Chapter 46- Antianginal Agents
What adverse reaction does the nurse anticipate if the 56-year-old patient takes his beta-blocker with clonidine? A) Hypertension B) Bradycardia C) Angina D) Syncope
Ans: A Feedback: A paradoxical hypertension occurs when clonidine is given with beta-blockers, and an increased rebound hypertension with clonidine withdrawal may also occur. It is best to avoid this combination. Bradycardia, angina, and syncope are not associated with this drug combination.
An asthmatic patient taking beta-blockers should be assessed by the nurse for what potential adverse reaction? A) Bronchospasm B) Hypoglycemia C) Pleural effusion D) Pneumonia
Ans: A Feedback: Bronchospasm can occur with beta blockade. The patient would not have to be observed for hypoglycemia, pleural effusion, or pneumonia.
The provider orders isosorbide dinitrate as oral maintenance drug to prevent angina. What dosage would the nurse administer without need to question the dose? A) 2.5 mg B) 80 mg C) 40 mg D) 5 mg
Ans: B Feedback: A maintenance oral dose of isosorbide dinitrate is 10 to 40 mg every 6 hours. Sublingual dose is 2.5 to 5 mg, sustained release is 40 to 80 mg, and the chewable tablet is 5 mg.
When providing patient education about nitroglycerin to the patient, what would the nurse include in the teaching plan about a nitroglycerin patch? A) "It only has to be administered once a week." B) "It is more effective than tablets in treating angina." C) "It has a longer duration of action." D) "It is faster acting than the tablets."
Ans: C Feedback: Transdermal nitroglycerin has a long 24-hour duration of action compared with the sublingual form that lasts 30 to 60 minutes or oral tablets that last 8 to 12 hours. Transdermal patches are neither more nor less effective, but rather it is the speed of onset and duration of action that differ.
A nurse is providing patient teaching to a patient who has been experiencing unstable angina. What will the nurse's explanation of this condition include? A) A coronary vessel has become completely occluded and is unable to deliver blood to your heart. B) The pain is caused by a spasm of a blood vessel, not just from the vessel narrowing. C) There is serious narrowing of a coronary artery that is causing a reduction in oxygen to the heart. D) Your body's response to a lack of oxygen in the heart muscle is pain.
Ans: C Feedback: Unstable angina is described as increased narrowing of coronary arteries with the heart experiencing episodes of ischemia even at rest. If a coronary vessel is completely occluded and unable to deliver blood to the cardiac muscle, a myocardial infarction has occurred. Prinzmetal's angina is an unusual form of angina caused by spasm of the blood vessel and not just by vessel narrowing. Although pain is the body's response to ischemia in the heart muscle, this description could encompass angina or a myocardial infarction and is not specific enough to explain the condition.
The nurse is caring for a patient diagnosed with human immunodeficiency virus (HIV) and newly diagnosed angina. What drug would the nurse question if ordered? A) Ranolazine (Ranexa) B) Nitroglycerin (generic) C) Propranolol D) Diltiazem
Ans: A Feedback: Drug-drug interactions can occur with ketoconazole, diltiazem, verapamil, macrolide antibiotics, and HIV protease inhibitors; these combinations should be avoided because ranolazine levels may become extremely high. The nurse should get a complete list of current medications and consult with the health care provider regarding drug interactions before administering the medication as ordered. Nitroglycerin, propranolol, and diltiazem have no contraindication with medications used to treat HIV.
The nurse is caring for a patient who takes nitroglycerin sublingually. When providing patient education, the nurse would tell the patient that she can expect relief of chest pain within what period of time? A) 1 to 3 minutes B) 5 to 10 minutes C) 15 to 20 minutes D) 30 to 60 minutes
Ans: A Feedback: Nitroglycerin acts within 1 to 3 minutes. Other options are incorrect.
