Antianginal PREPU

Beta-adrenergic blocking agents decrease the oxygen demands of the heart by what mechanism?

Increasing cardiac output, thereby increasing the oxygen supplied to the heart Rationale:

A patient is to take nifedipine (Adalat) 10 mg PO tid. How many milligrams will he take per dose?

10 mg Rationale: The patient will take 10 mg of nifedipine three times each day, for a total of 30 mg in each 24-hour period.

Your 54-year-old client has been prescribed sublingual nitroglycerin. After you have finished teaching him about the medication, what statement could he make to suggest that he understands proper self-administration?

"I can take up to three tablets at five-minute intervals." Rationale: Clients may take up to three doses of sublingual nitroglycerin at five-minute intervals to relieve anginal chest pain. They should take as few doses as necessary to relieve pain. Administration should begin at the first sign of pain.

Beta blockers decrease myocardial oxygen demand by increasing the heart rate and decreasing cardiac contraction.

False Rationale: Beta blockers prevent the activation of sympathetic receptors, which normally would increase the heart rate, increase blood pressure, increase cardiac contraction, and increase the myocardial oxygen demand. Beta blockers block these actions.

Mr. Lang, a 52-year-old man who experienced a myocardial infarction, has a physician's order for discharge. Part of the discharge teaching includes prior administration of nitroglycerin for chest pain. Which statement by the patient indicates that he understands the teaching provided?

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

A patient who uses sublingual nitroglycerin tells the nurse that when he puts it under his tongue, he feels a fizzing sensation. Which response by the nurse would be most appropriate?

"That means that the drug is still potent and working." Rationale: Fizzing indicates potency. Fizzing indicates potency, not irritation. Fizzing indicates potency, not deterioration. Fizzing indicates potency.

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

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

You are caring for a 59-year-old client who has been prescribed nitroglycerin to control angina. Which of the following adverse effects might you observe in this patient?

Hypotension Rationale: Adverse effects of nitroglycerin include hypotension, dizziness, lightheadedness, palpitations, and headache.

A patient is experiencing chest pain and administers her nitroglycerine sublingually. When will the patient expect to notice relief of her chest pain?

1-3 minutes Rationale: When given sublingually, nitroglycerin is absorbed directly into the systemic circulation and acts within 1-3 minutes. If the medication has not produced an effect in 5 minutes, it should be repeated. The nitroglycerine tablets have an onset of action of 1-3 minutes, not 5-60 minutes.

A patient has been prescribed diltiazem 360 mg/d PO in four divided doses. What amount of medication will the patient take in each dose?

90 mg Rationale: The patient will take 90 mg per dose. (360 mg/d ÷ 4 dose/d = 90 mg/dose.)

Your current patient, an overweight, 61-year-old man with a history of diabetes mellitus, is status post-MI 1 month and has returned for his cardiology follow-up. Included with his dietary changes, the cardiologist recommended which of the following nonpharmacological lifestyle changes to reduce microvascular changes?

Glucose control Rationale:

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 Rationale: 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.

A patient has substernal chest pain that radiates to the neck. The pain lasts 5 minutes and then subsides with relaxation. What is the cause of the chest pain?

Angina pectoris Rationale: Classic angina pain related to angina pectoris is substernal chest pain that can radiate to the jaw. Chest pain that lasts longer than 5 minutes is not associated with angina but is associated with myocardial infarction. Hypertension is usually a condition in which the patient is pain free. Intermittent claudication is not associated with chest pain.

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 of the following actions should the nurse do first when he complains of chest pain?

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

Ms. Quinn is admitted to the surgical intensive care unit after open heart surgery. The physician 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 Rationale: For a patient 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 patient'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 chest pain and pressure a client experiences during an anginal attack is caused by which of the following?

Decreased oxygen supply to the heart Rationale: Chest pain and pressures during an anginal attack is the result of decreased oxygen supply to the heart.

A patient receiving amlodipine for angina is complaining of dizziness. Which of the following interventions should the nurse implement to help alleviate the condition?

