Pharm Exam 2

Ch 23 Antianginal Drugs 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 one 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 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.

Ch 23 Antianginal Drugs 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, 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. • Rotation of sites is helpful for preventing irritation. • 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.

Ch 22 Antihypertensive Drugs 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 mm Hg. A (vasodilator) 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?

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). Treatment for the hypotension is supportive and symptomatic; if necessary, pressor drugs can be infused to raise blood pressure quickly.

Ch 22 Antihypertensive Drugs During a follow-up appointment, a 58-year-old man is pleased to hear that his blood pressure is 118/64 mm Hg. 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., renal function, the fundus of the eye).

Ch 23 Antianginal Drugs Which instruction should be included in the discharge teaching for a patient with a transdermal nitroglycerin patch? a.) "Apply the patch to a nonhairy, nonirritated area of the upper torso or arms." b.) "Apply the patch to the same site each day to maintain consistent drug absorption." c.) "If you get a headache, remove the patch for 4 hours and then reapply." d.) "If you get chest pain, apply a second patch right next to the first patch."

a.) "Apply the patch to a nonhairy, nonirritated area of the upper torso or arms." nitroglycerin patch should be applied to a nonhairy, nonirritated area for the best and most consistent absorption rates. Sites should be rotated to prevent skin irritation, and the drug should be continued if headache occurs because tolerance will develop. Sublingual nitroglycerin should be used to treat chest pain.

Ch 22 Antihypertensive Drugs Which statement, if made by your patient, signifies that additional patient teaching regarding antihypertensive treatment is required? a.) "I will check my blood pressure every day and take my medication when it is over 140/90." b.) "I will include rest periods during the day to help me tolerate the fatigue my medicine may cause." c.) "I will change my position slowly to prevent feeling dizzy." d.) "I will not mow my lawn until I see how this medication makes me feel."

a.) "I will check my blood pressure every day and take my medication when it is over 140/90." Antihypertensive medications need to be taken routinely in order to maintain a normotensive state and prevent occurrence of complications. Many patients do not adhere to this regimen because hypertension itself does not cause symptoms, whereas the medication can cause some untoward effects. Patient teaching is essential.

Ch 23 Antianginal Drugs When titrating intravenous nitroglycerin, which assessment findings does the nurse monitor? (Select all that apply.) a.) Blood pressure b.) Heart rate c.) Chest pain d.) Respiratory rate

a.) Blood pressure b.) Heart rate c.) Chest pain

Ch 22 Antihypertensive Drugs Which is a priority nursing diagnosis for a patient taking an antihypertensive medication? a.) Ineffective cerebral tissue perfusion related to disease process and/or medication b.) Deficient knowledge related to medication regimen c.) Fatigue related to side effects of medication d.) Risk for injury to mucous membranes related to medication side effects

a.) Ineffective cerebral tissue perfusion related to disease process and/or medication Ineffective cerebral tissue perfusion is always a priority over fatigue, risk for injury, and/or knowledge deficit. Patients taking antihypertensive medication are also at risk for ineffective renal and cardiac perfusion.

Ch 23 Antianginal Drugs Nitrates relieve angina pain by reducing preload. How would the nurse explain the term preload to a patient? a.) It is the blood volume within the heart. b.) It is the pressure within the superior vena cava. c.) It is the pressure against which the heart must pump. d.) It is the oxygen demand of the heart

a.) It is the blood volume within the heart. Preload is determined by the amount of blood in the ventricle just before contraction

Ch 22 Antihypertensive Drugs When teaching a patient about carvedilol (Coreg), the nurse explains that this medication reduces blood pressure by which actions? (Select all that apply.) a.) Reducing heart rate b.) Vasodilation c.) Decreasing stress d.) Increasing urine output

a.) Reducing heart rate b.) Vasodilation <div>Carvedilol (Coreg) has the dual antihypertensive effects of reducing heart rate (beta₁ receptor blockade) and also vasodilation (alpha₁ receptor blockade).</div>

Ch 22 Antihypertensive Drugs Which would be a priority assessment prior to administering eplerenone (Inspra)? a.) Serum electrolytes b.) Level of consciousness c.) Patient's knowledge level d.) Thiocyanate levels

a.) Serum electrolytes Eplerenone (Inspra) is contraindicated in patients with an elevated serum potassium level (greater than 5.5 mEq/L) or severe renal impairment, Therefore, it is imperative that the nurse assess the patient's most recent serum electrolytes before administering this medication.