A nurse is teaching the patient newly prescribed sublingual nitroglycerin how to take the medication. What will the nurse instruct the patient to do first? A) To check his radial pulse B) To place the tablet in the buccal cavity C) To take a sip of water D) To lie down for 15 minutes before administration
Ans: C Feedback: The nurse should instruct the patient to take a sip of water to moisten the mucous membranes so the tablet will dissolve quickly. The patient does not need to take his pulse or lie down before drug administration. For sublingual administration, the patient will place the tablet under his tongue and not in the buccal cavity (cheek area).
Which statement by the patient would lead the nurse to believe that he has understood the teaching provided regarding angina? A) "I will not exercise because it precipitates angina." B) "As long as I take the medicine, I need make no lifestyle change." C) "There is no correlation between my hypertension and angina." D) "Heavy meals and cigarette smoking can precipitate an angina attack."
Ans: D Feedback: Avoid stressful activities, especially in combination. For example, if you eat a big meal, do not drink coffee or alcoholic beverages with that meal. If you have just eaten a big meal, do not climb stairs; rest for a while. However, exercise is important and should not be eliminated, but managed in coordination with other activities. Smoking causes vasoconstriction that can result in angina attacks so lifestyle changes like reducing fat and calories in the diet, moderate exercise, reducing alcohol intake and avoiding smoking are all healthful choices. Hypertension does increase the risk of angina and coronary artery disease.
The nurse assesses patients receiving nifedipine (Adalat) for what adverse effects? A) Ascites B) Asthma C) Peripheral edema D) Tetany
Ans: C Feedback: Peripheral edema, heart block, bradycardia, and hypotension can occur with calcium-channel blockers. Asthma, ascites, and tetany are not associated with these drugs.
What drug would the nurse administer to the patient to control angina caused by atherosclerosis that would also slow the development of further plaque buildup on the arterial wall? A) Diltiazem (Cardizem) B) Propranolol (Inderal) C) Amyl Nitrates (generic) D) Isosorbide dinitrate (Isordil)
Ans: A Feedback: Diltiazem is a calcium channel blocker that is indicated to treat Prinzmetal's angina, chronic angina, effort-associated angina, and hypertension. Research has indicated these agents slow the development of atherosclerosis. Beta-blockers are indicated for long-term management of angina caused by atherosclerosis, but they do not slow the development of plaque deposits on the artery wall. Propranolol is a beta-blocker. Isosorbide dinitrate and amyl nitrate are nitrates and are indicated for relief acute anginal pain, but they are not used to prevent angina and have no effect on the progression of atherosclerosis.
The nurse is caring for a patient who is taking a sustained-release (SR) oral nitrate. How should the nurse instruct this patient to take the medication? A) With water B) Sublingually until absorbed C) With milk or milk products D) 1 hour after eating
Ans: A Feedback: Give SR forms with water, and caution the patient not to chew or crush them, because these preparations need to reach the gastrointestinal (GI) tract intact to avoid overdosage. They are not dissolved sublingually but swallowed whole. They are best taken on an empty stomach 1 hour before meals.
The nurse should instruct the patient to take what action if three nitroglycerin tablets taken sublingually are not effective in eliminating chest pain? A) To call 911 B) To call her health care provider C) To lie down after taking an aspirin D) To take more tablets until pain subsides
Ans: A Feedback: Instruct patient that a sublingual dose may be repeated in 5 minutes if relief is not felt, for a total of three doses, if pain persists, the patient or a family member should call 911 to ensure proper medical support if a myocardial infarction should occur. She should not waste time by calling the health care provider; she can lie down while waiting for the ambulance to arrive, she should not take more tablets.
The nurse is caring for a patient who takes metoprolol for angina. The patient asks how long it takes for the medicine to work. What is the nurse's best response? A) 15 minutes B) 30 minutes C) 1 hour D) 90 minutes
Ans: A Feedback: Oral metoprolol has an onset of action of 15 minutes. Other options are incorrect.