Instruct the patient to lie down. Rationale: Dizziness is a common central nervous adverse effect seen with calcium channel use. The nurse should instruct the patient to lie down until 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 practitioner. Increasing the fluid consumption will also not help in alleviating dizziness.

A group of students are reviewing the various antianginal agents. The students demonstrate a need for additional review when they identify which of the following as a beta blocker?

Isosorbide Rationale: Isosorbide is a nitrate. Metoprolol is a beta blocker. Nadolol is a beta blocker. Propranolol is a beta blocker.

Which of the following would a nurse identify as a nitrate?

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

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 of the following as a beta-blocker antianginal agent?

Nadolol Rationale: 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.

For relief of acute angina and for prophylaxis before events that cause acute angina, what is the primary drug of choice?

Nitroglycerin Rationale: For relief of acute angina and for prophylaxis before events that cause acute angina, nitroglycerin (sublingual tablets or translingual spray) is usually the primary drug of choice.

Ms. Catril is prescribed sublingual nitroglycerin by her physician for the treatment of stable angina. She contacts the physician office and states that she feels light-headed after taking the medication for an acute episode of chest pain. Based on your knowledge of nitroglycerin, what is the pathophysiology behind the patient having light-headedness?

Nitroglycerin causes relaxation of the arteries and veins, resulting in blood pooling in the extremities and the blood pressure dropping. Rationale: Nitroglycerin relaxes vascular smooth muscle and dilates both arterial and venous vessels. Dilation of veins is more predominant than dilation of arteries, resulting in peripheral pooling of blood and decreased preload. Blood pressure will decrease as a result of venous dilation. Reflex tachycardia may follow the drop in blood pressure.

The client is experiencing an acute onset of angina. The nurse would administer which of the following medications?

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

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

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

The use of nitrates should be avoided in clients taking which of the following medications? (Choose one)

Sildenafil (Viagra) Rationale: Patients taking phosphodiesterase inhibitors (erectile dysfunction drugs) should not use nitrates. Sildenafil is a phosphodiesterase inhibitor used to treat erectile dysfunction.

Which of the following should the nurse tell the client about storage of oral nitroglycerin products? Select all that apply:

Store oral nitroglycerin in the original container. Store oral nitroglycerin with the container lid tightly sealed. Store oral nitroglycerin away from light exposure. Rationale: The proper storage of oral nitroglycerin includes keeping tablets and capsules in their original container, never mixing oral nitroglycerin with other drugs in a container, never storing oral nitroglycerin in a plastic container, and always replace the container tightly and as soon as the drug is removed.

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. Rationale: 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 patient's angina?

The patient's angina may necessitate the use of a calcium channel blocker. Rationale: Calcium channel blockers are used in chronic stable angina when the patient 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.

Angina pectoris occurs when the myocardial demand for oxygen exceeds that which can be supplied.

True

Nitrates cause vasodilation and decrease venous return and arterial resistance.

True

You are caring for a client who takes sublingual nitroglycerin. This version of the drug typically begins acting within

one to three minutes. Rationale: Sublingual nitroglycerin acts within one to three minutes and lasts thirty minutes to an hour.

Which of the following is true of calcium channel blockers? (Select all that apply)

• Calcium channel blockers slow the conduction velocity of the cardiac impulse. • Calcium channel blockers depress myocardial contractility. • Calcium channel blockers dilate coronary arteries and arterioles. Rationale: Calcium channel blockers slow the conduction velocity of the cardiac impulse, depress myocardial contractility, and dilate coronary arteries and arterioles.

Your patient has been prescribed a beta-adrenergic blocker to help control angina. What effect might the patient experience as a result of the drug therapy?

Decreased cardiac output Rationale: Beta-adrenergic blockers reduce heart rate, cardiac output, and blood pressure. This reduces the heart's oxygen demand, which in turn decreases angina.

Which of the following indicates that a client understands how to use sublingual nitroglycerin?