Ch 23 Antianginal Drugs Which statement indicates that the patient understands discharge teaching about nitroglycerin? a.) "I will need to refill my prescription once a year in order to maintain potency." b.) "I will need to keep the nitroglycerin stored in the bottle it comes in." c.) "I will take a nitroglycerin tablet every 15 minutes until my chest pain is gone." d.) "I should take a nitroglycerin tablet 2 hours before I want to engage in activity that will cause chest pain."

b.) "I will need to keep the nitroglycerin stored in the bottle it comes in." Nitroglycerin needs to be stored away from heat, humidity, and light, all of which can decrease its potency. Keeping it in the brown light-resistant bottle helps achieve this. It should be replaced every 3 to 6 months in order to maintain potency. Nitroglycerin is used every 5 minutes for pain relief or just before engaging in activity that is known to cause chest pain.

Ch 23 Antianginal Drugs The patient asks how nitroglycerin should be stored while traveling. What is the nurse's best response? a.) "You can protect it from heat by placing the bottle in an ice chest." b.) "It's best to keep it in its original container away from heat and light." c.) "You can put a few tablets in a resealable bag and carry in your pocket." d.) "It's best to lock them in the glove compartment of your car to keep them away from heat and light."

b.) "It's best to keep it in its original container away from heat and light." Although nitroglycerin needs to be kept in a cool, dry place, it should not be placed in an ice chest where it could freeze. It should also not be locked up and needs to be kept away from light, not in a clear plastic bag.

Ch 22 Antihypertensive Drugs Which statement would be most appropriate during discharge teaching for a patient receiving transdermal clonidine (Catapres)? a.) "Your blood pressure should be checked by a physician at least once a year." b.) "The patch should be applied to a nonhairy site, and abrupt withdrawal should be avoided." c.) "Excessive exercise or prolonged standing is not a problem with clonidine as it can be with other antihypertensive drugs." d.) "If you are having difficulty with the common side effect of excessive drooling, notify your physician so your dosage can be adjusted."

b.) "The patch should be applied to a nonhairy site, and abrupt withdrawal should be avoided." Transdermal clonidine patches should be applied to nonhairy areas of the skin, and abrupt withdrawal should be avoided. The patient's blood pressure should be checked more frequently than once a year; prolonged standing can cause venous pooling and hypotension; and dry mouth, not drooling, is a common side effect of clonidine.

Ch 23 Antianginal Drugs When applying nitroglycerin ointment, the nurse should perform which action? a.) Use the fingers to spread the ointment evenly over a 3-inch area. b.) Apply the ointment to a nonhairy part of the upper torso. c.) Massage the ointment into the skin. d.) Apply two thick lines of ointment over the prescribed measured area on the nitroglycerin paper.

b.) Apply the ointment to a nonhairy part of the upper torso. Absorption is best over a nonhairy portion of skin. The upper torso is the preferred site of application. The nurse should wear gloves when applying to prevent transdermal absorption by the applier. The ointment is measured as one straight line on the nitroglycerin patch and is gently spread over paper and applied, but not rubbed, into the skin. Rubbing would increase absorption and risks of side effects.

Ch 23 Antianginal Drugs A patient receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's best action? a.) Assess the patient's lung sounds. b.) Decrease the intravenous nitroglycerin by 10 mcg/min. c.) Increase the intravenous nitroglycerin by 10 mcg/min. d.) Recheck the patient's vital signs in 1 hour.

b.) Decrease the intravenous nitroglycerin by 10 mcg/min. Nitroglycerin, as a vasodilator, causes a decrease in blood pressure. Because it is short-acting, decreasing the infusion rate will allow the blood pressure to rise. The patient should be monitored every 10 minutes while changing the rate of the intravenous nitroglycerin infusion.

Ch 22 Antihypertensive Drugs The nurse is conducting a community education program. When explaining different medication regimens to treat hypertension, it would be accurate to state that African Americans probably respond best to which combination of medications? a.) ACE inhibitors and diuretics b.) Diuretics and calcium channel blockers c.) Diuretics and beta blockers d.) ACE inhibitors and beta blockers

b.) Diuretics and calcium channel blockers Research has demonstrated that African Americans do not typically respond therapeutically to beta blockers or ACE inhibitors. They respond better to diuretics and calcium channel blockers.

