CH 22-23 Review questions
Your patient has been switched from oral nitroglycerin capsules to a transdermal form. What are the priorities for patient teaching regarding transdermal nitroglycerin therapy?
. Specific instructions concerning the ways in which the two dosage forms vary are important because of the differences between the two. Once the patient switches to the transdermal system, the following points must be emphasized: · Sites of application must be rotated to prevent skin irritation, and the skin must be washed when the patch is removed so as to remove medication residue. · The patch needs to be applied to clean, dry, and hairless skin. · Never apply a patch on irritated or open skin or into skin folds. · The old patch must not be left on when applying the new patch. · If the transdermal patch becomes loose, the patient needs to remove it and gently remove the residue with lukewarm soap and water, pat the area dry, and place another patch in another area. · The prescriber may order the removal of the patch for an 8-hour period on specific days or at specific times to help decrease or prevent drug tolerance. · The patch should not be cut because doing so may affect the dose. · The used patches need to be disposed of carefully. Follow the manufacturer's guidelines. Used patches may be toxic to children and pets. · Emphasize the same instructions as those for nitrate drugs with regard to avoiding alcohol, hot temperatures, emotional stress, smoking, and excessive physical activity. Last, the patient needs to be aware that the transdermal patch is intended to prevent angina episodes; it is not intended to stop angina once it has begun
Which statement by the patient reflects the need for additional patient education about the calcium channel blocker diltiazem (Cardizem)? a. "I can take this drug to stop an attack of angina." b. "I understand that food and antacids alter the absorption of this oral drug." c. "When the long-acting forms are taken, the drug cannot be crushed." d. "This drug may cause my blood pressure to drop, so I need to be careful when getting up."
A Rationale: Diltiazem is a CCB that is used for chronic stable angina. Therefore it helps prevent anginas attacks but will not stop it if one occurs.
When giving antihypertensive drugs, the nurse will consider giving the first dose at bedtime for which class of drugs? a. Alpha blockers such as doxazosin (Cardura) b. Diuretics such as furosemide (Lasix) c. ACE inhibitors such as captopril (Capoten) d. Vasodilators such as hydralazine (Apresoline)
A Rationale: Most commonly used Alpha blocker. Adrenergic drugs most common adverse effect is orthostatic hypotension and first dose syncope. To prevent syncope, the first dose is given at bedtime.
The nurse is reviewing drug interactions with a male patient who has a prescription for isosorbide dinitrate (Isordil) as treatment for angina symptoms. Which substances listed below could potentially result in a drug interaction? (Select all that apply.) a. A glass of wine b. Thyroid replacement hormone c. Tadalafil (Cialis), an erectile dysfunction drug d. Metformin (Glucophage), an antidiabetic drug e. Carvedilol (Coreg), a beta blocker
A, C, E Rationale: C is a contraindication when used with Nitrates. Alcohol and Beta blockers can add hypotensive effects with used in combination with nitrates.
When a patient is being taught about the potential adverse effects of an ACE inhibitor, which of these effects should the nurse mention as possibly occurring when this drug is taken to treat hypertension? (Select all that apply.) a. Fatigue b. Nausea c. Dry, nonproductive cough d. Diarrhea e. Dizziness
A, C, E Rationale: Dry cough is number one adverse effect for ACE inhibitors. Fatigue and dizziness should also be taken into consideration when dealing with hypertension.
While assessing a patient with angina who is to start beta blocker therapy, the nurse is aware that the presence of which condition may be a problem if these drugs are used? (Select all that apply.) a. Diabetes mellitus b. Essential tremors c. Exertional angina d. Asthma e. Hypertension
A, D Rationale: A; Beta blockers mask hyperglycemia induced tachycardia, you will not see tachycardia in patients taking a beta blocker due to its MOA. D; any level of beta 2 blocking can promote bronchoconstriction.
A 68-year-old male patient has been taking the nitrate isosorbide dinitrate (Isordil) for 2 years for angina. He recently has been experiencing erectile dysfunction and wants a prescription for sildenafil (Viagra). Which response would the nurse most likely hear from the prescriber? a. "He will have to be switched to isosorbide mononitrate if he wants to take sildenafil." b. "Taking sildenafil with the nitrate may result in severe hypotension, so a contraindication exists." c. "I'll write a prescription, but if he uses it, he needs to stop taking the isosorbide for one dose." d. "These drugs are compatible with each other, and so I'll write a prescription."
B Rationale: All erectile dysfunction drugs are a contraindication in nitroglycerin drugs.
A 46-year-old man started antihypertensive drug therapy 3 months earlier and is in the office for a follow-up visit. While the nurse is taking his blood pressure, he informs the nurse that he has had some problems with sexual intercourse. Which is the most appropriate response by the nurse? a. "Not to worry. Eventually, tolerance will develop." b. "The physician can work with you on changing the dose and/or drugs." c. "Sexual dysfunction happens with this therapy, and you will learn to accept it." d. "This is an unusual occurrence, but it is important to stay on your medications.""
B Rationale: Sexual dysfunction is a common adverse effect. Other Antihypertension drugs could be used such as ARBs. ARBs block vasoconstriction which allow for dilation, they also block aldosterone (steroid) which helps lower BP.
The nurse is administering antihypertensive drugs to older adult patients. The nurse knows that which adverse effect is of most concern for these patients? a. Dry mouth b. Hypotension c. Restlessness d. Constipation
B Rationale: There is a high incidence of orthostatic hypotension (aka postural hypotension), it is a sudden drop in blood pressure during position changes in patients taking alpha blockers.