After the patient's anginal pain is relieved he says to the nurse, "That nitroglycerin works great. How does it do that?" What is the nurse's best response? A) "Nitroglycerin decreases the amount of oxygen needed by the heart to function." B) "Nitroglycerin makes the coronary arteries open much wider." C) "Nitroglycerin promotes growth of new, smaller arteries to supply oxygen to the heart." D) "Nitroglycerin decreases preload and afterload."
Ans: A Feedback: The main effect of nitrates seems to be related to the drop in blood pressure that occurs. The vasodilation causes blood to pool in veins and capillaries, decreasing preload, while the relaxation of the vessels decreases afterload. The combination of these effects greatly reduces the cardiac workload and the demand for oxygen, thus bringing the supply-and-demand ratio back into balance. Because coronary artery disease causes a stiffening and lack of responsiveness in the coronary arteries, the nitrates probably have very little effect on increasing blood flow through the coronary arteries, so it would be incorrect to say that the coronary arteries become much wider. Although both preload and afterload are reduced, this is an explanation that the patient would not understand, so it is inappropriate. Nitroglycerin does not promote growth of compensatory circulation.
The nurse is caring for a patient prescribed ranolazine. The patient asks why this drug is different from the beta-blocker that he was previously taking. What is the nurse's best response? A) "This drug does not slow your heart rate." B) "This drug increases myocardial oxygen demand." C) "This drug slows the QT intervals." D) "This maintains blood pressure with no hypotensive effects."
Ans: A Feedback: 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.
The nurse, caring for a patient taking a beta-blocker and a nitrate to treat angina, recognizes the need for careful monitoring as the result of what secondary diagnosis? A) Chronic obstructive pulmonary disease (COPD) B) Rheumatoid arthritis (RA) C) Irritable bowel syndrome (IBS) D) Chronic urinary tract infection (UTI)
Ans: A Feedback: The nurse should assess for COPD, because the effect of beta-blockers in reducing effects of the sympathetic nervous system could exacerbate the respiratory condition. RA, IBS, and chronic UTI are not affected by the use of beta-blockers or nitrates to treat angina.
What would the nurse teach the patient about potency of nitroglycerin? (Select all that apply.) A) "The tablet should fizzle or burn when placed under the tongue." B) "Protect the drug from heat and light." C) "Always replace when past the expiration date." D) "Older tablets may require you to use two tablets at one time." E) "Nitroglycerin does not lose its potency easily."
Ans: A, B, C Feedback: Ask the patient if the tablet "fizzles" or burns, which indicates potency. Always check the expiration date on the bottle and protect the medication from heat and light because these drugs are volatile and lose potency easily.
The nurse teaches the patient how to use topical nitroglycerin and includes what teaching points in the teaching plan? (Select all that apply.) A) "Rotate application sites." B) "Assess the skin for signs of breakdown." C) "Make sure no one touches the side with the medication." D) "Do not shower with the patch in place." E) "Increase fluid intake to avoid hypotension."
Ans: A, B, C Feedback: 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 patient or anyone assisting in applying the patch. The patient may shower with the patch in place. There is no need to increase fluid intake but patients should be encouraged to maintain adequate intake.
A patient is diagnosed with Prinzmetal's angina. What drug would the nurse expect to administer to this patient? A) Nadolol B) Diltiazem C) Propranolol D) Metoprolol
Ans: B Feedback: Calcium channel blockers are indicated for the treatment of Prinzmetal's angina because these drugs relieve coronary artery vasospasm, increasing blood flow to the muscle cells. Diltiazem is a calcium channel blocker. Beta-blockers are not indicated for the treatment of Prinzmetal's angina because they could cause vasospasm due to blocking of beta-receptor sites. Propranolol, nadolol, and metoprolol are beta-blockers.
The nurse is preparing to administer sublingual nitroglycerin to a patient for the first time and warns that the patient may experience what right after administration? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia
Ans: B Feedback: 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 patient usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not occur as a result of nitroglycerin therapy.