Ch 22 Antihypertensive Drugs What side effect of angiotensin-converting enzyme (ACE) inhibitors most often results in the provider changing the treatment plan to an angiotensin receptor blocker? a.) Orthostatic hypotension b.) Dry, nonproductive cough c.) Fatigue d.) Hypokalemia

b.) Dry, nonproductive cough ACE inhibitors prevent the breakdown of bradykinin, frequently causing a nonproductive cough. Angiotensin receptor blockers do not block this breakdown, thus minimizing this annoying side effect.

Ch 23 Antianginal Drugs Which are common side effects of nitroglycerin? (Select all that apply.) a.) Blurred vision b.) Flushing c.) Headache d.) Hypotension

b.) Flushing c.) Headache d.) Hypotension

Ch 22 Antihypertensive Drugs When administering nitroprusside (Nipride) intravenously, the nurse would monitor for which sign of toxicity? a.) Fever b.) Hypotension c.) Extreme fatigue d.) Hyperglycemia

b.) Hypotension The main symptom of sodium nitroprusside overdose or toxicity is excessive hypotension.

Ch 22 Antihypertensive Drugs A patient prescribed prazosin (Minipress) does not have a history of hypertension. The nurse would assess for what disorder for which this medication is also used? a.) Pulmonary emboli b.) Obstructive benign prostatic hyperplasia c.) Seizure disorder d.) Subarachnoid hemorrhage

b.) Obstructive benign prostatic hyperplasia Alpha1 blockers have been useful in treating obstructive benign prostatic hyperplasia. The blocking of alpha-adrenergic receptors decreases the urine outflow obstruction related to benign prostatic hyperplasia by preventing smooth muscle contractions in the bladder neck and urethra.

Ch 23 Antianginal Drugs A patient who is taking sublingual nitroglycerin is complaining of flushing and headaches. What is the nurse's best response? a.) "This is a normal response to your chest pain." b.) "Stop taking the nitroglycerin because you are probably allergic to it." c.) "These are the most common side effects of nitroglycerin. They should subside with continued use of nitroglycerin." d.) "These symptoms are not related to your sublingual nitroglycerin. You should notify your doctor for diagnostic testing."

c.) "These are the most common side effects of nitroglycerin. They should subside with continued use of nitroglycerin." Headache and flushing are the most common side effects of nitroglycerin and will subside with continued use.

Ch 23 Antianginal Drugs In order to prevent the development of tolerance, the nurse instructs the patient to perform which action? a.) Apply the nitroglycerin patch every other day. b.) Switch to sublingual nitroglycerin when the patient's systolic blood pressure elevates to >140 mm Hg. c.) Apply the nitroglycerin patch for 16 hours each and remove for 8 hours at night. d.) Use the nitroglycerin patch for acute episodes of angina only

c.) Apply the nitroglycerin patch for 16 hours each and remove for 8 hours at night. Tolerance can be prevented by maintaining an 8-hour nitrate-free period each day.

Ch 23 Antianginal Drugs What is included in the priority assessment before administering isosorbide mononitrate (Imdur)? a.) Serum electrolytes b.) Blood urea nitrogen (BUN) and creatinine c.) Blood pressure d.) Level of consciousness

c.) Blood pressure Mononitrate is a vasodilator and thus can cause hypotension. It is important to assess blood pressure before administering.

Ch 23 Antianginal Drugs When caring for a patient with angina, the nurse would question an order for a noncardioselective beta blocker in a patient with what coexisting medical diagnosis? a.) Hypertension b.) Atrial fibrillation c.) Bronchial asthma d.) Myocardial infarction

c.) Bronchial asthma Noncardioselective beta blockers should be used with caution in patients with bronchial asthma since any level of blockade of beta2-receptors can promote bronchoconstriction through unopposed parasympathetic (vagal) tone.

Ch 22 Antihypertensive Drugs Carvedilol (Coreg) is classified as a a.) beta blocker. b.) alpha1 blocker. c.) Dual-action alpha1 and beta receptor blocker. d.) Calcium channel blocker.

c.) Dual-action alpha1 and beta receptor blocker. Carvedilol blocks both the alpha1 and beta receptors of the adrenergic nervous system.

Ch 22 Antihypertensive Drugs The nurse would question an order for a calcium channel blocker in a patient with which condition? a.) Angina pectoris b.) Increased intracranial pressure c.) Hypotension d.) Dysrhythmia

c.) Hypotension Calcium channel blockers cause vasodilation and thus a drop in blood pressure. They are contraindicated in the presence of hypotension.