"I should feel a fizzing or burning sensation." Rationale: A fizzing or burning sensation indicates that the tablet is potent. The client should place the tablet under his tongue and away from any lesions or abrasions. If needed, the client can take a sip of water to moisten the mucous membranes so that the tablet will dissolve quickly. After placing the tablet under the tongue, the client should close his mouth and wait until the table has dissolved.

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 which of the following statements?

"I will take three pills every 15 minutes until the pain subsides." Rationale: 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 prescribed sublingual nitroglycerin for treatment of angina. The nurse instructs the client to do what if chest pain occurs?

"If the chest pain doesn't go away after three tablets are given 5 minutes apart, call 911." Rationale: The client should take 1 pill as soon as chest pain occurs. Burning indicates the medication is active, and it often causes a headache because of the vasodilation. The pills are only good for approximately 6 months. If chest pain is not relieved after the first pill, the client may take the second pill 5 minutes after the first and then may take a third pill 5 minutes later. At this point, if the client still has chest pain, the client should call 911.

A patient 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 (Viagra).

"Nitroglycerine and Viagra cause a severe decrease in blood pressure." Rationale: Nitrates and phosphodiesterase enzyme type 5 inhibitors decrease blood pressure, and the combined effect can produce profound, life-threatening hypotension.

A patient is diagnosed with angina pectoris. Which of the following would the nurse include when explaining this condition to the patient?

"The heart muscle isn't getting enough oxygen." Rationale: 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.

A client prescribed nitroglycerin reports to the nurse that he is having headaches. How should the nurse best respond?

"You may experience headaches as an adverse reaction to nitroglycerin." Rationale: An adverse reaction of nitroglycerin includes headaches. The client should not reduce or stop taking the medication. Lying down will not prevent headaches associated with taking nitroglycerin.

Ms. Ross has used long-acting nitroglycerin pills, which the physician prescribed at a dosage of twice per day, for the last 6 months. She contacts the physician office and states that the medication is not working as well as when she started taking the medication. What would be the most appropriate nursing action?

Ask Ms. Ross how she is currently taking the medication so that you can determine whether she is taking the medication properly. Rationale: Answers to the nurse's inquiries would guide the next step in patient education. The patient developed a tolerance to the medication, but the reason for this is unclear without obtaining additional information from the patient. Tolerance to the vascular and antianginal effects may develop. Tolerance is minimized by starting with as small a dose as possible and removing the nitroglycerin (paste or transdermal patches) from the patient for 10 to 12 hours a day. The sublingual and translingual spray forms of the drug are the least likely to produce tolerance. The transmucosal form also appears to produce minimal tolerance.

The client is taking a calcium channel blocker. Which of the following assessment findings would the nurse expect?

Bradycardia Rationale: 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 patient with a diagnosis of asthma is prescribed a beta blocker. What should the patient be assessed for?

Bronchospasm Rationale: Patients with asthma should be observed for bronchospasm from blockage of beta2 receptors in the lung. The patient will not experience hyperglycemia, pleural effusion, or pneumonia.

A client with asthma has been prescribed a beta-blocker for management of angina. For what adverse reaction should you observe this client?

Bronchospasm Rationale: When taking beta blockers, patients with asthma should be observed for bronchospasm from blockage of beta2 receptors in the lung.

When caring for a patient with angina, the nurse instructs the patient to place the nitroglycerin tablet between the cheek and the gums. Which of the following routes of administration is the nurse referring to?

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

The client is experiencing chest pain and has taken three sublingual nitrogylcerin tablets, but the pain remains. What should the client do next?

Call 911. Rationale: Nitroglycerin should be administered every five minutes, times three doses. If the pain persists, 911 or the emergency system should be activated. The client should not take additional medication.

A 62-year-old woman with a history of MI is brought by the squad to your trauma center after an MVA in which she suffered extensive facial and oral trauma. She uses sublingual nitroglycerin in the management of her angina. What effect, if any, would this latest development have in her angina management?

Change nitroglycerin route to transdermal Rationale: Oral trauma would be expected to affect sublingual nitroglycerin circulation. Changing the route to transdermal will provide an effective route unaffected by the accident's trauma. Discontinuing the nitroglycerin will only endanger the patient; increasing the sublingual dose doesn't change the potential for uneven absorption due to tissue trauma.