An older adult patient who is taking metformin (Glucophage) has just been seen in the clinic. The doctor has ordered metoprolol (Toprol) for angina. What assessment data should the nurse monitor due to this drug combination? A) Blood pressure B) Blood glucose C) Heart rate D) Intake and output
Ans: B Feedback: Metformin is an antidiabetic drug and the nurse should monitor the patient's blood glucose frequently throughout the day. The patient will not have the usual signs and symptoms of hypoglycemia or hyperglycemia. Blood pressure, heart rate, and intake and output would not be affected by this drug-drug combination.
The nurse cautions the patient taking nadolol (Corgard) for angina that they may experience what adverse effect? A) Dry mouth B) Decreased exercise tolerance C) Constipation D) Problems with urination
Ans: B Feedback: 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, constipation, and problems with urination are effects often seen with anticholinergic drugs but not with beta-blockers.
The nurse teaches the patient wearing a nitroglycerin patch to avoid what? A) Exercise B) Alcoholic beverages C) Milk products D) Synthetic fabrics
Ans: B Feedback: Patients should be taught to avoid or at least decrease use of coffee, cigarettes, and alcoholic beverages. There is no need to avoid exercise, milk, or synthetic fabrics.
A patient who has been taking cyclosporine to prevent rejection of a kidney transplant has had diltiazem ordered. Why would the nurse question this order? A) Serious diltiazem toxicity could occur. B) The combination may result in elevated or even toxic cyclosporine levels. C) The combination could lead to kidney rejection. D) A kidney recipient would not effectively excrete the diltiazem.
Ans: B Feedback: Potentially serious adverse effects to keep in mind include increased serum levels and toxicity of cyclosporine if they are taken with diltiazem. This combination is not associated with diltiazem toxicity. A functioning implanted kidney should still excrete diltiazem. This drug would not cause rejection of a transplanted kidney.
What statements by the 54-year-old patient indicates an understanding of the nurse's teaching about how to take sublingual nitroglycerin? A) "A headache means a toxic level has been reached." B) "I can take up to 3 tablets at 5-minute intervals." C) "I can take as much nitroglycerin as I need because it is not habit forming." D) "If I become dizzy after taking the medication, I should stop taking it."
Ans: B Feedback: Sublingual nitroglycerin may be taken at 5-minute intervals up to a maximum of three doses to relieve anginal chest pain. Headaches are very common due to vasodilation and do not indicate a toxic level. Nitroglycerin causes significant peripheral vasodilation in addition to its therapeutic effects of coronary artery dilation so no more than three tablets should be taken, even though it is not habit forming. Dizziness could be an adverse effect of the drug or a manifestation of inadequate cardiac output, but it would not indicate the patient should stop taking it.
The nurse is caring for a patient who is taking a calcium-channel blocker. What adverse effects would the nurse caution this patient about? A) Hypertension and tachycardia B) Headache and dizziness C) Itching and rash D) Nausea and diarrhea
Ans: B Feedback: 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.
The patient, diagnosed with angina, tells the nurse he is having chest pain. There is an order for oral sublingual nitroglycerin as needed. What action should the nurse take? A) Place two nitroglycerin tablets under the patient's tongue and call the physician. B) Place one tablet under the patient's tongue and repeat every 5 minutes for total of three tablets until pain has been relieved. C) Have the patient swallow a tablet with a full glass of water and repeat in 10 minutes. D) Apply a nitroglycerin transdermal patch to the patient's back.
Ans: B Feedback: The correct administration for sublingual administration is to place one tablet under the patient's tongue and repeat every 5 minutes for a total of three tablets until pain is relieved. If pain is not relieved after three sublingual tablets, the health care provider should be notified. Transdermal application would be inappropriate and nitroglycerin is not swallowed. Administering two tablets at one time would be an inappropriate dosage and could cause serious adverse effects.