Ch 23 Antianginal Drugs Calcium channel blockers reduce myocardial oxygen demand by reducing afterload. How would the nurse explain afterload to the patient? a.) It is the blood volume within the heart. b.) It is the pressure within the heart. c.) It is the pressure against which the heart must pump. d.) It is the contractility of the heart muscle.

c.) It is the pressure against which the heart must pump. Afterload is determined by the pressure in the aorta just before systole.

Ch 22 Antihypertensive Drugs The nurse would plan to administer which calcium channel blocker to a patient with cerebral artery spasms following a subarachnoid hemorrhage? a.) amlodipine (Norvasc) b.) diltiazem (Cardizem) c.) nimodipine (Nimotop) d.) verapamil (Calan)

c.) nimodipine (Nimotop) Nimodipine crosses the blood-brain barrier and has a greater effect on the cerebral arteries than on other arteries in the body; thus, it is indicated for the treatment of cerebral artery spasm following subarachnoid hemorrhage.

Ch 23 Antianginal Drugs Which statement by the patient demonstrates a need for further education regarding nitroglycerin? a.) "If I get a headache, I should keep taking my nitroglycerin and use Tylenol for pain relief." b.) "I should keep my nitroglycerin in a cool, dry place." c.) "I should change positions slowly to avoid getting dizzy from the nitroglycerin's effect on my blood pressure." d.) "I can take up to four tablets at 5-minute intervals for chest pain."

d.) "I can take up to four tablets at 5-minute intervals for chest pain." Patients are taught to take up to three tablets 5 minutes apart. According to current guidelines, if the chest pain or discomfort is not relieved in 5 minutes, after one dose, the patient (or family member) must call 911 immediately.

Ch 23 Antianginal Drugs Patient teaching regarding sublingual nitroglycerin should include which statement? a.) "You can take up to five doses every 3 minutes for chest pain." b.) "Chew the tablet for the quickest effect." c.) "Keep the tablets locked in a safe place until you need them." d.) "Sit or lie down after you take a nitroglycerin tablet to prevent dizziness."

d.) "Sit or lie down after you take a nitroglycerin tablet to prevent dizziness." Nitroglycerin is a vasodilator and can cause orthostatic hypotension, resulting in dizziness. It should be kept in a readily accessible location for immediate use should chest pain occur. Three tablets may be taken 5 minutes apart. It should be placed under the tongue and allowed to dissolve.

Ch 23 Antianginal Drugs It is most important to instruct a patient prescribed nitroglycerin to avoid which substance(s)? a.) Antacids b.) Grapefruit juice c.) Thiazide diuretics d.) Erectile dysfunction medications

d.) Erectile dysfunction medications Concurrent administration of erectile dysfunction medications such as sildenafil citrate (Viagra) can cause an acute exacerbation of nitrate-related hypotension.

Ch 23 Antianginal Drugs Which nitrate preparation or dosage form has the longest duration of action? a.) Sublingual nitroglycerin b.) Sublingual isosorbide dinitrate c.) Oral isosorbide dinitrate d.) Transdermal nitroglycerin patch

d.) Transdermal nitroglycerin patch The transdermal patch has an 8- to 12-hour duration of action, compared with 0.5 to 6 hours for the other choices.

Ch 22 Antihypertensive Drugs Which medication would the nurse question if prescribed concurrently with ACE inhibitors? a.) furosemide (Lasix) b.) morphine c.) Colace d.) potassium

d.) potassium ACE inhibitors block the conversion of angiotensin I to angiotensin II, thus also blocking the stimulus for aldosterone production. Aldosterone is responsible for potassium excretion—decreased aldosterone can result in increased serum potassium.

Ch 22 Antihypertensive Drugs ACE inhibitors and angiotensin receptor blockers both work to decrease blood pressure by a.) preventing the formation of angiotensin II. b.) enhancing sodium and water resorption. c.) increasing the breakdown of bradykinin. d.) preventing aldosterone secretion.

d.) preventing aldosterone secretion. ACE inhibitors block the formation of angiotensin II, whereas angiotensin receptor blockers allow the formation of angiotensin II but block its effect at the receptors. Without the receptors stimulated (because of either drug), aldosterone is not produced, diminishing the reabsorption of sodium and water.