A patient has a new prescription for an ACE inhibitor. During a review of the patient's list of current medications, which would cause concern for a possible interaction with this new prescription? (Select all that apply.) a. A benzodiazepine taken as needed for allergies b. A potassium supplement taken daily c. An oral anticoagulant taken daily d. An opioid used for occasional severe pain e. An NSAID taken as needed for headaches
B, E Rationale: ACE inhibitors can promote hyperkalemia by reabsorbing potassium in the kidneys, taking a potassium supplement can increase potassium levels even higher. NSAIDs can reduce the antihypertensive effects that ACE inhibitors have.
A nurse with adequate knowledge about the administration of intravenous nitroglycerin will recognize that which statement is correct? a. The intravenous form is given by IV push injection. b. Because the intravenous forms are short-lived, the dosing must be every 2 hours. c. Intravenous nitroglycerin must be protected from exposure to light through use of special tubing d. Intravenous nitroglycerin can be given via gravity drip infusions.
C Rationale: Nitroglycerin must be kept air tight and UV protected in order to keep the medication active. Nitroglycerin can be given by metered IV drip, never IV push, this prevents hypotension.
A patient has a new prescription for transdermal nitroglycerin patches. The nurse teaches the patient that these patches are most appropriately used for which reason? a. To relieve exertional angina b. To prevent palpitations c. To prevent the occurrence of angina d. To stop an episode of angina
C Rationale: The transdermal patch is a long acting form of nitrate. It bypasses the liver and first dose effect and allows for slow consistent delivery of nitroglycerin for 12hrs.
The nurse is assessing a patient who will be starting antihypertensive therapy with an ACE inhibitor. Which condition, if present in the patient, would be a reason for cautious use? a. Asthma b. Rheumatoid arthritis c. Hyperthyroidism d. Renal insufficiency
D Rationale: ACE inhibitors reduce the glomerular filtration pressure, combined with renal insufficiency can cause acute renal failure.
A patient with angina has been given a prescription for a calcium channel blocker. The nurse knows that this class of drugs is used to treat which type of angina? a. Effort b. Unstable c. Crescendo d. Vasospastic
D Rationale: Vasospastic angina results from spasms in the layer of smooth muscle that surrounds coronary arteries. CCB are the best therapeutic drug for this.
Mrs. A. has been shoveling snow all morning. As you work on the snow in your yard, you see her suddenly sit down in her driveway. When you go over to check on her, she says that she has nitroglycerin tablets in her jacket pocket but she forgot how to take them. What is your priority action at this time?
Mrs. A. did the right thing by stopping her activity, but she needs to take the nitroglycerin immediately. The priority is relieving her chest pain, if possible, and accessing emergency assistance if needed. After verifying that the tablets are indeed sublingual nitroglycerin, she needs to place one tablet under her tongue and allow it to dissolve without swallowing it. You will stay with her and keep her calm and warm. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes after 1 dose, the patient (or family member) needs to call 911 immediately. Mrs. A. can take one more tablet while awaiting emergency care, and a third tablet 5 minutes later, but no more than three tablets in total. These guidelines reflect the fact that angina pain that does not respond to nitroglycerin may indicate a myocardial infarction. The sublingual dose will be placed under the tongue, and the patient needs to avoid swallowing until the tablet is dissolved; the patient should not eat or drink until the drug has completely dissolved. If the chest pain resolves, assist her carefully into her home; keep in mind that she may experience orthostatic blood pressure changes and may feel dizzy. It is important to get her into a warm environment as soon as possible. Make sure she is not left alone.
A 79-year-old woman has been admitted to the emergency department after experiencing severe headaches and "feeling faint." Upon admission, her blood pressure is measured as 286/190. A sodium nitroprusside infusion is started, and the nurse is monitoring the patient closely. After 8 minutes of infusion, the nurse notes that the patient's blood pressure suddenly drops to 100/60. What is the nurse's priority action at this time?
The main symptom of sodium nitroprusside overdose or toxicity is excessive hypotension. If it occurs while the patient is receiving this drug, the priority action is to discontinue the infusion. Doing this has an immediate effect because the drug is metabolized very rapidly (half-life of 2 minutes, duration 1 to 10 minutes). Treatment for the hypotension is supportive and symptomatic; if necessary, pressor drugs can be infused to raise blood pressure quickly.
During a follow-up appointment, a 58-year-old man is pleased to hear that his blood pressure is 118/64. He says, "I've been hoping to hear this good news! Now I can stop taking these pills, right?" What is the nurse's best answer?
The nurse should tell the patient that one reading of a good blood pressure result will not be grounds for discontinuing the blood pressure medication. The patient must manage hypertension by both pharmacologic and nonpharmacologic means. In addition to medications, the patient should modify his diet by reducing sodium and increasing fiber intake, exercising regularly, and trying to reduce the amount of stress in life. The nurse should remind the patient that hypertension increases the risk for cardiovascular injury, and he will have to be monitored for evidence of controlled blood pressure as well as for potential complications of treatment for the rest of his life. In addition, he must also be monitored constantly for the development of end-organ damage (i.e., checking renal function, examination of the fundus of the eye). Of course, the prescriber must be notified immediately. The nurse must monitor the patient closely, especially pulse, blood pressure, level of consciousness, and heart rhythm, until the drug's effects subside.