When the nurse administers a beta-adrenergic blocker to the patient with angina, the nurse expects the drug will help to control angina, but it also has what other effect? A) Increased heart rate B) Increased oxygen consumption C) Decreased strength of heart muscle contraction D) Decreased urinary output
Ans: C Feedback: Beta-blockers competitively block beta-adrenergic receptors in the heart and kidneys, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart. As a result, it decreases the strength of cardiac contraction, reducing cardiac output, which results in lowered blood pressure and decreased cardiac workload. It does not impact urinary output.
A 49-year-old patient is admitted with uncontrolled chest pain. He is currently taking nitroglycerin (Nitrostat). His physician orders nifedipine (Adalat) added to his regimen. The nurse should observe the patient for what adverse effects? A) Hypokalemia B) Renal insufficiency C) Hypotension D) Hypoglycemia
Ans: C Feedback: 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.
Ans: A Feedback: The main effect of nitrates seems to be related to the drop in blood pressure that occurs. The vasodilation causes blood to pool in veins and capillaries, decreasing preload, while the relaxation of the vessels decreases afterload. The combination of these effects greatly reduces the cardiac workload and the demand for oxygen, thus bringing the supply-and-demand ratio back into balance. Because coronary artery disease causes a stiffening and lack of responsiveness in the coronary arteries, the nitrates probably have very little effect on increasing blood flow through the coronary arteries, so it would be incorrect to say that the coronary arteries become much wider. Although both preload and afterload are reduced, this is an explanation that the patient would not understand, so it is inappropriate. Nitroglycerin does not promote growth of compensatory circulation.
Ans: C Feedback: The most appropriate nursing diagnosis is ineffective tissue perfusion related to reduced oxygen supply to the heart because this is the cause of the patient's pain. Further assessment would be needed to determine whether the patient lacks knowledge, fears death, or has made the necessary lifestyle changes.
The nurse is caring for a patient who is complaining of chest pain. The nurse is to administer 40 mg of isosorbide dinitrate (Isordil) to the patient. What is the nurse's priority assessment before administering the drug? A) Jaundice B) Headache C) Anemia D) Sinusitis
Ans: C Feedback: The nurse should assess for anemia because the decrease in cardiac output could be detrimental in a patient who already has a decreased ability to deliver oxygen because of a low red blood cell count. Jaundice and sinusitis would not be a contraindication to the drug. Headache is an adverse effect of isosorbide and would be expected after administration of the drug.
A patient is to receive diltiazem (Cardizem) 360 mg/d orally in four divided doses. How many mg will the nurse administer per dose? A) 30 mg B) 60 mg C) 90 mg D) 120 mg
Ans: C Feedback: The patient will take 90 mg/dose (360 divided by 4 doses equals 90 mg/dose). Therefore, the other options are incorrect.
Other than angina, what other medical condition might the nurse treat by administering nitroglycerin? A) Muscular dystrophy B) Pulmonary embolisms C) Polycythemia D) Anal fissures
Ans: D Feedback: In 2011, a nitroglycerin in ointment form, Rectiv 0.4%, was approved for the treatment of moderate to severe anal fissures. There is no documented benefit to the use of nitroglycerin to treat muscular dystrophy, pulmonary embolisms, or polycythemia.
An adult patient who experiences angina pectoris with exertion is informed by the nurse that the leading cause of angina is what? A) Smoking B) Inadequate cardiac output C) Infarction of the myocardium D) Coronary atherosclerosis
Ans: D Feedback: The person with atherosclerosis has a classic supply-and-demand problem. The heart may function without a problem until increases in activity or other stresses place a demand on it to beat faster or harder. Normally, the heart would stimulate the vessels to deliver more blood when this occurs, but the narrowed vessels are not able to respond and cannot supply the blood needed by the working heart. The heart muscle then becomes hypoxic. This imbalance between oxygen supply and demand is manifested as pain, or angina pectoris, which literally means "suffocation of the chest." Atherosclerosis of the coronary artery can block the coronary artery completely leading to infarction. Smoking causes further vasoconstriction, increasing risk of myocardial infarction or angina. Damage to the heart muscle causes a decrease in cardiac output.