After teaching a group of students about angina, the instructor determines that the teaching was successful when the students describe stable angina as which of the following?

Chest pain that is relieved by rest Rationale:

A client is diagnosed with atherosclerosis. What would the nurse say is the most likely cause of his angina?

Decreased oxygenation to the myocardium Rationale: Angina pectoris results from deficit in myocardial oxygen supply (myocardial ischemia) in relation to myocardial oxygen demand, most often caused by atherosclerotic plaque in the coronary arteries.

When describing the possible adverse effects associated with nitroglycerin, which of the following would the nurse include?

Dizziness Rationale: Dizziness is a possible adverse effect. Hypotension is a possible adverse effect. Flushing is a possible adverse effect. Constipation is not associated with nitroglycerin.

A patient arrives at the community health care center complaining of chest pain and is diagnosed with angina pectoris. Which of the following drugs is administered for treating angina?

Nicardipine Rationale:

A male client asks the nurse why the doctor has added combined aspirin, antilipemics, and antihypertensives to his medication regimen when he feels fine and hasn't experienced an anginal episode in a year. The nurse explains that this combination of drugs is given for what reason?

Prevents progression of myocardial ischemia to MI Rationale: Aspirin, antilipemics, and antihypertensives are used in conjunction with antianginal drugs to prevent progression of myocardial ischemia to MI.

A patient arrives at the community healthcare center complaining of chest pain. After diagnosis, the healthcare provider has prescribed amlodipine for the patient's condition. Which of the following conditions should the nurse identify as an indication for amlodipine therapy?

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

A patient is prescribed ranolazine (Ranexa) to treat chronic angina. Which of the following electrocardiogram changes will contraindicate the use of ranolazine?

QT prolongation Rationale:

A patient is being discharged after being treated with nitroglycerin for angina. Which of the following instructions should the nurse include in the teaching plan for the patient?

Recap the container tightly after taking the capsules. Rationale: The nurse should instruct the patient to recap the container tightly after taking the nitroglycerin capsule. This is to ensure that the potency of nitroglycerin is not lost on exposure to air. Nitroglycerin should be stored in a dark container and protected from direct light exposure. The nurse should instruct the patient to never store nitroglycerin under bright sunlight or in a plastic container. Nitroglycerin deteriorates when stored in plastic containers and on exposure to air and light. The nurse should instruct the patient not to store nitroglycerin along with other drugs, as it loses its potency.

A patient calls the clinic and reports that he is having chest pain. The patient states that "I'm scared that I am going to die and I've been pacing up and down my driveway." After calming the patient, the initial instruction by the nurse would be to

have the patient go into his house and sit or lie down. Rationale: The nurse should instruct the patient to sit or lie down before taking nitroglycerin to prevent dizziness or fainting. The nurse should then inform the patient to place the tablet under his tongue and that he can take another tablet in 5 minutes and again in 10 minutes if the pain has not subsided. However, if the pain still has not subsided, the patient should call 911 because the patient may be experiencing a myocardial infarction. The nurse may stay on the phone with the patient while he is taking the medication if the patient is overly anxious. The nurse may ask the patient after the medication administration to check his pulse to help determine the patient's level of anxiety and cardiac function.

Which of the following anti-anginal medications are indicated for the prevention of angina pectoris? Select all that apply:

• Isosorbide dinitrate (Isordil) • Isosorbide mononitrate (Monoket) • Topical nitroglycerin • Oral nitroglycerin • Transdermal nitroglycerin Rationale: All nitroglycerin dosages forms are indicated for the prevention of angina pectoris.

Anti-anginal drugs are used in the treatment of cardiac disease for which of the following? Select all that apply.

• Relieve the pain of acute anginal attacks. • Prevent angina attacks. • Treatment chronic stable angina pectoris. Rationale: Anti-anginal drugs are used to relieve pain of acute anginal attacks, prevent angina attacks, and treat chronic stable angina pectoris. Antianginals have no effect on HDL or triglycerides.