be affected by the IV therapy.

The nurse should instruct the client to take what action if nitroglycerin tablets taken sublingually are not effective in eliminating chest pain?

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 waste time by calling the primary health care provider or lying down. It would be unsafe to take more tablets.

The client is taking a calcium-channel blocker. What adverse effects might the client experience?

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

Clients suffering from frequent anginal attacks should be instructed to keep a record of each attack. What information should the client document in the record? Select all that apply. Date of attack Time of attack Drug used to relieve the acute pain Dose of drug use to relieve the acute pain

Date of attack Time of attack Drug used to relieve the acute pain Dose of drug use to relieve the acute pain Clients should keep a record of the frequency of acute anginal attacks including date, time of attack, drug and dose used to relieve the acute pain. The client should bring this record to each visit.

A client has been diagnosed with angina and has been prescribed sublingual nitroglycerin tablets to treat acute episodes. After using the medication several times over the past 3 weeks, the client states that they develop a headache shortly after each administration. What is the nurse's best action?

Describe why this adverse effect often occurs and discuss analgesia solutions. Explanation: Headache and dizziness may occur with sublingual nitroglycerin. These effects are usually temporary and dissipate with continued therapy. If headache is severe, clients may take aspirin or acetaminophen with the nitrate drug. They should not reduce drug dosage or take the drug less often to avoid headaches because loss of effectiveness may occur. Unless the headaches are severely debilitating, there is no time-dependent need to report this effect or advocate for a change in medication.

A male client does not respond to traditional treatment for his chronic angina. The health care provider orders ranolazine (Ranexa) and orders a baseline ECG prior to medication administration. Three months later, the health care provider orders a repeat ECG. For what reason is the provider monitoring the client?

Dose-dependent QT prolongation Explanation: Ranolazine (Ranexa) represents a new classification of antianginal medication, metabolic modulators, used in people with chronic angina. The drug is labeled for use in combination with amlodipine, beta-blockers, or nitrates. After oral administration, peak plasma concentrations are reached within 2 to 5 hours. The drug is rapidly and extensively metabolized in the liver. Because of a risk of dose-dependent QT prolongation on electrocardiogram, ranolazine is reserved for the treatment of clients with chronic angina who have not achieved a satisfactory antianginal response with traditional drugs.

A client receiving amlodipine for angina is now reporting dizziness. Which intervention should the nurse prioritize to help alleviate the condition?

Instruct the client to lie down. Explanation: Dizziness is a common central nervous system adverse effect seen with calcium channel blocker use. The nurse should instruct the client to lie down until the dizziness passes. Applying a cold cloth over the forehead will not relieve the dizziness. The dosage should not be reduced or altered unless instructed by the health care provider. Increasing the fluid consumption will also not help in alleviating dizziness.

Which would a nurse identify as a nitrate?

Isosorbide Explanation: Isosorbide is classified as a nitrate. Metoprolol is a beta-blocker. Amlodipine and nicardipine are calcium channel blockers.

What are the home care nurse's responsibilities in the care of clients who are receiving antianginal medications? (Select all that apply.) Monitoring the client's response to antianginal medications Teaching clients and caregivers how to use, store, and replace medications to ensure a constant supply Discussing circumstances for which the client should seek emergency care Assisting clients to modify factors that contribute to angina

Monitoring the client's response to antianginal medications Teaching clients and caregivers how to use, store, and replace medications to ensure a constant supply Discussing circumstances for which the client should seek emergency care Assisting clients to modify factors that contribute to angina The home care nurse's responsibilities may include monitoring the client's response to antianginal medications; teaching clients and caregivers how to use, store, and replace medications to ensure a constant supply; and discussing circumstances in which the client should seek emergency care. The client should also be instructed in factors that contribute to angina such as smoking and obesity.

After teaching a group of students about drugs used as antianginal agents, the instructor determines that the teaching was successful when the students identify which as a beta-blocker antianginal agent?

Nadolol Explanation: Nadolol is a beta-blocker used as an antianginal agent. Amlodipine and verapamil are calcium channel blocker antianginal agents. Ranolazine is classified as a piperazine acetamide.

A patient arrives at the community health care center reporting chest pain and is diagnosed with angina pectoris. Which drug is administered for treating angina?

Nicardipine Explanation: Nicardipine is the drug used in the treatment of angina. Nicardipine is a calcium channel blocker used as an anti-anginal drug. Isospin, papaverine, and cilostazol are peripheral vasodilating drugs used in the treatment of peripheral vascular diseases.

A client arrives at the urgent care center reporting chest pain and is diagnosed with angina pectoris. Which drug would the nurse expect to be prescribed?

Nicardipine Explanation: Nicardipine is the drug used in the treatment of angina. Nicardipine is a calcium channel blocker used as an antianginal drug. Hydralazine and minoxidil are vasodilators primarily used to treat hypertension. Nimodipine is a calcium channel blocker used to treat subarachnoid hemorrhage.

After teaching a group of nursing students about antianginal drugs, the instructor determines that the teaching was successful when the students correctly choose which drugs as a calcium channel blocker?

Nifedipine Explanation: Nifedipine is a calcium channel blocker used to treat angina. Minoxidil and hydralazine are peripheral vasodilators. Isosorbide is a nitrate.

A male client is having angina. As the nurse prepares to administer sublingual nitroglycerin, it is noted that the client's blood pressure is 82/54. What is the best action of the nurse?

Notify the health care provider. Explanation: The client is having angina and it must be addressed. If the blood pressure is less than 90 systolic, the nurse should not administer the medication and call the provider immediately.

A patient is using propranolol for treatment of angina. The nurse understands that this drug is administered by which route?

Oral Explanation: Propranolol is used orally as treatment for angina.

Clients who are taking nifedipine should be monitored for which of the following adverse effects?

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 nurse is assessing a client with angina who has received diltiazem. Which finding should the nurse prioritize and notify the health care provider for further instructions?

Pulse rate is 45 beats per minute Explanation: The nurse should withhold the drug and notify the health care provider when the client's pulse rate is 45 beats per minute. When calcium channel blockers are administered, there may be a fall in the pulse rate. When the pulse rate falls below 50 beats per minute, the nurse should notify the health care provider. When the systolic pressure falls below 90 mm Hg, the nurse should notify the primary health care provider. Weight gain, and not weight loss, occurs with the use of calcium channel blockers. The nurse should report weight gain. Lightheadedness is a common central nervous system adverse reaction occurring after taking the drug, and the nurse should instruct the client to lie down until the symptoms pass.

A nursing instructor overhears a group of nursing students comparing various drugs used for cardiac disorders. The instructor determines the previous class was successful when the students correctly determine antianginals provide which action(s)? Select all that apply. Relief of pain of acute anginal attacks Prevention of anginal attacks Treatment of chronic stable angina pectoris

Relief of pain of acute anginal attacks Prevention of anginal attacks Treatment of chronic stable angina pectoris Explanation: Antianginal drugs are used to relieve the pain of acute anginal attacks, prevent anginal attacks, and treat chronic stable angina pectoris. Antihyperlipidemics are used to correct elevated HDLs and triglycerides.

Antianginal drugs are most often used to manage what conditions? (Select all that apply.) Severe angina Severe hypertension Serious cardiac arrhythmias

Severe angina Severe hypertension Serious cardiac arrhythmias Explanation: Antianginal drugs have multiple cardiovascular effects and may be used alone or in combination with other cardiovascular drugs in clients with critical illness. They are probably used most often to manage severe angina, severe hypertension, or serious cardiac arrhythmias. They are not indicated for treatment of serious heart failure.

The nurse would avoid administering nitrates to clients using which medication?

Sildenafil Explanation: Clients taking phosphodiesterase inhibitors (erectile dysfunction drugs), such as sildenafil, should not use nitrates. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. Simvastatin is an HMG-CoA reductase inhibitor known as a statin used to lower cholesterol and triglycerides. Albuterol is a bronchodilator used in the treatment of asthma to open airways to the lungs.

The nurse is working with a client who is taking nadolol for angina. What action should the nurse perform to best address the likely adverse effects?

Spread out the client's activities to prevent fatigue or overexertion. Explanation: Nadolol is a beta-blocker that can cause a decreased tolerance to exercise because of the inability to experience the effects of the stress reaction. Dry mouth and constipation are often seen with anticholinergic drugs but not with beta-blockers. There is no need to have the client void because urinary function is rarely affected.

Which statement correctly distinguishes between the therapeutic effects of sublingual isosorbide and sublingual nitroglycerin?

Sublingual isosorbide has a slower onset and a longer duration of action than sublingual nitroglycerin. Explanation: Sublingual isosorbide has a slower onset and a longer duration of action than sublingual nitroglycerin. Because sublingual isosorbide does not relieve chest pain as rapidly as nitroglycerin, isosorbide is limited to treating acute angina in patients intolerant of or unresponsive to sublingual nitroglycerin. Although nitroglycerin may be used occasionally, with adequate monitoring during the early phases of acute MI, isosorbide should never be used, because of its greater sustained effects.

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?

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.

A 49-year-old client is admitted with uncontrolled chest pain. The client is currently taking nitroglycerin. The primary health care provider adds nifedipine to the client's regimen. The nurse should observe the client for what adverse effect?

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.

When prescribed for angina, how does oral nifedipine achieve a therapeutic effect?

inhibiting the influx of calcium through slow channels. Explanation: Nifedipine inhibits the influx of calcium entering through slow channels, producing vasodilation of the peripheral blood vessels and coronary arteries. None of the other options accurately describes the action of nifedipine.

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?

orthostatic hypotension Explanation: Underlying hypotension can be exacerbated by nitroglycerin, creating a risk for syncope or falls. GERD, depression, and Raynaud's syndrome do not complicate the use of nitrates for angina.

While teaching a patient about sublingual nitroglycerin, the nurse explains proper use and storage. When the patient asks whether the medication ever expires, the nurse should respond that it:

should be replaced every six months. Explanation: Sublingual nitroglycerin tablets should be replaced every 6 months because they become ineffective over time.

The nurse is preparing to administer sublingual nitroglycerin to a client for the first time. What effect might the client experience right after administration?

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.